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Based on record review, policy review and interview, the facility failed to ensure that social service assessments were completed in a timely manner for 2 of 9 sample patients (A11 & B10). As a result, the treatment team did not have current baseline social functioning information on these patients for establishing treatment goals and interventions.

Findings include:

A. Record review:

Patient A-11: (admitted 4/14/11) the comprehensive social history was not completed until 4/27/11 or 13 days after the patient's admission.
Patient B-10: (admitted 4/19/11) the comprehensive social history was not completed as of 4/28/11 or 9 days after the patient's admission.

B. Policy Review:

The Social Assessment policy ("DATE ISSUED: 03/14/95"; then next line reads: "DATE REVIEWED: 07/12/05"; then next line reads: "DATE REVIEWED: 07/18/08"), under Procedure #2 states, "The social assessment is to be completed within 6 days, including weekends and holidays."

C. Interview:

In an interview on 4/28/11 at 10:30am with social work caseworker (SWA), the caseworker agreed the psychosocial assessment for sample patient B10 had not been completed in a timely fashion.

Based on record review and interview, the hospital failed to provide psychiatric evaluations that reported orientation and memory functioning for 1 of 9 sample patients (A15). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review:

Patient A15: In the psychiatric evaluation dated 4/1/11 there was no assessment of orientation or memory functioning.

B. Interview:

In an interview with the Medical Director on 4/28/11 at 2:30pm, the above findings were presented to him and discussed. He acknowledged that the above record was deficient.

Based on record review and interview the facility failed to ensure that the frequency of physician progress notes was sufficient to address the acuity level of 4 of 9 sample patients (#A11, A15, B10, C8). These failures made it difficult to follow the patients' progress toward achieving their treatment goals and prevented other team members from having the physician input about patient progress.

Findings include:

A. Record review:

1. Patient A11: Patient was admitted on 4/14/11 with a diagnosis of Major Depressive Disorder, recurrent. Suicidal ideation was documented as well as a history of previous suicide attempts. There was a Psychiatry admission note on 4/14/11 and an initial progress note on 4/15/11. There were no further psychiatry progress notes until 4/25/11 and 4/28/11.

2. Patient A15: Patient was admitted on 3/29/11 due to suicidal ideation with a diagnosis of depressive disorder, PTSD, and alcohol dependence. There was a psychiatry note on 3/31/11 and 4/7/11. There were no further psychiatry progress notes until 4/28/11.

3. Patient B10: Patient was admitted on 4/19/11 due to an acute manic episode with both suicidal and homicidal ideation. Diagnosis was Bipolar I disorder with psychotic features and cannabis abuse. There was a psychiatry admission note on 4/20/11 and a third year medical student note on 4/21/11 which was not countersigned by the attending psychiatrist. There were no further psychiatry progress notes as of the date of this survey.

4.Patient C8: Patient was admitted on 2/1/11 with a diagnosis of Schizophrenia, undifferentiated type and Personality Disorder NOS. There was a medical student admission note on 2/1/11 and medical progress on 2/4/11. These were countersigned by the attending psychiatrist with no written entry by the attending psychiatrist. The only other attending psychiatrist progress notes were on 2/14/11, 3/11/11 and 4/11/11.

B. Interview:

In an interview with the Medical Director On 4/28/11 at 2:30pm, the Medical Director acknowledged that the lack of sufficient progress notes in the above cases was a problem, and that it was "probably not acceptable for acute admissions."

Based on record review, staff interview and policy review, the facility failed to ensure that weekly social work progress notes were completed in accordance with the hospital policy for 2 of 2 active sample patients (C8, C9) on Unit 3 (Community Reintegration Unit). This practice potentially hampers treatment and discharge planning.

Findings include:

A. Record reviews

1. Patient C8 (admitted 2/1/2011). There were no weekly social work progress notes documented in the patient record for 7 of 8 weeks (2/8/11, 2/22/11, 3/1/11, 3/8/11, 3/15/11, 3/22/11, and 3/29/11).

2. Patient C9 (admitted 1/26/11). There were no weekly social work progress notes documented in the patient record for 7 of 8 weeks (2/2/11, 2/9/11, 2/16/11, 2/23/11, 3/2/11, 3/3/11, and 3/23/11).

B. Interview

In an interview on 4/28/11 at 1:30pm, social worker B stated that the social work progress notes were expected to be completed weekly for the first four weeks and then monthly.

C. Policy Review

Copies of two facility policies were reviewed which specified requirements for weekly progress note completion by each clinical discipline and clarified social worker responsibilities. The policies included "Completion of Medical Records", revised 10/29/10 and policy "Social Work Duties and Responsibilities", revised 2/18/10.

Based on record review and interview the Medical Director failed to monitor medical staff activities to assure all required documentation was present.
Findings include:

1.The psychiatric evaluation of 1 of 9 sample patients (A15) did not contain documentation of orientation and memory testing. Refer to B116 for findings.

2. In 4 of 9 sample patients' records (#A11, A15, B10, C8) there was insufficient documentation of timely physician progress notes. Refer to B126 for findings.

Based on medical record review and staff interview, the Social Work Director failed to monitor social service documentation in the medical record. This practice effects delivery of social services including assessment, treatment and discharge planning.

Findings include:

1. For 2 of 9 sample patients (A11 & B10) the psychosocial assessments were not completed within the timeframe specified by the facility, and were not available when the master treatment plan was developed.. Refer to B108 for findings.
2. For 2 of 2 active sample patients (C8, C9) on Unit 3 (Community Reintegration Unit) weekly social work progress notes were not documented in the patient medical records as specified by facility policy. Refer to B130 for findings.

B. Interview

In an interview on 4/20/11 at 10:40am, the Social Work Director stated that there was certainly room for improvement in the system for monitoring timely completion of psychosocial assessments and documentation of social work progress notes that were expected to be completed weekly.