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Based on record review and interview the facility failed to ensure that the interdisciplinary treatment plans, for 5 out of 10 medical records reviewed, were created and maintained by addressing the patients nursing care needs. In 5 of 10 (#'s 12, 15, 16, 17, & 19) medical records reviewed the "Master Treatment Plan" did not address the patient's nursing care needs including treatment goals, physiological, psychosocial factors and patient discharge planning. This has the ability to affect all 57 in patients in facility during the investigation survey.

Findings include:

Per facility policy titled "Treatment Planning" #04-057-0216 reviewed on 8/10/17 at 1:45 PM under "Policy" #1. "The treatment plan will encompass issues that brought the patient to the current level of care." Under #5. "The master problem list is developed by the treatment team from the interdisciplinary assessments. Any problems not deferred should be addressed by the treatment team. The Diagnosis portion of the Master Problem List is completed by the medical staff caring for the patient." #6. "Discharge planning will be addressed on the treatment plan and will be updated at every staffing."

Patient #12's medical record was reviewed on 8/10/17 at 11:56 AM, "Ongoing Discharge Planning Note" dated 8/8/17 identified patient as "homeless." "Master Treatment Plan" revealed two identified problems for suicidal ideation's and anxiety. An interview was conducted with Staff C (Chief Nursing Officer) at the time of review who stated "it would be expected that discharge needs post hospitalization would be on Master Treatment Plan and it is not."

Patient #15's medical record was reviewed on 8/10/17 at 1:44 PM, admission history and physical, completed by psychiatrist, documents admission diagnosis' of Post Traumatic Stress Disorder from Sexual Abuse, Bi polar, and opiate abuse. "Master Treatment Plan" reviewed revealed one identified problem for substance abuse. An interview was conducted with Staff C (Chief Nursing Officer) at time of review who stated it would be expected that treatment plan would contain a "more holistic" list of problems based on diagnosis' and that those were not included on "Master Treatment Plan" for Patient #15.

Patient #16's medical record was reviewed on 8/10/17 at 2:28 PM, identified Patient #16 as "homeless". Master treatment plan reviewed revealed one identified problem for substance abuse. An interview was conducted with Staff C (Chief Nursing Officer) at the time of review who stated it would "be expected that discharge needs post hospitalization" would be on Master Treat Plan" and that it was not on Patient #16.

Patient #17's medical record was reviewed on 8/10/17 at 2:56 PM, admission history and physical, completed by psychiatrist, documents admission diagnosis of depression, diabetes and "detox". Review revealed no "Master Treatment Plan" in Patient #17's medical record for hospitalization 2/28/17-3/3/17. Staff D (Physician Adoption Specialist/Registered Nurse) confirmed in interview that there was no "Master Treatment Plan" for Patient #17 (discharged 3/3/17).

Patient #19's medical record was reviewed on 8/10/17 at 3:20 PM, admission history and physical, completed by psychiatrist on admission, lists diagnosis of "detox", alcohol, cocaine, opiod use, history of Major Depressive Disorder recurrent episodes severe, hypertension and Chrons Disease (gastrointestinal disease). "Master Treatment Plan" reviewed revealed one identified problem for substance abuse. Staff D (Physician Adoption Specialist/Registered Nurse) interviewed at the time of review who stated "I would not expect that there would be problems for Hypertension and Chrons because that is not what they are here for. But there should be a problem addressing depression."

During an interview with Staff A (Chief Operating Officer), and Staff F (Continuous Improvement) on 8/10/17 4:45 PM. Staff F (Continuous Improvement) stated "I am surprised because we have been working on treatment plans to include diagnosis'".

Based on interview the facility failed to have a mechanism in place for ongoing reassessment to track readmissions rates and identify potentially preventable readmissions and the effectiveness of the discharge planning and include in the hospital wide Quality Program in 1 of 1 discharge planning process. This deficiency has the potential to affect all 57 inpatients in the facility during this survey.

Findings include:

An interview was conducted with Staff F (Continuous Improvement) on 8/10/17 at 4:00 PM who stated Quality Program looks at Readmission rates for each hospital. Staff F (Continuous Improvement) stated "there is no policy in place for ongoing reassessment of discharge planning process and we do not go back and look at what happened with readmissions."