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Based on record reviews and interview, the hospital failed to adequately perform and document the required screening neurological examination for 8 of 10 active sample patients (A2, A3, A4, A5, A6, A7, A8 and A9). This omission could result in the failure of staff to be aware of, monitor, and treat medical conditions, leading to inaccurate treatment and/or harm to patient health. Incomplete neurological exams also can result in patients not receiving adequate care for primary neurological illnesses or for secondary medical and/or psychiatric problems.

Findings include:

A. Record Review

1. Patient A2 was admitted on 12/02/2008. In the history and physical examination done on 03/03/2010, the Nervous System examination stated "Resting Tremor, Bradykinesia." The facility did not document a descriptive neurological examination indicating what tests were performed to assess neurological functioning.

2. Patient A3 was admitted on 07/11/2009. In the history and physical examination done on 07/14/2010, the Nervous System examinations stated "Mildly Parkinsonism." The facility did not document a descriptive neurological examination.

3. Patient A4 was admitted on 07/24/2002. In the history and physical examination done on 01/15/2010, the Nervous System examination stated "No neurological deficit." The facility did not document a descriptive neurological examination indicating what tests were performed to assess neurological functioning.

4. Patient A5 was admitted on 05/13/1999. In the history and physical examination done on 01/25/2010, the Nervous System examination was checked as "Normal." The facility did not document a descriptive neurological examination indicating what tests were performed to assess neurological functioning.

5. Patient A6 was admitted on 09/08/2010. In the history and physical examination done on 09/08/2010, the Nervous System examination was checked as "Intact." The facility did not document a descriptive neurological examination indicating what tests were performed to assess neurological functioning.

6. Patient A7 was admitted on 08/25/2010. In the history and physical examination done on 08/25/2010, the Nervous System examination was checked as "Grossly Intact." The facility did not document a descriptive neurological examination indicating what tests were performed to assess neurological functioning.

7. Patient A8 was admitted on 08/18/2010. In the history and physical examination done on 08/18/2010, the Nervous System examination was checked as "Alert and Oriented Times 3." The facility did not document a descriptive neurological examination indicating what tests were performed to assess neurological functioning.

8. Patient A9 was admitted on 01/12/2009. In the history and physical examination done on 03/16/2010, the Nervous System examination was checked as "Normal." The facility did not document a descriptive neurological examination indicating what tests were performed to assess neurological functioning.

B. Interview

In an interview on 09/14/2010 at 2:00PM, the Medical Director acknowledged that the history and physical examinations of the sample patients did not include descriptive screening neurological examinations.

Based on record review and interview, it was determined that the hospital failed to perform and document with supportive information a psychiatric evaluation that included a medical history for10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10). Failure to perform and document a medical history compromises the identification of pathology that may contribute to the current mental illness; it also hampers staff's ability to do future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

A. Record Review

1. Patient A1 was admitted on 12/15/2009. The psychiatric evaluation done on 01/12/2010 did not document a medical history.

2. Patient A2 was admitted on 12/02/2010. The psychiatric evaluation done on 01/28/2010 did not document a medical history.

3. Patient A3 was admitted on 07/11/2009. The psychiatric evaluation done on 01/22/2010 did not document a medical history.

4. Patient A4 was admitted on 07/04/2002. The psychiatric evaluation done on 08/08/2010 did not document a medical history.

5. Patient A5 was admitted on 05/13/1999. The psychiatric evaluation done on 08/08/2010 did not document a medical history.

6. Patient A6 was admitted on 09/08/2010. The psychiatric evaluation done on 09/08/2010 did not document a medical history.

7. Patient A7 was admitted on 08/25/2010. The psychiatric evaluation done on 08/26/2010 did not document a medical history.

8. Patient A8 was admitted on 08/18/2010. The psychiatric evaluation done on 08/18/2010 did not document a medical history.

9. Patient A9 was admitted on 01/12/2009. The psychiatric evaluation done on 01/08/2010 did not document a medical history.

10. Patient A10 was admitted on 12/01/2006. The psychiatric evaluation done on 08/08/2010 did not document a medical history.

B. Interview

1. In a treatment team meeting on 09/14/2010 at 10:15AM, both the Medical Director of the hospital and Physician #1 stated that they do not document a medical history in the psychiatric evaluations, but that only the abnormal laboratories values are documented if they are available.

2. In an interview on 09/14/2010 at 2:00PM, the Medical Director acknowledged that the psychiatric evaluations did not contain a medical history.

Based on record review and interviews, it was determined that the Medical Director failed to assure that:

I. Physicians adequately performed and documented the required neurological screening examinations for 8 of 10 active sample patients (A2, A3, A4, A5, A6, A7, A8, and A9). This omission could result in the failure of staff to be aware of, monitor, and treat medical conditions, leading to inaccurate treatment and/or harm to patient health. Incomplete neurological exams also can result in patients not receiving adequate care for primary neurological illnesses or for secondary medical and/or psychiatric problems. (Refer to B109)

II. Physicians performed and documented with supportive information a psychiatric evaluation that included a medical history for10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10). Failure to perform and document a medical history compromises the identification of pathology that may contribute to the current mental illness; it also hampers staff's ability to do future comparative re-examinations to assess patient's response to treatment interventions. (Refer to B112)
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