HospitalInspections.org

Based on Medical Record review and staff interview it was determined that for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8), the facility failed to document tests performed to assess orientation, memory, and intellectual functioning in a sufficiently descriptive manner to establish diagnosis and an objective baseline for future comparisons. This may result in failure to identify medical conditions that impact treatment and in the establishment of inappropriate treatment goals.

Findings include:

A. Record Review

1. Patient A1's psychiatric evaluation dated 2/25/11 contained a Mental Status Exam which stated, "Memory- Not assessed. Intelligence- Not assessed. Orientation-Not to place."

2. Patient A2's psychiatric evaluation dated 2/20/11 contained a Mental Status Exam which stated, "Orientation- fully intact. Memory: Immediate: Intact, Recent: Intact. Intelligence-Not assessed."

3. Patient A3's psychiatric evaluation dated 2/23/11 contained a Mental Status Exam which stated, "Orientation: Fully intact. Memory-Immediate: Intact, Recent: Intact, Remote: Intact. Intelligence: not assessed."

4. Patient A4's psychiatric evaluation dated 2/26/11 contained a Mental Status Exam which stated, "Orientation: fully intact. Memory: Immediate: intact, Recent: intact, Remote: intact. Intelligence: average."

5. Patient A5's psychiatric evaluation dated 2/17/11 contained a Mental Status Exam which stated, "Orientation: fully intact. Memory: Immediate: intact, Recent: intact, Remote: intact. Intelligence: not assessed."

6. Patient A6's psychiatric evaluation dated 2/16/11 contained a Mental Status Exam which stated, "Orientation: fully intact. Memory: Immediate: intact, Recent: intact, Remote: intact. Intelligence: average."

7. Patient A7's psychiatric evaluation dated 2/23/11 contained a Mental Status Exam which stated, "Orientation: fully intact. Memory: Immediate: intact, Recent: intact, Remote: intact. Intelligence: average."

8. Patient A8's psychiatric evaluation dated 2/25/11 contained a Mental Status Exam which stated, "Orientation: fully intact. Memory: Immediate: intact, Recent: intact, Remote: intact. Intelligence: average."

B. Staff Interview

In an interview on 3/1/11 at 1:00pm with Physician #3 and Medical Director at 1:30pm they agreed that the tests performed to assess cognitive function were not adequately documented.

Based on record review and staff interview it was determined that 4 of 5 Discharge Summaries (D1, D2, D4 and D5) reviewed did not contain sufficient information in the recapitulation of the hospital course. This compromises the effective transfer of the patient's care to the next care provider.

Findings include:

A. Record Review

1. Patient D1 was hospitalized on 1/3/11 and discharged on 1/7/11. The Hospital Course documented in the Discharge Summary contained the following: "Pt. (patient) progressed well. Compliant with (his/her) medication and tolerating well. Not aggressive or assaultive. Denies SI (suicidal ideations), HI (homocidal ideations) and overt psychotic symptoms. Safe and stable for discharge. Refused family meeting."

2. Patient D2 was hospitalized on 1/6/11 and discharged on 1/12/11. The Hospital Course documented in the Discharge Summary contained the following: "Pt. progressed well. Denies SI, HI and overt psychotic symptoms. Safe and stable for discharge."

3. Patient D4 was hospitalized on 1/3/11 and discharged on 1/6/11. The Hospital Course documented in the Discharge Summary contained the following: "Pt. progressed well. Denies SI, HI and overt psychotic symptoms. Safe and stable for discharge."

4. Patient D5 was hospitalized on 12/26/10 and discharged on 1/4/11. The Hospital Course documented in the Discharge Summary contained the following: "Was admitted in a psychotic state treated with the medications described until psychosis under better control. Not suicidal. Safe for discharge. Patient was instructed not to operate heavy machinery or drive after discharge until (he/she) will be free of side effects and safe to do so. [sic]"

B. Staff Interview

In a meeting with the Medical Director at 1:30pm on 3/1/11, the Medical Director concurred that the Hospital Course section of the Discharge Summary did not sufficiently recapitulate the course of hospitalization.