HospitalInspections.org

Based on record review, policy review, observation and interview the facility failed to:

1. Consistently provide Medical/Psychiatrist attendance at treatment planning meetings. This practice has the potential to have patient care not being under the direction of a physician and potentially compromise a patient's medical and psychiatric care. (Refer to B118).

2. Assess memory functioning for five (5) of 10 sample patients with diagnoses of Dementia in a sufficiently descriptive manner. This failure makes it impossible to establish baseline functioning for future comparisons. (Refer to B116).

3. To insure the Master Treatment Plans (MTP) for seven (7) of 10 sample patients included a substantiate diagnosis- This failure has the potential to compromise the treatment team's ability to identify specific Psychiatric and Physical problems to be addressed during current hospitalization. (Refer to B120).

4. To insure the Master Treatment Plans for 10 of 10 sample patients had patient-related short term and long term goals in observable, measurable and behavioral terms. This failure hinders the ability of the team to measure change in the patient as a result of treatment interventions and the potential to address patient's needs at or after discharge. (Refer to B121).

5. To develop specific treatment interventions based on individual needs of the patients for 10 of 10 active sample patients- This deficiency results in failure to guide staff in providing focused treatment and consistent approaches to patient's identified problems. (Refer to B122).

Based on record review, staff interview and patient interview the facility failed to assess and estimate memory functioning in a sufficiently descriptive manner to establish baseline parameters for five (5) of 10 active sample patients with a diagnosis of Dementia. This failure makes it impossible to establish objective baseline functioning for future comparisons and follow changes to adjust treatments as appropriate.

Findings include:

Record review:

1. Patient A1 was hospitalized on 1/31/15. Psychiatric Evaluation of 1/31/15 lists patient's diagnosis on Axis I: "Alzheimer's Dementia with Psychosis". The mental status examination and the memory estimation in the same document states "Short-term and long-term memory appears impaired".

2. Patient A5 was hospitalized on 01/28/15. Psychiatric Evaluation of 01/28/15 lists patient's diagnosis on Axis I: "Dementia with Psychosis, Likely residual encephalopathy". The mental status evaluation and the memory estimation in the same document states "poor insight, judgment, impulse control, safety awareness, abstraction, memory and orientation".

3. Patient A7 was hospitalized on 01/22/15. Psychiatric Evaluation of 01/22/15 lists patient's diagnosis on Axis I: "Dementia with Psychosis and Behavioral disturbance". The mental status evaluation and the memory estimation in the same document states "poor insight, judgment, impulse control, safety awareness, abstraction, memory and orientation".

4. Patient A9 was hospitalized on 01/27/15. Psychiatric Evaluation of 01/28/15 lists patient's diagnosis on Axis I: "Dementia with Behavioral disturbances". The mental status evaluation and the memory estimation in the same document states "poor insight, judgment, impulse control, safety awareness, abstraction, memory and orientation".

5. Patient A10 was hospitalized on 01/29/15. Psychiatric Evaluation of 01/30/15 lists patient's diagnosis on Axis I: "Dementia with Behavioral disturbances". The mental status evaluation and the memory estimation in the same document states "poor insight, judgment, impulse control, safety awareness, abstraction, memory and orientation".

Patient interview:

In a meeting with the patient A7 on 2/2/15 at 10:45 AM, the patient was not sure how long he/she was in the hospital or reasons for his/her hospitalization or today's day/date/year.

Staff interview:

In a meeting and review with the acting Medical Director on 2/3/15 at 9:15 AM, the acting Medical Director concurred with the finding that the memory estimation was lacking in specificity and without supporting information.

Based on observation, interview, and record review this facility failed to consistently provide Medical/Psychiatrist attendance at treatment planning meetings. This practice has the potential to have patient care not under the direction of a physician and potentially compromise a patient's medical and psychiatric care.

Findings include:

A. Observations

1. On 2/2/15 at 11:00 AM, a Treatment Team Meeting was observed on the Adult Unit. The surveyor attended the meeting from 11:15 AM-12:10 PM. There was no physician present for the Treatment Team Meeting.

2. On 2/3/15 at 9:00 AM, a Treatment Team Meeting was observed on the Adult Unit. The surveyor attended the meeting from 9:00 AM-11:00 AM. There was no physician present for the Treatment Team Meeting.

B. Interview

1. During an interview on 2/3/15 at 1:00 PM with the Director of Social Service stated that the Physicians attend Treatment Plan meetings "sporadically".

Based on record review and interview, the facility failed to insure that the Master Treatment Plans (MTP's) of seven (7) of 10 active sample patients (A1, A2, A3, A4, A5, A8 and A10) included substantiated diagnoses. Absence of substantiated diagnoses on patients' Master Treatment Plans compromises the ability of the treatment team to identify specific psychiatric and physical problems and plan effective treatment during the current hospitalization.

Findings include:

A. Record Review

Seven (7) (A1 dated 2/1/15, A2 dated 1/30/15, A3 dated 1/30/15, A4 dated 1/31/15, A5 dated 1/29/15, A6 dated 5/6/15, A8 dated 1/30/15 and A10 dated1/31/15) of 10 active sample patients' Master Treatment Plans failed to include substantiated diagnoses.

B. Interview

On 2/2/15 at 2:45 PM, the Senior Vice President, Clinical Operations acknowledged that diagnoses were not included in patients' Master Treatment Plans.

Based on record review, policy review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short-term goals [STG] and long-term goals [LTG] stated in observable, measurable, behavioral terms for 10 of 10 active patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10). Lack of measurable, patient specific STG hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs. Lack of LTG leaves the potential for the treatment team to fail to address patient's needs at or after discharge.

Findings Include:

A. Medical Record Review

1. Patient A1 admitted 1/31/15 with a diagnosis of Alzheimer's Dementia with Psychosis had listed on MTP dated 2/1/15 for the problem, "Agitation", the following STG: "Patient will make needs known in an appropriate manner daily for LOS [length of stay] with staff assistance." No long term goals were addressed.

2. Patient A2 admitted 1/28/15 with a diagnosis of "Schizophrenia and Alcohol Dependence" had listed on MTP dated 1/30/15 for the problem, "Agitation", the following STG: "Patient will accept care and treatment with a decrease in symptoms within three (3) days and maintain for LOS [length of stay]." No long term goals were addressed.

3. Patient A3 admitted 1/29/15 with a diagnosis of "Psychotic Disorder, not otherwise specified and likely Schizophrenia" had listed on MTP dated 1/30/15 for the problem, "Agitation", the following STG: "Patient will accept care and treatment with a decrease in symptoms within three (3) days and maintain for LOS [length of stay]." No long term goals were addressed.

4. Patient A4 admitted 1/30/15 with a diagnosis of "Bipolar I most recently with psychosis" had listed on the MTP dated 1/31/15 for the problem, "Agitation", the following STG: "Patient will demonstrate a decrease in her symptoms of agitation daily for LOS [length of stay]." No long term goals were addressed.

5. Patient A5 admitted on 1/28/15 with diagnosis of "Dementia with Psychosis likely residual encephalopathy" had listed on the MTP review dated 1/29/15 for the problem, "Agitation", the following STG "Patient will accept care and treatment with a decrease in symptoms within three (3) days and maintain for LOS [length of stay]." No long term goals were addressed.

6. Patient A6 admitted on 1/28/15 with a diagnosis of "Schizoaffective Disorder" had listed on the MTP dated 2/2/15 for the problem, "Agitation AEB [as evidenced by] loud, disruptive and intrusive behaviors, pacing, poor response to limit setting and redirection", the following STG: "Patient will accept care and treatment with a decrease in symptoms within three (3) days and maintain for LOS [length of stay]." No long term goals were addressed.

7. Patient A7 admitted on 1/22/15 with a diagnosis of "Dementia with psychosis and behavioral disturbance" had listed on the MTP dated 1/29/15 for the problem, "Agitation", the following STG "Patient will accept care and treatment with a decrease in symptoms within three (3) days and maintain for LOS [length of stay]." No long term goals were addressed.

8. Patient A8 was admitted on 1/29/15 with a diagnosis of "Major depressive disorder, recurrent and severe without psychotic features, Opiate Dependence, and Benzodiazepine Dependence" had listed on the MTP dated 1/30/15 for the problem, "Depressed mood AEB [as evidenced by] the patient has been crying, stating that she feels hopeless" and, the following STG: "The patient will report and demonstrate a decrease in her depressive symptoms daily for LOS [length of stay]." No long term goals were addressed.

9. Patient A9 was admitted on 1/27/15 with diagnosis of "Dementia with behavioral disturbance" had listed on MTP dated 1/28/15 for problem, "Agitation" and the following STG: "Patient will demonstrate a decrease in her symptoms of agitation for LOS [length of stay]" No long term goals were addressed.

10. Patient A10 was admitted on 1/29/15 with diagnosis of "Dementia with behavioral disturbances" had listed on MTP for Problem, "Agitation" and the following STG: "Patient will demonstrate a decrease in symptoms of agitation daily for LOS [Length of stay]" No long term goals were addressed.

B. Policy Review

1. Clinical staff failed to follow their own facility policy titled, "Treatment Plan" dated 9/24/14. This policy stipulated that, "The MTP [Master Treatment Plan] formulation will include at least will include at least the following information: ....identified problem(s), short and long-term goals, interventions, responsible clinical staff. Identify, at minimum, one (1) psychiatric problem...Each active problem will have individual measurable goals and interventions".

C. Interview

1. In interview on 2/4/15 at 10:00 AM, the Director of Nursing, Director of Social Work, and Senior Vice President, Clinical Operations acknowledged that the goals listed on the treatment plans for the sample patients were neither observable nor measurable.

Based on record review, policy review and interview, the facility failed to identify in the MTP focused treatment interventions/modalities to address identified patient problems and goals for 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10). The treatment interventions were stated in vague terms and were non-individualized generic discipline functions rather than directed at specific interventions. In addition, duration, frequency and scheduled times of interventions were not specified. This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients.

Findings Include:

A. Medical Record Review

1. Patient A1 admitted 1/31/15 with a diagnosis of Alzheimer's Dementia with Psychosis had listed on MTP [Master Treatment Plan] dated 2/1/15 for the problem, "Agitation", the following Short-Term Goal [STG]: "Patient will make needs known in an appropriate manner daily for LOS [length of stay] with staff assistance." No evidence of interventions related to the diagnosis of Dementia listed.

Treatment interventions listed were: "Medicate patient as ordered and report adverse side effects to MD and assist patient with discharge planning and offer community referrals, as needed."

2. Patient A2 admitted 1/28/15 with a diagnosis of "Schizophrenia and Alcohol Dependence" had listed on MTP dated 1/30/15 for the problem, "Agitation", the following STG: "Patient will accept care and treatment with a decrease in symptoms within three (3) days and maintain for LOS [length of stay]."

Treatment interventions listed were: "Medicate patient as ordered and report adverse side effects to MD and assist patient with discharge planning and offer community referrals, as needed."

3. Patient A3 admitted 1/29/15 with a diagnosis of "Psychotic Disorder, not otherwise specified and likely Schizophrenia" had listed on MTP dated 1/30/15 for the problem, "Agitation", the following STG: "Patient will accept care and treatment with a decrease in symptoms within three (3) days and maintain for LOS [length of stay]." The Psychiatric evaluation of 1/30/15 states "making accusations and increasingly paranoid" Mental status evaluation: "present delusion thinking"- No evidence of delusions being identified as a problem or interventions listed for the same.

Treatment interventions listed were: "Medicate patient as ordered and report adverse side effects to MD and assist patient with discharge planning and offer community referrals, as needed."

4. Patient A4 admitted 1/30/15 with a diagnosis of "Bipolar I most recently with psychosis" had listed on the MTP dated 1/31/15 for the problem, "Agitation", the following STG: "Patient will demonstrate a decrease in her symptoms of agitation daily for LOS [length of stay]."

Treatment interventions listed were: "Medicate patient as ordered and report adverse side effects to MD and assist patient with discharge planning and offer community referrals, as needed."

5. Patient A5 admitted on 1/28/15 with diagnosis of "Dementia with Psychosis likely residual encephalopathy" had listed on the MTP review dated 1/29/15 for the problem, "Agitation", the following STG "Patient will accept care and treatment with a decrease in symptoms within three (3) days and maintain for LOS [length of stay]." For the problem of "Confusion", Patient will accept care and treatment with a decrease in symptoms within three (3) days of LOS- No evidence of interventions specific to the diagnosis of Dementia listed.

Treatment interventions listed were: "Medicate patient as ordered and report adverse side effects to MD and assist patient with discharge planning and offer community referrals, as needed" and Provide reassurance at times of increased symptoms and frequent 1:1 contact to establish rapport and trust."

6. Patient A6 admitted on 1/28/15 with a diagnosis of "Schizoaffective Disorder" had listed on the MTP dated 2/2/15 for the problem, "Agitation AEB [as evidenced by] loud, disruptive and intrusive behaviors, pacing, poor response to limit setting and redirection", the following STG: "Patient will accept care and treatment with a decrease in symptoms within three (3) days and maintain for LOS [length of stay]."

Treatment interventions listed were: "Medicate patient as ordered and report adverse side effects to MD and assist patient with discharge planning and offer community referrals, as needed."

7. Patient A7 admitted on 1/22/15 with a diagnosis of "Dementia with psychosis and behavioral disturbance" had listed on the MTP dated 1/29/15 for the problems, "Agitation" and aggressive Behavior", the following STG "Patient will accept care and treatment with a decrease in symptoms within three (3) days and maintain for LOS [length of stay]." The Physicians progress notes dated 1/25/15, 1/26/15 and 1/27/15 states "The patient is endorsing auditory hallucinations", "need further hospitalization due to active psychosis"- No evidence of problems of Dementia and Psychosis identified or interventions specific to Dementia or Psychosis listed.

Treatment interventions listed were: "Medicate patient as ordered and report adverse side effects to MD and assist patient with discharge planning and offer community referrals, as needed."

8. Patient A8 was admitted on 1/29/15 with a diagnosis of "Major depressive disorder, recurrent and severe without psychotic features, Opiate Dependence, and Benzodiazepine Dependence" had listed on the MTP dated 1/30/15 for the problem, "Depressed mood AEB [as evidenced by] the patient has been crying, stating that she feels hopeless" and the following STG: "The patient will report and demonstrate a decrease in her depressive symptoms daily for LOS [length of stay]." No evidence of Problems and interventions related to Opiate and Benzodiazepine dependence listed.

Treatment interventions listed were: "Medicate patient as ordered and report adverse side effects to MD and assist patient with discharge planning and offer community referrals, as needed."

9. Patient A9 was admitted on 1/27/15 with a diagnosis of "Dementia with behavioral disturbance" had listed on MTP dated 1/28/15 for problem, "Agitation", the following STG: Patient will demonstrate a decrease in her symptoms of agitation for LOS for "Aggressive behavior" STG: "Patient will exhibit no further physically aggressive behaviors for LOS"- No evidence of Problems and interventions specific to Dementia were listed.

Treatment interventions listed were: "Medicate patient as ordered and report adverse side effects to MD."

10. Patient A10 was admitted on 1/29/15 with a diagnosis of "Dementia with behavioral disturbances" had listed on MTP dated 1/31/15 for problem "Agitation", the following STG: "Patient will demonstrate a decrease in symptoms of agitation daily for LOS" and for "Aggressive Behavior"- "Patient will exhibit no further physically aggressive behavior daily for LOS"- No evidence of Problems and interventions specific to Dementia were listed.

Treatment interventions listed were: "Medicate patient as ordered and report adverse side effects to MD."

B. Policy Review

1. Clinical staff failed to follow their own facility policy titled, "Individual Treatment Plan" dated 9/24/14. This policy stipulated that, "The MTP [Master Treatment Plan] formulation will include at least will include at least the following information: ....identified problem(s), at minimum, short and long-term goals, interventions, responsible clinical staff. Identify, at minimum, one (1) psychiatric problem...Each active problem will have individual measurable goals and interventions"

C. Interview

1. In interview on 2/4/15 at 10:00 AM, the Director of Nursing, Director of Social Work, and Senior Vice President, Clinical operations acknowledged that the interventions listed on the treatment plans for the sample patients were vague, generic routine discipline functions and were not individualized to the patients' needs.

The Clinical Director failed to adequately monitor and evaluate the quality of care provided to patients at the facility. Specifically, the Clinical Director failed to ensure that:

(A) The Medical/Psychiatrists were consistently present at the treatment plan meetings. (Refer to B118).

(B) Assessment and estimation of memory functioning was documented in a sufficiently descriptive manner to allow for future comparisons, especially for patients with a diagnosis of dementia. (Refer to B116).

(C) The Master Treatment Plans included substantiated diagnoses. (Refer to B120).

(D) The Master Treatment Plans include short-term and long-term goals per hospital policy. (Refer toB121).

(E) The facility provided focused, patient specific treatment interventions for identified patient specific problems and goals. (Refer to B122).

In an interview with the Clinical Director on 2/3/15 at 9:15 AM, the Clinical Director concurred with the above deficiencies.

Based on record review and interview, the Nursing Director failed to ensure that nursing staff developed interventions on the Master Treatment plans that addressed the individual needs for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The Master Treatment Plans included written interventions which were routine, generic discipline functions that lacked focus for treatment and interventions, in addition, duration and scheduled times of interventions were not specified. These failures resulted in treatment plans that did not reflect comprehensive, integrated, individualized approach to multidisciplinary treatment. Instead, many interventions were routine, generic discipline functions that would be provided for any patient regardless of specific goals and needs. This deficiency resulted in treatment plans that did not reflect comprehensive, integrated individualized approach to patient care (see B120, B121, and B122).