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Based on record review, staff interview and review of hospital policies, the hospital failed to ensure that patient records included documentation that described patient response to mental health treatments for 2 of 2 patients reviewed who received mental health care from the county mental health service (Patients #1 and #3).

Failure to promptly document in the patient record the patient's response to mental health treatments and interventions impeded hospital staff's ability to accurately assess and formulate effective care plan interventions to maximize the patients' mental well-being.

Findings:
Patient #1 was admitted to a long term care swing bed in the critical access hospital on 6/12/2014 with diagnoses including chronic paranoid schizophrenia and mood swings with possible bi-polar components.

Review of the care plan dated 8/13/2015 identified problems of socially inappropriate behaviors that included a history of striking out toward staff and other residents, agitation and aggressiveness. Staff interview and the care plan revealed that the patient went to the local county mental health office at least once a week for a planned activity with the case worker, and frequently visited the mental health office to play games such as pool and foosball.

A Safety Plan developed as part of the patient's care plan identified that local county mental health professionals conducted a behavior assessment on 9/3/2015 following an incident of inappropriate behavior and physical contact with another resident, and verbally threatening a staff member.

As of the date of this investigation (9/22/2015), there was no documentation in the patient's record of the mental health assessment completed on 9/3/2015 or documentation of any of the mental health interventions or recommendations provided by the county mental health professionals who treated the patient. Staff interview on 9/22-23/2015 revealed that other health care providers in the community who provided services to patients routinely submitted a brief report of patient response to their treatments or interventions that were included in the patient record, but the county mental health had not provided a report of patient response to mental health interventions or treatments.

A similar finding was identified for Patient #3 who had requested and received mental health care for depression.

Mental health staff did not attend or participate with hospital staff to formulate hospital patient care plans. There was no documentation of the patients' response to mental health activities or interventions for hospital staff to review as part of the patients' comprehensive assessment and care planning processes. Mental health information, important in the care of the residents, was not available in the patients' records.
Review of hospital policies and staff interview revealed there was no hospital policy requiring outside providers to submit documentation of a patient ' s response to interventions or treatments.
The hospital had no policy to ensure that patient response to interventions and treatments from providers outside the hospital was documented and submitted to the patient record and as part of a comprehensive assessment and care plan to maximize a patient ' s physical, mental and spiritual status.