HospitalInspections.org

Based on review of documentation and interview, it was discovered that 3 of 6 medical records of minor patients reviewed failed to reveal involvement of family members/guardians in Treatment Team meetings.

Findings were:

Facility policy entitled " Master Treatment Plan " stated in part:

A. Every patient shall have an individualized, comprehensive Master Treatment Plan.
B. The needs, strengths, preferences and goals of the patient are identified based on multi-disciplinary screening and assessments
C. Patient care decisions are collaborative and multi-disciplinary when more than one discipline is involved.
D. Every patient ' s Master Treatment Plan shall identify patient goals and associated objectives and interventions deemed necessary to meet the identified goals.
E. Goals are time-limited, measurable, and achievable ...

2. The organization documents family participation (if any) in the patient ' s medical record. "

Review of 3 of 6 medical records revealed no indication that the parents or guardians of these minor patients participated in treatment team meetings. In a telephone interview with the parent/guardian of Patient # 1 on 6/23/16, the parent denied being informed of the date and time of his child ' s treatment team meeting.

In an interview the CEO on June 22, 2016, the lack of parental involvement in treatment team meetings was confirmed.

Based on review of medical records and interview, it was determined that medical records were not being completed in a timely fashion.

Findings were:

6 medical records were reviewed. The following was revealed:

· Patient # 1, discharged in January, 2016 had no Psychiatric Discharge Summary
· Patient # 3, discharged in January, 2016 had no Psychiatric Discharge Summary
· Patient # 4, discharged in April, 2016 had no Psychiatric Discharge Summary
· Patient # 5, discharged in January, 2016 had no Psychiatric Discharge Summary
· Patient # 6, discharged in January, 2016 had no Psychiatric Discharge Summary

In an interview with the Chief Executive Officer on June 22, 2016 the incomplete medical records were acknowledged.

Based on review of medical records and interview, it was determined that discharge summaries were not being completed on all of its patients..

Findings were:

6 medical records were reviewed. The following was revealed:

· Patient # 1, discharged in January, 2016 had no Psychiatric Discharge Summary
· Patient # 3, discharged in January, 2016 had no Psychiatric Discharge Summary
· Patient # 4, discharged in April, 2016 had no Psychiatric Discharge Summary
· Patient # 5, discharged in January, 2016 had no Psychiatric Discharge Summary
· Patient # 6, discharged in January, 2016 had no Psychiatric Discharge Summary

In an interview with the Chief Executive Officer on June 22, 2016 the delinquent patient records were acknowledged.