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Based on record review and interview, the facility failed to provide adequate neurological screening examinations for 4 of 6 active sample patients (A4, A5, A7 and A10); and failed to document the specific neurological tests performed for the same 4 patients. This failure compromises the database from which diagnoses are determined and prevents the identification of potential neurological problems that may influence the presentation of a psychiatric illness.

A. Record Review

1. Patient A4 was admitted 03/18/11. The History and Physical (PE) was performed on 03/19/11. The cranial nerve portion of the neurological examination reported "CN II-XII(Cranial Nerves 2-12) grossly wnl (within normal limits)" without documentation of the specific tests performed.

2. Patient A5 was admitted 03/18/11. The PE was performed on 03/19/11. The cranial nerve and sensory portion of the neurological examination reported "CN II-XII grossly wnl, sensations grossly wnl" without documentation of the specific tests performed.

3. Patient A7 was admitted 03/20/11. The PE was performed on 03/22/11. The cranial nerve and sensory portions of the neurological examination reported "CN II-XII grossly wnl, sensations grossly wnl" without documentation of the specific tests performed.

4. Patient A10 was admitted 03/21/11 and had a PE performed on 03/22/11. The cranial nerve and sensory portions of the neurological examination reported "CN II-XII grossly wnl, sensations grossly wnl" without documentation of the specific tests performed.


B. Staff Interview

In an interview on 3/24/11 at 1:25 PM with the Medical Director the lack of adequate documentation was discussed; she agreed that the documentation should be improved.

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations of 2 of 6 active sample patients (A2 and A4) included a medical history. This failure results in the inability to assess the impact of an acute or chronic medical condition on the current psychiatric presentation.

A. Record Review:

1. Patient A2, readmitted 3/16/11 after a discharge of 3/9/11, had a psychiatric evaluation performed on 3/16/11 which contained no medical history, although she was known to have hypertension, which was being treated at the time.

2. Patient A4 was readmitted 03/18/11 after a recent discharge on 3/15/11. The psychiatric evaluation contained no medical history.

B. Staff Interview

In an interview on 3/24/11 at 1:25 PM with the Medical Director the lack of adequate documentation was discussed; she agreed that such documentation was important.

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations of 6 of 6 active sample patients (A1, A2, A4, A5, A7 and A10) included an assessment of recent and remote memory function in measurable, behavioral terms that clearly reflected patients' abilities in those areas. This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions can be measured.

Findings include:

A. Record Review:

The psychiatric evaluation is dictated and entered into a computerized medical record with the Mental Status Exam (MSE) a section of the evaluation.

1. Patient A1, admitted 3/14/11, had a psychiatric evaluation done 3/15/11 with an MSE which reported, "Her memory for recent and remote events could not be assessed." There was no indication of specific memory tests attempted nor was there any documentation of memory testing being performed at a later date. This limited the opportunity to assess the patient's change over the course of treatment.

2. Patient A2, admitted 3/16/11, had a psychiatric evaluation done 3/16/11 with an MSE which had no mention of memory function.

3. Patient A4, admitted 3/18/11 had a psychiatric evaluation done 3/19/11 with an MSE which reported, "Her memory was grossly intact." There was no indication of specific memory tests performed. This limited the opportunity to assess the patient's change over the course of treatment.

4. Patient A5, admitted 3/18/11, had a psychiatric evaluation done 3/19/11 with an MSE which reported, "His memory for recent and remote events is grossly intact." There was no indication of specific memory tests performed which limits the opportunity to assess the patient's change over the course of treatment.

5. Patient A7, admitted 3/20/11, had a psychiatric evaluation done 3/21/11 with an MSE which reported, "Her memory for recent and remote events is grossly intact." There was no indication of specific memory tests performed which limits the opportunity to assess the patient's change over the course of treatment.

6. Patient A10, admitted 3/21/11, had a psychiatric evaluation done 3/22/11 with an MSE which reported, "Her memory for recent and remote events is grossly intact." There was no indication of specific memory tests being performed, limiting the opportunity to assess the patient's change over the course of treatment.

B. Staff Interview

In an interview on 3/24/11 at 1:25 pm with the Medical Director, she was asked about the MSE and the lack of documentation of specific memory tests performed. She said she understood the problem.

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an inventory of patients' assets for 5 of 6 active sample patients (A1, A2, A4, A5 and A7). This deficiency results in a lack of documented patient strengths (assets) that can be utilized in treatment planning and implementation.

Findings include:

A. Record Review

The psychiatric evaluation is dictated and entered into a computerized medical record with "ASSETS/STRENGTHS & BARRIERS" a section of the evaluation.

1. Patient A1, admitted 3/14/11, had a psychiatric evaluation done 3/15/11 with "ASSETS/STRENGTHS & BARRIERS: Needs further assessment." This is not useful in treatment planning.

2. Patient A2, admitted 3/16/11, had a psychiatric evaluation done 3/16/11 with no section for "ASSETS/STRENGTHS & BARRIERS" or listing of such strengths, even though the patient was well known from previous admissions.

3. Patient A4, admitted 3/18/11 had a psychiatric evaluation done 3/19/11 which reported, "STRENGTHS, ASSETS & BARRIERS: However the patient will not admit it at this time she seems to have a good support system available to her. She denies any drug history but this is very questionable." This is not useful in treatment planning.

4. Patient A5, admitted 3/18/11, had a psychiatric evaluation done 3/19/11 with "PATIENT'S STRENGTHS/ASSETS: The patient will be kept on his pre-admitting medication except for Paxil that will be increased from 20 to 30 mg daily." This was not an asset, and no other listing of assets was reported.

5. Patient A7, admitted 3/20/11, had a psychiatric evaluation done 3/21/11 which stated, "PATIENT'S ASSETS/STRENGTHS & BARRIERS: The patient has a good support system available to her, mostly from her husband." There were no personal strengths listed that could be useful in treatment planning.

B. Staff Interview

In an interview on 3/24/11 at 1:25 pm with the Medical Director, she was asked about the psychiatric evaluation and the lack of identifying patient assets that can be used in treatment planning. She said she understood the problem.

Based on record review and interview, the hospital failed to identify individualized, goal directed treatment interventions for 6 of 6 active sample patient records reviewed (A1, A2, A4, A5, A7, and A10). Many interventions were routine assessments, care, and treatment expected to be provided for all patients, or were lists of daily groups without individual focus of the group for each patient. The failure to document specific treatment interventions results in lack of consistent guidance for staff in providing effective psychiatric care and treatment.

Findings include:

A. Record Review

1. The treatment plan for patient A1, dated 3/22/11, included the following interventions:
"Psychiatric Services/Medication Monitoring"
"Frequency: Patient will participate in an initial psychiatric evaluation with Dr. [name]/psychiatrist and medication monitoring with Dr. [name]/psychiatrist 5-6 times a week as prescribed."
"Nursing Care Plan"
"Frequency: Patient will follow Nursing Care Plan for health/medical issues, monitor vitals and labs and medication monitoring, administration and education to eliminate delusional and psychotic symptoms."
"Groups/Group Therapy"
"Clinical Group, Evening Wrap Up Group, and Activities Group M-F to eliminate psychotic and delusional symptoms"
"Individual Sessions"
"Frequency: Patient will participate in 1:1 sessions with psychiatrist, 5 days a week and participate in 1:1 sessions with social worker for treatment planning, discharge planning and family meetings if she chooses."

2. The treatment plan for patient A2, dated 3/16/11, included the following interventions:
"Psychiatric Services/Medication Monitoring"
"Frequency: [patient] will participate in an initial psychiatric evaluation with Dr.[name]/psychiatrist and medication monitoring with Dr. [name]/psychiatrist 5-6 times a week as prescribed."
"Nursing Treatment Plan"
"Frequency: [patient] will follow Nursing Treatment Plan for monitoring of health issues, monitoring for safety, hygiene and medication administration, education and monitoring to reduce manic symptoms, disorganized thinking and behaviors as inappropriate behaviors with peers and staff."
"Groups/Group Therapy"
"Frequency: [patient] will participate daily in the following groups: Morning Goals Group, Clinical Group (as offered), Nursing Group (as offered), Evening Wrap-up Group, and Activities Group, M-F to reduce manic symptoms, improve social skills, self-esteem and reduce inappropriate in [sic] intrusive behaviors."
"Individual Sessions/Therapy"
"Frequency: [patient] will participate in 1:1 sessions with psychiatrist at least 5 days a week and will participate in 1:1 sessions with social workers for treatment planning, discharge planning and family meeting/AFT [sic]."

3. The treatment plan for patient A4, dated 3/18/11, included the following interventions:
"Provide Step One Work and Substance Abuse Treatment"
"Frequency: Daily"
"Anti-psychotic Medication Education and Monitoring"
"Frequency: Daily, as prescribed"

4. The treatment plan for patient A5, dated 3/21/11, included the following interventions:
"Psychiatric Services/Medication Monitoring"
"Frequency: [patient] will participate in an initial psychiatric evaluation with Dr. [name]/psychiatrist and medication monitoring with Dr. [name]/psychiatrist 5-6 times a week as prescribed."
"Nursing Treatment Plan"
"Frequency: [patient] will follow Nursing Treatment Plan for monitoring of health issues, monitoring for safety, hygiene and medication administration, education and monitoring to reduce manic symptoms, disorganized thinking and behaviors as inappropriate behaviors with peers and staff."

5. The treatment plan for patient A7, dated 3/22/11, included the following interventions:
"Psychiatric Services/Medication Monitoring"
"Frequency: Patient will participate in an initial psychiatric evaluation with Dr [name]/psychiatrist and medication monitoring with Dr [name]/psychiatrist 5-6 times a week as prescribed."
"Nursing Care Plan"
"Frequency: Patient will follow Nursing Care Plan for health/medical issues, monitor vitals and labs and medication monitoring, administration and education to reduce symptoms [sic]."
"Groups/Group Therapy"
"Frequency: Patient will participate in daily groups as offered: Morning Goals Group, Clinical Group, Evening Wrap Up Group, and Activities Group M-F to reduce symptoms."

6. The treatment plan for patient A10, dated 3/24/11, included the following interventions:
"Psychiatric Services/Medication Monitoring"
"Frequency: [patient] will participate in an initial psychiatric evaluation with Dr. [name]/psychiatrist and medication monitoring with Dr. [name]/psychiatrist 5-6 times a week as prescribed."
"Nursing Care Plan"
"Frequency: [patient] will follow Nursing Care Plan for health/medical issues, monitor of vitals and labs and medication monitoring [sic], administration and education to reduce symptoms and complete detoxification."
"Case Management"
"Frequency: PRN [as needed], coordination of care with outpatient services, PCP [primary care physician], for counseling and medication management as needed after discharge."

B. Interview

In an interview on 3/24/11 at 2:45 PM, the Acting Coordinator of Social Work stated that she is responsible for gathering information and writing the treatment plan, using a computerized program. She agreed that some of the interventions are general and not specific for each patient's problems and are nearly identical for each patient.

Based on record review and interview, the hospital failed to designate the treatment team member responsible for implementing treatment interventions on the treatment plans for 6 of 6 active patients (A1, A2, A4, A5, A7, and A10). The "Responsible Person" for most interventions was listed as "CCC [Community Counseling Center] Staff, client/family." The failure to identify the treatment team member responsible for intervention may result in the failure to implement and document the effects of specific treatments for the patient, potentially prolonging inpatient care.

A. Record Review

1. The treatment plan for patient A1 included the following:
For the treatment intervention: "Clinical Group, Evening Wrap Up Group, and Activities Group M-F to eliminate psychotic and delusional symptoms," the "Responsible Person" was listed as: "CCC Staff, client/family."

2. The treatment plan for patient A2 included the following:
For the treatment intervention: "[patient] will follow Nursing Treatment Plan for monitoring of health issues, monitoring for safety, hygiene and medication administration, education and monitoring to reduce manic symptoms, disorganized thinking and behaviors as inappropriate behaviors with peers and staff," the "Responsible Person" was listed as: "CCC Staff, client." For the treatment intervention: "[patient] will participate in 1:1 sessions with psychiatrist at least 5 days a week and will participate in 1:1 sessions with social workers for treatment planning, discharge planning and family meeting/AFT [sic]," the "Responsible Person" was listed as: "CCC Staff, client."

3. The treatment plan for patient A4 included the following:
For the treatment intervention: "Provide Step One Work and Substance Abuse Treatment," the "Responsible Person" was listed as "CCC Staff, client/family/parent."
For the treatment intervention: "Anti-psychotic Medication Education and Monitoring," the "Responsible Person" was listed as "CCC Staff and [patient]."

4. The treatment plan for patient A5 included the following:
For the treatment intervention: "[patient] will follow Nursing Treatment Plan for monitoring of health issues, monitoring for safety, hygiene and medication administration, education and monitoring to reduce manic symptoms, disorganized thinking and behaviors as inappropriate behaviors with peers and staff," the Responsible Person was listed as: "CCC Staff, client."

5. The treatment plan for patient A7 included the following:
For the treatment intervention: "Patient will participate in daily groups as offered: Morning Goals Group, Clinical Group, Evening Wrap Up Group, and Activities Group M-F to reduce symptoms," the "Responsible Person" was listed as: "CCC Staff, client/family."

6. The treatment plan for patient A10 included the following:
For the treatment intervention: "[patient] will follow Nursing Care Plan for health/medical issues, monitor of vitals and labs and medication monitoring [sic], administration and education to reduce symptoms and complete detoxification," the Responsible Person was listed as: "CCC Staff, client/family."
For the treatment intervention: "Frequency: PRN [as needed], coordination of care with outpatient services, PCP [primary care physician], for counseling and medication management as needed after discharge," the Responsible Person was listed as: "CCC Staff, client/family."

B. Interview

In an interview on 3/24/11 at 2:45 PM, the Acting Coordinator of Social Work stated that she is responsible for gathering information and writing the treatment plan. She stated that the wording "Responsible Person: CCC Staff, client/family/parent" is on the computerized record program; she agreed that the responsible staff person for each intervention is not designated on the written treatment plan.

Based on record review and interview, the Medical Director failed to:

I. Ensure that physicians document the specific neurological tests performed during neurological screening examinations for 4 of 6 active sample patients (A4, A5, A7 and A10). This failure compromises the database from which diagnoses are determined and prevents the identification of potential neurological problems that may influence the presentation of a psychiatric illness. (Refer to B109)

II. Ensure that the psychiatric evaluations of 2 of 6 active sample patients (A2 and A4) included a medical history. This failure results in the inability to assess the impact of an acute or chronic medical condition on the current psychiatric presentation. (Refer to B112)

III. Ensure that the psychiatric evaluations for 6 of 6 active sample patients (patients A1, A2, A4, A5, A7 and A10) included an assessment of recent and remote memory function in measurable, behavioral terms that clearly reflected patients' abilities in those areas. This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions might be measured. (Refer to B116)

IV. Ensure that psychiatric evaluations included an inventory of patient assets for 5 of 6 active sample patients (A1, A2, A4, A5 and A7). This deficiency results in a lack of documented patient strengths (assets) that can be utilized in treatment planning and implementation. (Refer to B117)

V. Ensure that clinical staff identified individualized, goal directed treatment interventions for 6 of 6 active sample patient records reviewed (A1, A2, A4, A5, A7, and A10). Many interventions were routine assessments, care, and treatment expected to be provided for all patients or lists of daily groups without individual focus of the group for each patient. The failure to document specific treatment interventions results in lack of consistent guidance for staff in providing effective psychiatric care and treatment. (Refer to B122)

VI. Ensure that individual staff members were designated for implementing treatment interventions on the master treatment plans for 6 of 6 active sample patients (A1, A2, A4, A5, A7, and A10). The "Responsible Person" for most interventions was listed as "CCC [Community Counseling Center] Staff, client/family." The failure to identify the treatment team member responsible for intervention may result in the failure to implement and document the effects of specific treatments for the patient, potentially prolonging inpatient care. (Refer to B123)