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Based on record review and staff interview, the facility failed to document a descriptive neurological screening examination, indicating what tests were performed and the results of the testing for 8 of 8 active sample patients (A30, B2, C6, D1, E12, F2, G2 and H2). The absence of neurological screening compromises the treatment team's ability to plan effective interventions and determine changes in the patient's condition in response to treatment interventions.

Findings include:

A. Record Review

Review of the sample patients' physical exams revealed the following:

1. The physical exam (PE) for patient A30 stated "CNS exam is normal."

2. The physical exam (PE) for patient B2 stated "Cranial nerves are grossly intact. Motor and sensory intact....Gate [sic] is fairly stable."

3. The physical exam (PE) for patient C6 stated "Cranial nerves intact. Motor and sensory [sic] grossly intact."

4. The physical exam (PE) for patient D1 stated "Cranial nerves II-XII grossly intact. Motor and sensory [sic] intact."

5. The physical exam (PE) for patient E12 stated "Cranial nerves II-XII appear intact."

6. The physical exam (PE) for patient F2 stated "Cranial nerves II-XII are intact."

7. The physical exam (PE) for patient G2 stated "No motor deficits present. No cranial nerve abnormality noted."

8. The physical exam (PE) for patient H2 stated "Cranial nerves are intact. Motor and sensory grossly intact."

B. Staff Interviews

In an interview on 8/24/10 at 9:00AM, when queried about documentation of a descriptive neurological screening exam in the PE, Physician P1 (Acting Medical Director) stated "It's not being done."

Based on record review, policy review and interview, the facility failed to ensure that 1 of 8 active sample patients (E12) received a psychiatric evaluation. This failed practice can result in compromised treatment.

Findings include:

A. Record Review

The psychiatric evaluation for Patient E12, dictated 8/07/10, states the following on page 2 under the "Mental status exam": "[Patient E12] speaks Russian and I cannot understand her without an interpreter."

B. Policy Review

The facility's Policy and Procedure No. RI 100.116 states on page 1: "1. ...Qualified interpreters must be used in the following situations: a. taking histories...d. psychiatric evaluation and treatment."

C. Staff Interviews

In an interview on 8/24/10 at 9:00AM, Physician P1 (Acting Medical Director) stated "We use staff and can get translation services."

Based on record review and staff interview, the facility failed to provide and document that a psychiatric evaluation (PE) was completed and in the medical record within 24 hours for 1 of 8 active sample patients (A30). This deficiency results in the lack of psychiatric assessment, formulation, and diagnoses that can inform the treatment team and be utilized in development of a treatment plan.

Findings include:

A. Record Review

Patient A30 was admitted on 7/31/10. The Initial Psychiatric Assessment (IPA) was dictated and transcribed on 8/6/10.

B. Staff Interview

In an interview on 8/25/10 at 9:30AM, when queried regarding the delayed psychiatric evaluation for Patient A30, Physician P4 stated "I don't remember. I follow her in my office."

Based on record review and staff interview, the hospital failed to provide psychiatric evaluations that contained a mental status examination (MSE) with measurable estimates of: (1) intellectual functioning for 6 of 8 active sample patients (A30, D1, E12, F2, G2 and H2); (2) memory functioning for 4 of 8 active sample patients (A30, E12, F2 and G2); and (3) orientation for 3 of 8 active sample patients (B2, F2 and G2). This failed practice hampers the treatment team's ability to accurately understand the patient's condition, formulate treatment plans, and determine changes in the patient's condition in response to treatment interventions.

Findings include:

A. Record reviews:

1. Intellectual Functioning

a. Patient A30's physical examination (PE) stated "Intellect and judgment are okay."

b. Patient D1's PE stated "His cognitive abilities appeared to be intact."

c. Patient E12's PE stated "Insight, judgment, reasoning, executive functioning also impaired."

d. Patient F2's PE stated "Thought process logical and sequential...Insight and judgment is limited."

e. Patient G2's PE stated "Intellect average but the patient is very impulsive."

f. Patient H2's PE stated, "Insight and judgment were poor."

2. Memory Functioning

a. Patient A30's physical examination (PE) stated, "Memory is intact."

b. Patient E12's PE stated, "Memory and concentration impaired."

c. The PE's for patients F2 and G2 did not contain an estimate or description of memory functioning.

3. Orientation

a. The PE's for patients B2 and F2 stated "...oriented X2."

b. There was no description of the level of orientation in Patient G2's PE.

B. Staff interviews

In an interview on 8/24/10 at 9:00a.m., physician P1 (who was Acting Medical Director) acknowledged that compliance is incomplete.

Based on record review and interview, the facility failed to insure that treatment plans included substantiated diagnoses based on input from the treatment team for 8 of 8 active sample patients (A30, B2, C6, D1, E12, F2, G2 and H2). This practice compromises the staff's ability to deliver clinically focused treatment.

Findings include:

A. Record review

A review of the following sample patients' treatment plans (dates of plans in parentheses) revealed no substantiated diagnoses, based on input from the treatment team members for use in treatment planning: A30 (8/1/10), B2 (8/23/10) C6 (8/11/10), D1 (8/22/10), E12 (8/6/10), F2 (7/1/10), G2 (8/19/10) and H2 (8/17/10).

B. Staff Interviews

1. In an interview on 8/23/10 at 2:34AM, Physician P3 stated "We have mostly problems in the treatment plan. It's [the treatment plan] problem oriented."

2. In an interview on 8/24/10 at 9:00AM, Physician P1 (who was Acting Medical Director) stated "Most treatment plans have problems listed."

Based on record review, policy review and staff interviews, the facility failed to include the names of staff responsible for interventions/modalities on the Master Treatment Plans of 8 of 8 active sample patients (A30, B2, C6, D1, E12, F2, G2 and H2). This practice impairs the facility's ability to monitor accountability for specific treatment modalities.

Findings include:

A. Record Review

Review of the following patient's Master Treatment Plans (dates of plans in parentheses) revealed that the staff persons responsible for interventions were not listed on the plans: A30 (8/1/10); B2 (8/23/10); C6 (8/11/10); D1(8/22/10); E12 (8/9/10); F2(6/30/10); G8/19/10); and H2 (8/17/10). Instead of staff names, the treatment plans only listed the disciplines: MD, RN, MHC, CM [Case Manager], ET staff [sic], and PCT [sic]

B. Policy Review

The facility's Policy Number PC 1200.001c states the following: "Interventions for appropriate disciplines will be included for each problem. The intervention includes...responsible staff...[And] the discipline of the specific staff members responsible for the provision of the intervention."

C. Staff interviews

1. In an interview on 8/24/10 at 9:00AM, Physician P1 (Acting Medical Director) acknowledged that a specific staff member was not named for interventions on the sample patients' treatment plans. Physician P1 also stated "I don't see how a single person could be responsible" seven days a week.

2. In an interview on 8/24/10 at 11:35AM, RN P6 stated "People responsible for interventions are not listed by name, only discipline."

3. In an interview with R.N., P2 conducted on 8/24/10 at 3:50 PM, RN P2 stated "The names of individual's responsible for interventions are not on the MTP's."

4. In an interview on 8/25/10 at 9:30AM, the Director of Nursing stated "The MTP does not have the names of disciplines responsible for the interventions listed. The reason that discipline only is listed is in preparation for putting the MTP's on Meditech."

Based on document review and medical record review, the facility failed to ensure that 3 of 5 sample discharge records (S1, S2 and S4) contained complete discharge summaries. This failure compromises the effective transfer of information obtained during hospitalization to the next care provider, potentially resulting in ineffective follow-up care for patients.

Findings include:

A. Document Review

The facility's "Medical Staff Rules and Regulations," page 10, Appendix III, Section V, Paragraph A. states "The discharge summary is to be entered in the patient's record within 30 days following discharge. No medical record shall be filed until it is complete..."

B. Record Review (discharge dates in parentheses)

A review of the medical records for the discharge sample on 8/24/10 revealed no discharge summaries for patients S1 (7/16/10), S2 (7/19/10), and S4 (7/17/10).

Based on interview, record review and policy review, it was determined that the Medical Director failed to ensure that:

I. The physical exams for 8 of 8 active sample patients (A30, B2, C6, D1, E12, F2, G2 and H2) contained a descriptive neurological screening examination, indicating what tests were performed and the results of the testing. The absence of neurological screening data compromises the treatment team's ability to plan effective interventions and determine changes in the patient's condition in response to treatment interventions. (Refer to B109)

II. One of 8 active sample patients (E12) received a psychiatric evaluation. This failure could result in compromised treatment. (Refer to B110)

III. A psychiatric evaluation (PE) was completed and in the medical record within 24 hours for 1 of 8 active sample patients (A30). This deficiency results in the lack of psychiatric assessment, formulation, and diagnoses that can inform the treatment team and be utilized in development of the treatment plan. (Refer to B111)

IV. Psychiatric evaluations contained a Mental Status Examination that included a measurable estimate of: (1) intellectual functioning for 6 of 8 active sample patients (A30, D1, E12, F2, G2 and H2); (2) memory functioning for 4 of 8 active sample patients (A30, E12, F2 and G2), and (3) orientation for 3 of 8 active sample patients (B2, F2 and G2). This failure hampers staff's ability to accurately understand the patient's condition, formulate treatment plans, and determine changes in the patient's condition in response to treatment interventions. (Refer to B116)

V. Treatment plans included substantiated diagnoses based on input from the treatment team for 8 of 8 active sample patients (A30, B2, C6, D1, E12, F2, G2 and H2). This deficient practice compromises the staff's ability to deliver clinically focused treatment. (Refer to B120)

VI. Three of 5 sample discharge records (S1, S2 and S4) contained complete discharge summaries. This failed practice compromises the transfer of information obtained during hospitalization to the next care provider, and can result in ineffective follow-up care. (Refer to B133)