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Based on medical record reviews and interview, the hospital failed to ensure that the psychiatric admission evaluation of an admitted patient included an assessment of the patient's memory functioning in 9 (patient #1, #2, #3, #4, #5, #6, #7, #8 and #9) of 9 reviewed open medical record. Findings include:

(1) The 8/10/2010 and 8/11/2010 review of medical records revealed that:
a) The psychiatric admission evaluation of patient #1 admitted to the hospital on 8/08/2010 did not document the patient ' s memory functioning.
b) The psychiatric admission assessment of patient #2 admitted to the hospital on 8/03/2010 did not document the patient ' s memory functioning.
c) The psychiatric admission evaluation of patient #3 admitted to the hospital on 8/4/2010 did not document the patient ' s memory functioning.
d) The psychiatric admission assessment of patient #4 admitted to the hospital on 8/07/2010 did not document the patient ' s memory functioning.
e) The psychiatric admission evaluation of patient #5 admitted to the hospital on 7/15/2010 did not document the patient ' s memory functioning.
f) The psychiatric admission assessment of patient #6 admitted to the hospital on 8/05/2010 did not document the patient ' s memory functioning.
g) The psychiatric admission evaluation of patient #7 admitted to the hospital on 7/30/2010 did not document the patient ' s memory functioning.
h) The psychiatric admission evaluation of patient #8 admitted to the hospital on 8/05/2010 did not document the patient ' s memory functioning.
i) The psychiatric admission evaluation of patient #9 admitted to the hospital on 7/30/2010 did not document the patient ' s memory functioning.

(2) On 8/10/2010 at approximately 1350 hours, at the Adolescent Unit Nursing station, the Director of Nursing and Unit Nursing Supervisor reviewed the medical records and confirmed that the psychiatric admission evaluations in the medical records of patient #7, #8, and #9, did not contain an estimate of memory functioning.

The Director of Nursing, interviewed on 8/11/2010 at 1630 hours, was asked to review the psychiatric admission evaluations of patient # 4, #5, and #6. The Director of Nursing confirmed that the psychiatric admission evaluations of patient #4, #5, and #6 did not include an evaluation of the patient's memory functioning.

Based on medical record review and interview, the hospital failed to ensure that developed individualized comprehensive treatment plans entitled Multidisciplinary Master Treatment Plan " (MTP) included an inventory of the patient's strengths that were identified by the treatment team and incorporated into the patient's MTP in 9 (patient #1, #2, #3, #4, #5, #6, #7, #8, and #9) of 9 active sampled patients. Findings include:

(1) The 8/10/2010 and 8/11/2010 medical record review revealed that:

a) The format of the hospital's MPT has sections entitled "patient strength, patient weakness, and patient goal for treatment "

b) Patient #1 MTP "patient strength" section stated: "I have a strong heart".
The "patient weakness" section stated: "Panic".
The "patient goal for treatment" section stated" I just want to realize that I can succeed".

c) Patient #2 MTP "patient strength" section stated: "That I am different, enjoy reading, like to get a lot of knowledge".
The "patient weakness" section stated: " My teeth, otherwise, there's nothing I don't like about myself."
The "patient goal for treatment" section stated: "To get out".

d) Patient #3 MTP "patient strength" section stated: "Very smart, easy to talk to."
The "patient weakness" section stated: "Very difficult for me to make friends".
The "patient goal for treatment" section stated "Learn more about myself and get better".

(2) The Director of Clinical Services, interviewed 8/11/2010, was asked to provide clarification as to the source of the data documented in the patient strength and weakness sections as the documented information did not appear to be based on a compilation derived from the treatment team's assessments. The Director stated that these sections documents the patient's perception of his/her "strengths" and "weakness".

The Director of Clinical Services confirmed that the current format of the MTP does not formally identify the treatment team's assessment of a patient ' s strengths and weakness.

Based on medical record review, the hospital failed to ensure that a patient's written individualized comprehensive treatment plan entitled Multidisciplinary Treatment Plan (MTP) included measurable long term goals in 9 (patient #1, #2, #3, #4, #5, #6, #7, #8, and #9) of 9 sampled active cases. Findings include:

The 8/10/2010 and 8/11/2010 review of patient #1, #2, #3, #4, #5, #6, #7, #8, and #9 MTP revealed that:

(1) The Hospital's MTP format has a menu of long term goals that can be selected by the treatment team. Listed long term treatment goals were generic and not measurable.

(2) Patient #1's selected long term goals were:
a) Patient will verbalize symptoms have stabilized to the point patient can safely be discharged from the hospital.
b) No longer threat to self.
c) Verbalize need for and commitment to prescribe medication and their common side effects.
d) Improved in mood stabilization, thinking/ and or behavior.

(3) Patient #2's selected long term goals were:
a) Patient will verbalize symptoms have stabilized to the point patient can safely be discharged from the hospital.
b) No longer threat to self.
c) Verbalize need for and commitment to prescribe medication and their common side effects.
d) Improved in mood stabilization, thinking/ and or behavior.

(4) Patient #3's selected long term goals were:
a) Patient will verbalize symptoms have stabilized to the point patient can safely be discharged from the hospital.
b) No longer threat to self.
c) Verbalize need for and commitment to prescribe medication and their common side effects.
d) Improved in mood stabilization, thinking/ and or behavior.

(5) Patient #4's selected long term goals were:
a) Patient will verbalize symptoms have stabilized to the point patient can safely be discharged from the hospital.
b) No longer threat to self.
c) Verbalize need for and commitment to prescribe medication and their common side effects.
d) Improved in mood stabilization, thinking/ and or behavior.

(6) Patient #5's selected long term goals were:
a) Patient will verbalize symptoms have stabilized to the point patient can safely be discharged from the hospital.
b) No longer threat to self.
c) Verbalize need for and commitment to prescribe medication and their common side effects.
d) Improved in mood stabilization, thinking/ and or behavior.

(7) Patient #6's selected long term goals were:
a) Patient will verbalize symptoms have stabilized to the point patient can safely be discharged from the hospital.
b) No longer threat to self.
c) Verbalize need for and commitment to prescribe medication and their common side effects.
d) Improved in mood stabilization, thinking/ and or behavior.

(8) Patient #7's selected long term goals were:
a) No longer threat to self.
b) No longer threat to others.

(9) Patient #8's selected long term goals were:
a) Patient will verbalize symptoms have stabilized to the point patient can safely be discharged from the hospital.
b) No longer threat to self.
c) No longer threat to others.
d) Verbalize need for and commitment to prescribe medication and their common side effects.
e) Improved in mood stabilization, thinking/ and or behavior.

(10) Patient #9's selected long term goals were:
a) Patient will verbalize symptoms have stabilized to the point patient can safely be discharged from the hospital.
b) No longer threat to self.
c) No longer threat to others.
d) Verbalize need for and commitment to prescribe medication and their common side effects.
e) Improved in mood stabilization, thinking/ and or behavior.

(11) The hospital's MTP format has provisions were individualized long term goals can be recorded in a fill in line in the MTP. None of the 9 reviewed MTPs had any activated individualized long term goals.

Based on record review and interview, the facility failed to develop an individualized treatment plan specific to the identified "problems" of the patient in 3 of 3 records reviewed. Findings include:

Review of the document Multidisciplinary Master Treatment Plan for patient ' s # 4, #5 and #6 all revealed that on page 3 under the section of Problem Number (#), the area was left blank. The document is supposed to contain the identified problem (#) from page 2 that the patient has and then address the staff responsible for the interventions related to that specific problem.

Patient # 4 ' s document revealed that on page 2 problems were #1 depression, #2 suicidal ideations/self mutilation and #3 anxiety. On page 3 of the document it list physician interventions and nursing staff but not to what problems they are addressing such as 1, 2, or 3. Problems identified and interventions are addressed only by the Case manager and Activity Therapy for this patient.

Patient #5 ' s document revealed that on page 2 problems were identified as #1 auditory hallucinations, #2 mood symptoms and #3 alcohol abuse. On page 3 only activity therapy was documented as addressing the 3 problems identified the other disciplines were all left blank for what problems they were addressing.

Patient #6 ' s document revealed that on page 2 problems were identified as #1 Suicidal ideation, #2 depression and #3 flashbacks and nigh mares. On page 3 only the case manager was documented as addressing the 3 problems identified the other disciplines were all left blank for what problems they were addressing.

These documents were reviewed and findings verified with RN #1 at the time of each respective record review (08/11/2010 at 1130). RN #1 confirmed that the documentation on the care plans did not address what problem each discipline was addressing.

Based on record reviews and interview on 08/10/10 and 08/11/2010, it was determined that the facility failed to ensure that medical records contained documentation of progress notes by the physician in 3 (patient #7, #8, and #9) of 9 reviewed open medical records. Findings include:

On 8/10/2010 at approximately 1350 hours, at Adolescent Unit Nursing station, review of the medical record for Pt # 7 demonstrates absence of physician progress notes for the following dates: 7/31, 8/2, 8/3, 8/4, 8/5, (not signed on 8/6), 8/8 and 8/9. Review of the medical record for Pt # 9 demonstrates absence of physician progress notes for the following dates: 8/1, 8/7, 8/8, 8/9 and 8/10. The DON and Unit Nursing Supervisor verified these findings.

On 8/11/10 at approximately 1245, at Adolescent Unit Nursing station, review of the medical record for Pt # 8 demonstrates absence of physician progress notes for the following dates: 8/6, 8/7, 8/8, and 8/9. These findings were verified by RN # (AS).

Based on record reviews and interview on 08/10/10 and 08/11/2010, it was determined that the facility failed to ensure that medical records contained documentation of the patient's progress with the treatment plan in 3 (patient #7, #8, and #9) of 9 reviewed open medical records. Findings include:

On 8/10/2010 at approximately 1350, at Adolescent Unit Nursing station, review of the medical record for Pt # 7 demonstrates absence of physician progress notes for the following dates: 7/31, 8/2, 8/3, 8/4, 8/5, (not signed on 8/6), 8/8 and 8/9. Review of the medical record for Pt # 9 demonstrates absence of physician progress notes for the following dates: 8/1, 8/7, 8/8, 8/9 and 8/10. The DON and Unit Nursing Supervisor verified these findings.

On 8/11/10 at approximately 1245, at Adolescent Unit Nursing station, review of the medical record for Pt # 8 demonstrates absence of physician progress notes for the following dates: 8/6, 8/7, 8/8, and 8/9. These findings were verified by RN # (AS).