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Based on document review, staff interview and hospital policy review, the facility failed to ensure that the Initial Case Management Note/Psychosocial Assessment for 14 of 16 active sample patients (A2, A3, A4, A7, A8, A9, A10, A11, A12, A13, A14, A15, A16, A17) included: 1) an evaluation of high risk psychosocial issues requiring early treatment planning and intervention; 2) recommendations concerning anticipated necessary steps to be taken for discharge to occur; and 3) anticipated Social Work roles in treatment and discharge planning. This results in critical patient psychosocial and discharge information necessary for informed treatment planning decisions not being available to the treatment teams.

Findings include:

A. Record Review

1. Patient A2 was admitted for suicidal ideation and depression to the Admissions Unit on 6/30/10. The Psychosocial Assessment completed on 6/30/10 did not contain sufficient information to develop the patient's treatment plan. It lacked information relative to family, social supports and previous community resources. It also did not contain patient strengths and deficits, high risk psychosocial issues and lacked specific community resources in the anticipated social work role for appropriate treatment and discharge planning.

2. Patient A3 was admitted for exhibiting psychotic symptoms to the Admissions Unit on 6/24/10. The Psychosocial Assessment completed on 6/25/10 did not contain sufficient information to develop the patient treatment plan. It lacked information relative to previous medical, psychiatric and substance abuse issues, social supports and previous community resources. It also did not contain patient strengths and deficits, high risk psychosocial issues and lacked specific community resources for utilization in discharge planning. The Initial Anticipated Aftercare Plan stated "Living Situation-friend's house" and there was no social work role in treatment and discharge planning.

3. Patient A4 was admitted for paranoid delusions to the Bipolar/Psychotic Unit on 6/9/10. The Psychosocial Assessment completed on 6/10/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to family and home plans, social supports and previous community resources. It also did not contain patient strengths and deficits, high risk psychosocial issues and lacked specific community resources in the anticipated social work role for appropriate treatment and discharge planning. The Initial Anticipated Aftercare Plan stated "Living Situation-home w/mother" and there was no social work role in treatment and discharge planning.

4. Patient A7 was admitted for dementia with increasing symptoms of aggressive behavior and sleep disturbance to the Dementia/Psychosis Unit on 6/29/10. The Psychosocial Assessment completed on 6/30/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to previous medical, psychiatric and substance abuse/legal history. It also did not contain patient strengths and deficits, high risk psychosocial issues and lacked specific community resources in the anticipated social work role for appropriate treatment and discharge planning. The Initial Anticipated Aftercare Plan stated "Assisted Living (AL) possibly returns to Wingate...." and there was no social work role in treatment and discharge planning.

5. Patient A8 was admitted for dementia with increasing symptoms of aggressive behavior and depression to the Dementia/Psychosis Unit on 6/25/10. The Psychosocial Assessment completed on 6/25/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to previous psychiatric history, history of physical and emotional abuse and substance abuse/legal history. It also did not contain patient strengths and deficits, high risk psychosocial issues and the anticipated social work role for appropriate treatment and discharge planning.

6. Patient A9 was admitted for psychotic behavior, confusion, and somnolence to the Psychotic Disorders Unit on 6/27/10. The Psychosocial Assessment completed on 6/28/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to family and home plans, previous medical and psychiatric history, history of physical and emotional abuse and previous community resources for utilization in discharge planning. It also did not contain patient strengths and deficits, high risk psychosocial issues and the anticipated social work role for appropriate treatment and discharge planning.

7. Patient A10 was admitted for increased anxiety/depression over recent death of father and substance abuse dependence (opiates) to the Dual Diagnosis Unit on 7/10/10. The Psychosocial Assessment completed on 7/11/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to patient's relationship to family and home plans, history of physical and emotional abuse and previous substance abuse/legal/employment history. It also did not contain patient strengths and deficits, and high risk psychosocial issues. The section on Case Management and Aftercare Planning stated "Pt requesting Res TX post discharge, Pt not allowed to return home". There was no anticipated social work role in treatment and discharge planning.

8. Patient A11 was admitted for increased depression, suicidal ideation, and ETOH dependence to the Dual Diagnosis Unit on 7/8/10. The Psychosocial Assessment completed on 7/09/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to history of physical and emotional abuse and previous employment and military history. It also did not contain patient strengths and deficits, and high risk psychosocial issues. There was no anticipated social work role in treatment and discharge planning.

9. Patient A12 was admitted for suicide attempt via slashing her throat, deterioration in mood and exacerbation of psychotic symptoms to the Dissociative Disorders Unit on 6/29/10. The Psychosocial Assessment completed on 6/30/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to history of psychiatric, medical and substance abuse and history of physical and emotional abuse issues. It also did not contain patient strengths and deficits, and high risk psychosocial issues in identifying potential obstacles to present treatment and discharge planning. There was no anticipated social work role in treatment and discharge planning.

10. Patient A13 was admitted for depression and suicidal ideation to the Dissociative Disorders Unit on 6/24/10. The Psychosocial Assessment completed on 6/24/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to patient's relationship with family, history of educational/employment/legal issues and history of physical and emotional abuse issues. It also did not contain patient strengths and deficits, and high risk psychosocial issues in identifying potential obstacles to present treatment and discharge planning. There was no anticipated social work role in treatment and discharge planning.

11. Patient A14 was admitted for non-verbal learning deficit, command and auditory hallucinations, and suicidal ideation to the Adult Psychiatric-(McLean South) Unit on 6/29/10. The Psychosocial Assessment completed on 6/30/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to patient's relationship with family, history of educational/employment/legal issues, history of physical, sexual and emotional abuse and psychiatric, medical and substance abuse history. It also did not contain patient strengths and deficits, and high risk psychosocial issues in identifying potential obstacles to present treatment and discharge planning. There was no anticipated social work role in treatment and discharge planning.

12. Patient A15 was admitted for homicidal ideation towards brother via face book and destruction of home property to the Adult Psychiatric-(McLean South) Unit on 7/6/10. The Psychosocial Assessment completed on 7/7/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to patient's relationship with family, history of educational/employment/legal issues, history of physical, sexual and emotional abuse and psychiatric, medical and substance abuse history. It also did not contain patient strengths and deficits, and high risk psychosocial issues in identifying potential obstacles to present treatment and discharge planning. There was no anticipated social work role in treatment and discharge planning.

13. Patient A16 was admitted for social isolation and increased anxiety to the Psychotic Disorders Unit on 7/1/10. The Psychosocial Assessment completed on 7/2/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to history of educational/legal issues/employment. It also did not contain patient strengths and deficits, and high risk psychosocial issues in identifying potential obstacles to present treatment and discharge planning. There was no anticipated social work role in treatment and discharge planning.

14. Patient A17 was admitted for suicidal ideation such as increasing thoughts of harming self to the Admissions unit on 7/7/10. The Psychosocial Assessment completed on 7/8/10 did not contain sufficient information to develop the treatment plan. It lacked information relative to patient's relationship with family educational/legal issues/employment history and psychiatric, medical and substance abuse history. It also did not contain patient strengths and deficits, and high risk psychosocial issues in identifying potential obstacles to present treatment and discharge planning. There was no anticipated social work role in treatment and discharge planning.

B. Staff Interviews

1. The surveyor met with SW #4 regarding Patient A14 on 7/14/10 at 10:30 a.m. in reference to the Psychosocial Assessment. SW #4 stated "I did not complete this assessment and this does not have an individual case management aftercare plan"; "I use another form that does not look like this." She acknowledged the need for a comprehensive psychosocial assessment.

2. The surveyor met with the Director of Social Work on 7/14/10 at 12:35 p.m. in a local conference room. The Director of Social Work acknowledged there were incomplete Psychosocial Assessments on several assessments reviewed ( A2, A3, A4 and A10). She stated "All of this information is not an assessment because social workers utilize the Initial Admission Note by the physician and believe the psychosocial history is written there."

C. Policy Review and Staff Interviews

The surveyor met with the Director of Social Work on 7/14/10 at 12:55 p.m. to review the "Handbook on Social Work-Case Management" dated June 2010. The Director of Social Work acknowledged this was not updated in the Hospital Policy Manual for Social Work. Case Management/Social Work is required to document a Comprehensive Initial Case Management Note/Psychosocial Assessment upon first meeting (usually within 24 hours). As required by their guidelines, the Initial Assessment shall contain at least the following components: Relevant social/historical info; Social Evaluation; and Conclusions and Recommendations for discharge planning needs.

The Director of Social work also acknowledged that her staff did not follow their guidelines and had not identified and addressed discharge planning needs for a complete initial comprehensive psychosocial assessment for sample patients A2, A3, A4, A7, A8, A9, A10, A11, A12, A13, A14, A15, A16, and A17.

Based on a record review and patient and staff interview, the facility failed to complete an adequate and/or complete neurological examination (screening) for 7 of 16 active sample patients (A2, A4, A6, A7, A8, A9, and A12). Failure to perform and record findings from neurological testing could result in lack of identification of treatable conditions and/or inability to document changes from baseline status during patient's hospital stay. This makes it impossible to ascertain progression/worsening of the condition on subsequent re-examination.

Findings include:

A. Record Review

1. A2 was a 22 year old male re-hospitalized within 72 hrs of discharge on 6/30/10. The admission Physical Exam was not completed on 6/30/10 per hospital policy which states it must be completed within 72 hours of re-admission. It referred to the 6/21/10 admission Physical. In the 6/21/10 Physical Exam, the Cranial Nerves I-XII were not examined.

2. A4 was a 48year old male hospitalized on 6/9/10. The patient was referred to the Internal Medicine MD. In the Physical Examination conducted on 7/5/10, the Cranial Nerves were not examined.

3. A6 was an 80 year old female hospitalized on 7/8/10. The admission Physical, conducted by the admitting MD, defers the Physical to be conducted by the Internal Medical MD. The Physical conducted by the Internist on 7/11/10 did not have a recorded neurological examination.

4. A7 was a 66 year old man hospitalized on 6/29/10 with a history of Parkinson Disease. The admission Physical, conducted on 6/29/10 by the admitting Physician defers the Physical to be conducted by the Internal Medicine MD. The Physical conducted by the Internist on 6/28/10 did not have a neurological examination.

5. A9 was a 51 year old female hospitalized on 6/27/10. The patient refused the admission Physical on 6/27/10 and the examination conducted on 6/28/10 by the Internist states, "CN II-XII intact" without documenting the methods used to evaluate Cranial Nerves.

6. A8 was an 80 year old female hospitalized on 6/25/10 for possible Delirium/Dementia. A complete Physical Exam was deferred, to be conducted by the Internist. The Physical Examination conducted on 6/26/10 by the Internist did not include Cranial Nerve examination.

7. A12 was a 49 year old female hospitalized on 6/29/10 with a history of Type II Diabetes and Lumbar-Back pain "shooting down legs." She described the pain as an 8 on a scale of 1 to 10. The Physical Exam was deferred to Internal Medicine on 6/29/10. In the Physical Examination conducted by the Internist on 7/8/10 there was no evidence of a Neurological Examination, including Cranial Nerve testing.

B. Staff Interview

1. In an interview on 7/12/10 at 2:00 p.m. regarding patient A12, RN 7 agreed the neurological examination for the patient was not done.

2. In an interview on 7/14/10 at 1:30 p.m., after reviewing the above sample patients' Physical Exams, the Medical Director agreed that neurological screenings/exams were either inadequate or incomplete.

Based on record review and interview, the facility failed to provide and document a psychiatric evaluation for 5 of 16 active sample patients (A2, A3, A4, A10 and A16) that contained an estimate of intellectual functioning, memory functioning and orientation in a sufficiently descriptive manner to provide an objective baseline for future comparisons.

Findings include:

A. Record Review

1. Patient A2 was a 22 year old male admitted on 6/30/10. The psychiatric evaluation of the same date did not contain memory assessment or an estimation of intellectual functioning.

2. Patient A3 was a 19 year old male admitted 6/24/10. The psychiatric evaluation was completed on 6/24/10 and did not contain an estimation of intellectual functioning or orientation and memory is estimated as "intact" without documentation of appropriate methods applied to evaluate the same.

3. Patient A4 was a 48 year old man admitted on 6/9/10. The psychiatric evaluation was completed on the same day. The mental status examination did not contain an estimate of intellectual functioning or orientation, and "memory is judged to be intact by asking if he had any memory problems" without documenting methods used to evaluate memory functioning.

4. Patient A10 was a 28 year old woman admitted on 7/10/10 whose psychiatric evaluation, completed on the same day, did not contain an estimation of intellectual functioning or orientation or methods applied to evaluate memory functioning other than to state "Memory intact assessed by questioning".

5. Patient A16 was a 41 year old man admitted on 7/1/10. The psychiatric evaluation, completed the same day, did not contain an estimation of intellectual functioning or orientation and no documentation of the methods applied to evaluate memory other than to state "memory and cognition were grossly intact."

B. Interview

In an interview on 7/14/10 at 1:30 p.m., the Medical Director acknowledged that memory, intellectual functioning and orientation assessments for the above sample patients were either lacking or incomplete.

Based on record review and staff interview, the facility failed to provide treatment plans that included specific patient interventions for 16 of 16 active sample patients (A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A13, A14, A15, A16 and A17). Interventions were generic, lacked patient specificity, and consisted of routine discipline practices that were not individualized or focused. These failures resulted in the treatment team members and the patients not having clear direction for providing treatment, which ultimately may impede patients' progress.

Findings include:

A. Record Review

The facility's "Multidisciplinary Treatment Plans" were preprinted forms with check-boxes and no spaces for specific individualized documentation of interventions. Each patient's record had a formatted treatment plan for one of 4 possible disorders; 1) "Bipolar or Psychotic Disorder," 2) "Geriatric/Psychiatric Dementia," 3) "Major Depression," and 4) "Substance Use Disorder." This resulted in treatment interventions being by diagnosis, not based on individual patient assessments.

Review of the "Multidisciplinary Treatment Plan" for patients A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A13, A14, A15, A16 and A17 also revealed boxes checked for generic treatment interventions that consisted mostly of routine clinical practices. (See specific findings below).

1. Patient A2 was admitted on 6/30/10 with a diagnosis of Major Depression. "Multidisciplinary Treatment Plan" interventions dated 7/01/10 stated "Physician provide psychiatric/medical visits daily as needed..., provide case management, daily or as needed..., nursing implement standards of care for depression..."

2. Patient A3 was admitted on 6/24/10 with a diagnosis of Bipolar or Psychotic Disorder. The "Multidisciplinary Treatment Plan" interventions dated 6/25/10 stated "Physician provide psychiatric/medical visits, daily as needed..., provide case management, daily or as needed..., nursing implement standards of care for Bipolar Disorder, Manic, Schizophrenia..."

3. Patient A4 was admitted on 6/9/10 with a diagnosis of Bipolar or Psychotic Disorder. Interventions on the "Multidisciplinary Treatment plan" dated 6/10/10 stated "Physician provide psychiatric/medical visits, daily as needed..., provide case management, daily or as needed..., nursing implement standards of care for Bipolar Disorder, Manic, Schizophrenia..."

4. Patient A5 was admitted on 6/24/10 with a diagnosis of Major Depression. The "Multidisciplinary Treatment Plan" interventions dated 06/25/10 stated "Physician provide psychiatric/medical visits, daily as needed..., provide case management, daily or as needed ...", nursing implement standards of care for depression..."

5. Patient A6 was admitted 7/8/10 with a diagnosis of Recurrent Depression-Severe. She was grieving the recent loss of her husband, exhibiting neuro-vegetative symptoms and was passively suicidal. She was in the process of being medically cleared for ECT. The interventions on the "Multidisciplinary Treatment Plan" were generic and not individualized such as "provide psychiatric/medical visits", "evaluate for and prescribe medication as needed", "implement standards of care for depression" and "provide case management, daily or as needed."

6. Patient A7 was admitted on 6/29/10 with a diagnosis of Dementia and Major Depression. He had been combative at the nursing home and the purpose of hospitalization was to extinguish this behavior and return to the nursing home. He also had Parkinson's, foot drop, and required a walker. The interventions listed on the "Multidisciplinary Treatment Plan" were generic and not individualized for this patient. Examples are: "provide psychiatric/medical visits", "evaluate for and prescribe medications/ECT as needed", "implement appropriate nursing protocols for medications, falls, nutrition, fluid/volume deficits or others", and "provide case management, as needed."

7. Patient A8 was admitted on 6/25/10 with a diagnosis of Dementia and Depression. She has pulmonary fibrosis and is on oxygen. She becomes panicky and confused at night, often screaming. She has a history of falling and is a DNR. Interventions on the "Multidisciplinary Treatment Plan" were generic and not individualized. Examples are: "provide psychiatric/medical visits, daily or as needed", "implement appropriate nursing protocols for medications, falls, nutrition, fluid/volume deficits or others", and "provide case management, as needed."

8. Patient A9 was admitted 6/27/10 with a diagnosis of Schizoaffective Disorder. Symptoms included auditory hallucinations, psychomotor retardation and decreased sleep. Interventions on the "Multidisciplinary Treatment Plan" were generic and not individualized for this patient. Examples are: "provide psychiatric/medical visits, daily or as needed", "evaluate for and prescribe medications as needed" and "provide case management, daily or as needed."


9. Patient A10 was admitted 7/10/10 with a diagnosis of Opiate Dependence, PTSD by history and Major Depression. Patient was undergoing detoxification and grieving over her father's death. Interventions on the "Multidisciplinary Treatment Plan" were generic and not specific to this patient. Examples are: "provide psychiatric/medical visits, daily or as needed", "implement appropriate nursing protocols for medications, detoxification, risk of self harm, sleep disturbance or others", and "provide case management, daily or as needed."

10. Patient A11 was admitted on 7/8/10 with a diagnosis of Ethanol Dependence and Major Depression. The "Multidisciplinary Treatment Plan" interventions dated 7/08/10 stated "Physician provide psychiatric/medical visits, daily as needed...," "educate about risks/benefits of meds...", "provide case management, daily or as needed...", and "nursing implement standards of care for substance dependence/abuse..."

11. Patient A12 was admitted on 6/29/10 with a diagnosis of Schizoaffective Disorder. She was depressed and had suicidal ideation, back pain shooting down her legs, and Type II Diabetes. Interventions on the "Multidisciplinary Treatment Plan" were generic and not individualized for this patient. Examples include: "provide psychiatric/medical visits as needed", "implement appropriate nursing protocols for medications, risk of self harm, sleep disturbance, detoxification, nutrition or others", and "provide case management, daily or as needed."

12. Patient A13 was admitted on 6/24/10 with a diagnosis of Major Depression-Bipolar Disorder. Patient presented with plan to kill herself by overdosing or driving her car into a tree. The "Multidisciplinary Treatment Plan" interventions dated 6/25/10 stated "Physician provide psychiatric/medical visits, daily as needed...", "educate about risks/benefits of meds...", "provide case management, daily or as needed..." and "...nursing implement standards of care for depression..."

13. Patient A14 was admitted on 6/29/10 with a diagnosis of Schizoaffective Disorder. The patient presented with command and visual hallucinations. The "Multidisciplinary Treatment Plan" interventions dated 6/25/10 stated "Physician provide psychiatric/medical visits, daily as needed...", "educate about risks/benefits of meds...", "provide case management, daily or as needed..." and "...provide, on a 24 hour basis, assessment/monitoring of mental status, safety, activity..."

14. Patient A15 was admitted on 7/6/10 with a diagnosis of Bipolar I Disorder. He came to the hospital because he was threatening to kill his brother and was damaging property. Interventions on the "Multidisciplinary Treatment Plan" were generic and not individualized for this patient. Examples include: "provide psychiatric/medical visits as needed", "implement standards of care for Bipolar Disorder, Manic, Schizophrenia" and "case management daily, or as needed."

15. Patient A16 was admitted on 7/01/10 with a diagnosis of Depressive Disorder NOS. The "Multidisciplinary Treatment Plan" interventions dated 7/02/10 stated "Physician provide psychiatric/medical visits, daily as needed...", "educate about risks/benefits of meds...", "provide case management, daily or as needed..." and "...provide, on a 24 hour basis, assessment/monitoring of mental status, safety, activity..."

16. Patient A17 was admitted on 7/07/10 with a diagnosis of Obsessive Compulsive Disorder. The "Multidisciplinary Treatment Plan" interventions dated 7/02/10 stated "Physician provide psychiatric/medical visits, daily as needed...", "educate about risks/benefits of meds...", "provide case management, daily or as needed..." and "....provide, on a 24 hour basis, assessment/monitoring of mental status, safety, activity..."

B. Staff Interviews

Interviews with the Chief Quality Officer and Vice President of Nursing on 7/13/10 at 11:30 a.m. and on 7/14/10, at 9:05 a.m., confirmed that treatment plan methodologies and interventions were not specific to individual patient needs.

Based on record review and interview, the Clinical Director (Medical Director) failed to assure that:

I. Neurological screenings/examinations were conducted and documented for 7 of 16 active sample patients (A2, A4, A6, A7, A9, A8, and A12). Failure to conduct and document neurological findings can limit the clinician's ability to accurately diagnose the patient's condition, thereby potentially adversely affecting patient care. (Refer to B109)

II. Intellectual functioning, memory and orientation were adequately evaluated for 5 of 16 active sample patients (A2, A3, A4, A10 and A16). Failure to evaluate and document these functions may result in failure to identify organic conditions that may impact treatment. It also results in lack of an objective baseline for future comparisons. (Refer to B116)

III. Master Treatment Plans included specific patient interventions for 16 of 16 active sample patients (A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A13, A14, A15, A16 and A17). Interventions were generic, lacked patient specificity, and consisted of routine discipline practices that were not individualized or focused. These failures resulted in the treatment team members and the patients not having clear direction for providing treatment, which ultimately may impede patients' progress.

Based on record review and interview, the Director of Social Services failed to assure that psychosocial assessments included an evaluation of high risk psychosocial issues requiring early treatment planning and intervention; and conclusions and recommendations related to anticipated steps for discharge for 14 of 16 active sample patients (A2, A3, A4, A7, A8, A9, A10, A11, A12, A13, A14, A15, A16 and A17). The Director failed to monitor and evaluate the quality and appropriateness of these assessments completed by the staff. These failures potentially result in lack of professional social work treatment services. In addition, the treatment team may fail to identify/address important treatment issues and discharge planning needs. (Refer to B108)