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Based on record review, staff interview, and document review it was determined that the hospital failed in 5 of 8 active sample patient records (A10, A15, A16, B1, and B13 ) to ensure the provision of psychosocial assessments which provided conclusions, and recommendations that describe anticipated social work roles in treatment and discharge planning. This failure results in a lack of description of what specifically social services would be doing for these patients, thereby compromising an integrated treatment process.

Findings include:

A. Record Review:

Review of the Psychosocial Assessments of the following sample patients (dates of assessment in parentheses) revealed no description of the role that the social worker would fulfill during the inpatient hospitalization: Patient A10 (2/19/11); Patient A15 (2/21/11); Patient A16 (2/21/11); Patient B1 (1/30/11); and B13 (2/25/11).

B. Document Review.

In the hospital policy titled "Integrated Summary: Hospital Form F 001-05 (2/10) Comprehensive Assessment Tool," page 6/6, #19, it states: "Psychosocial Assessment and Recommendations include suggested problems to be addressed during this episode of treatment, anticipated outcomes, and anticipated treatment interventions."

C. Interview

During an interview with the Interim Director of Social Services on 3/01/11 the above findings were reviewed. The Interim Director reviewed and acknowledged the findings.

Based on record review and staff interviews, it was determined that the hospital failed to ensure the reporting of memory functioning in measurable, behavioral terms which clearly reflected the patient's ability to function in those areas for 4 of 8 active sample patients (A7, B1,C11, C13). This compromises the database from which diagnosis is determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review

1. Patient A7, admitted on 2/17/11: Mental status examination dated 2/18/11 made no mention of memory function.

2. Patient B1 admitted on 1/29/11: Mental status examination dated 1/29/11 reported "Diffuse memory loss for recent and emote events is present. Periods of confusion with disorientation and memory problems occur."

3. Patient C11 admitted on 2/24/1: Mental status examination performed on 2/25/11 reported "Memory is grossly intact."

4. Patient C13 admitted on 2/25/11: Mental status examination performed on 2/26/11 reported "memory is grossly intact."

B. Staff Interview

During an interview with MD #1 on or around 1:45 PM on 3/1/11 the above findings were reviewed. MD #1 acknowledged the findings.

Based on record review, interview, and document review, the facility failed to develop and document comprehensive treatment plans based on the individual patient needs. Specifically, the facility failed to develop and document treatment plans that:

1. Included short-and long-term goals as specific, measurable patient behaviors to be achieved for 8 of 8 active sample patients (A7, A10, A15, A16, B1, B13, C11 and C13). This resulted in a document that failed to identify expected treatment outcomes in a manner that could be understood by treatment staff and patients (Refer to B121).

II. Included individualized treatment interventions based on the needs of 4 of 8 active sample patients (A10, A15, A16, and C11). The interventions were generic and described routine discipline functions and failed to include frequency and/or delivery method. This results in staff being unable to provide consistent and focused treatment. (Refer to B122).

III. Identified the assigned treatment team members responsible for treatment interventions for 8 of 8 active sample patients (A7, A10, A15, A16, B1, B13, C11 and C13). Identification of those staff members responsible for ensuring compliance with particular aspects of the patient's master treatment plan is essential to the provision of care. Uncoordinated care in which clinical team members do not understand their assigned duties or the assigned duties of their colleagues can result in delay of the patient's discharge and recovery. (Refer to B123)

Based on record review and interview, the facility failed to ensure that the treatment plans of 8 of 8 active sample patients (A7, A10, A15, A16, B1, B13, C11, and C13) defined short-and long-term goals as specific, measurable patient behaviors to be achieved. This practice compromises staff's ability to evaluate patient progress in treatment and to make necessary modifications in patients' treatment plans.

Findings include:

A. Record Review

1. Patient A7: The long-term goal on her Master Treatment Plan dated 2/18/11 was: "Patient will demonstrate ability to verbally communicate with appropriate boundaries." The short-term patient goal/objective was: "Patient will take lamictal as prescribed by MD to improve thought process/function." The goal and objective were not measurable in behavioral terms.

2. Patient A10 : The long-term goal on the Master Treatment Plan dated 2/21/11 was: "Patient will remain abstinent from ______________ (treatment team did not complete statement)." The short-term patient goal/objective was: "Patient will comply with detox medication regimen of____________ (treatment team did not complete statement). The goal and objective were not complete or measurable in behavioral terms."

3. Patient A15: The long-term goals on the Master Treatment Plan dated 2/22/11 was: "Patient will be free of frequent crying spells." "Patient will verbalize hope for the future as well as long term goals for continued recovery." The short-term patient goal/objective was: "Patient will identify ________ (treatment team did not complete statement) triggers to increased crying spells." The goals and objective were not complete or measurable in behavioral terms.

4. Patient A16: The long-term goal on the Master Treatment Plan dated 2/22/11 was, "Patient will be free of frequent crying spells." "Patient will verbalize hope for the future as well as long term goals for continued recovery." The short-term patient goal/objective was "Patient will identify ____ (treatment team did not complete statement) triggers to increased crying spells." The goals and objective were not complete or measurable in behavioral terms.

5. Patient B1: The long-term goal on the Master Treatment Plan dated 1/30/11 was: "Patient will remain abstinent from _____________ (treatment team did not complete statement)." The short-term patient goal/objective was, "Patient will comply with detox medication regimen of_______________ (treatment team did not complete statement)." The goal and objective were not complete or measurable in behavioral terms.

6. Patient B13: The long-term goal on the Master Treatment Plan dated 2/25/11 was: "Patient will report absence of suicidal thoughts and/or suicide plan." The short-term patient goal/objective was, "Patient will comply with med recommendations of Zyprexa for mood/thought stabilization." The goal and objective were not complete or measurable in behavioral terms.

7. Patient C11: The long-term goals were: "Patient will be free of frequent crying spells," and "Patient will verbalize hope for the future as well as long term goals for continued recovery." The short-term goals/objectives were, "Patient will identify ____ (treatment team did not complete statement) triggers to increase crying spells." "Patient will identify _____ (treatment team did not complete statement) methods to increase level of hope for future." The goals and objectives were not complete or measurable in behavioral terms.

8. Patient C13: The long-term goal was, "Patient will demonstrate ability to maintain self-control and deny thought and/or intent to harm." The short-term goal/objective was, "Patient will comply with med recommendations of ______________ (treatment team did not complete statement) for mood/thought stabilization." The goal and objective were not complete or measurable in behavioral terms.

B. Staff Interview

In an interview with the Director of Nursing (DON) on 3/2/11 at approximately 9:30AM, while she was reviewing the master treatment plan of Patient C11, she stated; "not good, no identification of the issues being addressed...."

Based on record review and interview, the facility failed to provide 4 of 8 active sample patients (A10, A15, A16, and C11) with Master Treatment Plans that delineated individualized treatment modalities. Instead, interventions on the plans included: 1. Routine generic discipline functions; and, 2. Interventions that failed to include frequency and/or delivery method. This resulted in a treatment plan that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings are:

1. Routine, generic discipline functions.


A. Record Review


1. Patient A10 was admitted 2/18/11. The master treatment plan dated 2/21/11 noted the following routine, generic discipline functions: "Educate patient on and administer________ (treatment team did not complete statement) detox meds per MD orders, by means of 1:1/ psycho-ed groups____ (treatment team did not complete statement) times per week."

2. Patient A15 was admitted 2/21/11. The master treatment plan dated 2/22/11 noted the following routine, generic discipline function: "Educate patient on & administer___________ (treatment team did not complete statement) as prescribed by MD."

3. Patient A16 was admitted 2/21/11. The master treatment plan dated 2/22/11 noted the following routine, generic discipline function: "Educate patient on & administer___________ (treatment team did not complete statement) as prescribed by MD."

4. Patient C11 was admitted 2/24/11. The master treatment plan dated 2/26/11 noted the following routine, generic discipline function: "Educate patient on & administer___________ (treatment team did not complete statement) as prescribed by MD."

II. Interventions that failed to include frequency and/or delivery method.

1. Patient A10 was admitted 2/18/11. The master treatment plan dated 2/21/11 failed to note frequency and delivery method (individual or group sessions) for the following intervention: "Facilitate a family session."

2. Patient A15 was admitted 2/21/11. The master treatment plan dated 2/22/11 failed to note frequency and delivery method (individual or group sessions) for the following intervention: "Assist patient in identifying reasons for increased hope through 1:1 education___ (treatment team did not complete statement) times per week and group therapy ____ (treatment team did not complete statement) times week."

3. Patient A16 was admitted 2/21/11. The master treatment plan dated 2/22/11 failed to note frequency and delivery method (individual or group sessions) for the following intervention: "Educate patient on and assist patient in identifying triggers through 1:1 psycho-ed groups___ (treatment team did not complete statement) times week."

4. Patient C11 was admitted 2/24/11. The master treatment plan dated 2/26/11 failed to note frequency and delivery method (individual or group sessions) for the following intervention: "Pt. (patient) will see medical MD to r/o (rule out) throat infection."

B. Staff Interview

In an interview with RN2 on 3/1/11 at approximately 9:50AM she acknowledged the incomplete interventions on the treatment plans.

In an interview with RN1 on 3/1/11 at approximately 12:05PM she said; "sometimes they're completed (meaning treatment plans); it depends on the number of admissions we do."

Based on record review and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the multidiscipline treatment plans in 8 of 8 treatment plans of active sample patients (A7, A10, A15, A16, B1, B13, C11, and C13). This resulted in the facility's inability to monitor staff accountability for specific treatment modalities.

Finding Include:

A. Record Review

1. Review of the following multidisciplinary treatment plans (dates in parentheses) revealed that they did not delineate the names and responsibilities of treatment team members: Patient A7 (2/18/11); Patient A10 (2/21/11); Patient A15 (2/22/11) Patient A16 (2/22/11) Patient B1 (1/30/11); Patient B13 (2/25/11); Patient C11 (2/26/11); and Patient C16 (2/26/11).

B. Staff Interview

In an interview with RN1 on 2/28/11 at approximately 10:30AM she stated, "We do sign the front page of the treatment plan and the (treatment) team signs the other side. The SS (social service) could be any therapist and the RN responsible could change depending on the staffing."

C. Document Review

Policy # PC042 "Interdisciplinary Treatment Plan" in Procedure section 3.0 reads, "The treatment plan shall contain specific interventions that relate to goals, written in behavioral and measurable terms, and include expected achievement dates as well as person responsible for implementation."

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

I. To ensure the provision of psychosocial assessments which provided conclusions and recommendations that describe anticipated social work roles in treatment and discharge planning in 5 of 8 active sample patient records (A10, A15, A16, B1, and B13). This failure results in a lack of description of what specifically the social services would be doing for these patients compromising an integrated treatment process. (Refer to B108)

II. To ensure the reporting of memory functioning in measurable, behavioral terms which clearly reflected the patient's ability to function in this areas for 4 of 8 active sample patients (A7, B1,C11, C13). This compromises the database from which diagnosis is determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

III. Ensure that comprehensive treatment plans were developed based on the individual patient needs. Specifically, the facility failed to develop and document treatment plans that included measurable patient goals/objectives based on the individual needs of 8 of 8 active sample patients (A7, A10, A15, A16, B1, B13, C11, and C13) (Refer to B121); included individualized treatment interventions based on individualized needs for 4 of 8 active sample patients (A10, A15, A16, and C11) (Refer to B122); and identified the assigned treatment team members responsible for treatment interventions for 8 of 8 active sample patients (A7, A10, A15, A16, B1, B13, C11, and C13) (Refer to B123).