HospitalInspections.org

Based on document review and staff interviews, the facility failed to ensure the patient participated in the development and implementation of his/her care plan and failed to follow facility policy for treatment plans for 5 of 5 patients (patients #1-5).

Findings include:

1. Facility policy titled "Interdisciplinary Treatment Plan" last reviewed/revised 10/09 states under policy: "Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, ................................. Treatment shall be planned, reviewed, and evaluated at regular intervals by a Multidisciplinary Treatment Team. This team shall consist of the: physician, nurse, therapist, a representative of specialized therapies, the patient and other disciplines as appropriate......" Page 2 states under 3.0: "............Weekly multidisciplinary treatment-planning meetings, under the direction of the attending or covering physician, occur to plan, develop, review and revise the treatment plan based on an assessment of the patient's progress and goal achievement." Page 3 states under 9.0: "The treatment plan will be formally reviewed in a multidisciplinary treatment planning meetings occurring at least at seven (7) day intervals or more often if indicated."

2. Review of patient #1 medical record indicated the following:
(A) The medical record lacked evidence that the patient or responsible party participated in the development or implementation of the treatment plan. The initial treatment plan dated 9/17/12 lacked signatures from the patient or parent/guardian. The signature section for both was blank. Additionally, there was no evidence that the patient, parent/guardian, or all staff members required per policy were involved in the updates and revisions. Document titled "INTERDISCIPLINARY MASTER TREATMENT PLAN UPDATE/REVISIONS" dated 9/24/12 lacked a signature of nursing, patient/parent, or utilization review. The section for the above disciplines to sign as attending, was left blank. The same titled document dated 10/1/12 lacked a signature of nursing, patient/parent, and therapist. The section for the above disciplines to sign as attending was left blank.

3. Review of patient #2 medical record indicated the following:
(A) The medical record lacked evidence that the patient or responsible party participated in the revisions/updates to the treatment plan per policy. The initial treatment plan was developed on 9/22/12. The patient was discharged from the facility on 10/5/12. There were no revisions or updates to the treatment plan made during the stay.

4. Review of patient #3 medical record indicated the following:
(A) The medical record lacked evidence that the patient, parent/guardian, or all staff members required per policy were involved in the updates and revisions to the treatment plan. Document titled "INTERDISCIPLINARY MASTER TREATMENT PLAN UPDATE/REVISIONS" dated 10/4/12 lacked a signature of nursing and the patient/parent. The section for the above disciplines to sign as attending, was left blank. The same titled document dated 10/11/12 lacked a signature of nursing, patient/parent, and utilization review. The section for the above disciplines to sign as attending was left blank. Additionally, the activities therapist did not sign the document dated 10/11/12 until 10/31/12. The same document dated 10/18/12 lacked a signature of the physician, nursing, patient/parent, and utilization review. The section for the above disciplines to sign as attending was left blank. Additionally, the activity therapist did not sign the document dated as 10/18/12 until 10/31/12, therefore it would appear that the only discipline involved in the revision on 10/18/12 was the therapist. The same update/revision document dated 10/25/12 lacked a signature of the physician, nursing, patient/parent, and utilization review. The section for the above disciplines to sign as attending was left blank. Additionally, the activity therapist signed the document dated 10/25/12 on 10/31/12, therefore it would appear that the only discipline involved in the revision on 10/25/12 was the therapist.

5. Review of patient #4 medical record indicated the following:
(A) The medical record lacked evidence that the patient, parent/guardian, or all staff members required per policy were involved in the updates and revisions to the treatment plan. Document titled "INTERDISCIPLINARY MASTER TREATMENT PLAN UPDATE/REVISIONS" dated 9/6/12 lacked a signature of nursing, patient/parent, or utilization review. The section for the above disciplines to sign as attending, was left blank. Additionally, the activity therapist did not sign the document until 10/3/12 after the patient was discharged. The same titled document dated 9/13/12 lacked a signature of nursing, patient/parent, and utilization review. The section for the above disciplines to sign as attending was left blank. Additionally, the activities therapist did not sign the document dated 9/13/12 until 10/3/12 after the patient was discharged . The same document dated 9/20/12 lacked a signature of nursing and the patient/parent. The section for the above disciplines to sign as attending was left blank. Additionally, the activity therapist did not sign the document dated as 9/20/12 until 10/3/12 after the patient was discharged. The same titled document dated 9/27/12 lacked a signature of nursing and the patient/parent. The section for the above disciplines to sign as attending was left blank. Additionally, the activities therapist did not sign the document until 10/3/12 after the patient was discharged.

6. Review of patient #5 medical record indicated the following:
(A) The medical record lacked evidence that the patient, parent/guardian, or all staff members required per policy were involved in the updates and revisions to the treatment plan. Document titled "INTERDISCIPLINARY MASTER TREATMENT PLAN UPDATE/REVISIONS" dated 8/16/12 lacked a signature of nursing and the patient/parent. The section for the above disciplines to sign as attending, was left blank. The same titled document dated 8/23/12 lacked a signature of nursing, patient/parent, and activity therapy. The section for the above disciplines to sign as attending was left blank.

7. Staff member #1 verified the above medical record information in interview beginning at 2:45 p.m. on 11/7/12: