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Based on record review and interview the facility failed to provide a listing of assets on the psychiatric assessments (PA) that were specific to the patient's treatment for 7 of 8 active records (1E, 8E, 16E, 22E, 9W, 15W and 24W.) Failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy.


Findings:


Record Review:


Patient 1E: admitted 2/07/12: PA dated 2/08/12 listed the strength as "reasonable physical health."
Patient 8E: admitted 2/06/12: PA dated 2/07/12 listed the strength as "reasonable physical health."
Patient 16E: admitted 2/09/12: PA dated 2/10/12 listed the strength as "reasonable physical health."
Patient 22E: admitted 2/04/12: PA dated 2/05/12 listed the strength as "reasonable physical health."
Patient 9W: admitted 2/09/12: PA dated 2/10/12 simply the strength as "has a place to live."
Patient 15W: admitted 2/01/12: PA dated 2/02/12 simply listed the strength as "has a home to live in."
Patient 24W: admitted 2/05/12: PA dated 2/05/12 listed strengths as "ambulatory, relatively stable health."


Interview:


In an interview with the Hospital Medical Director on 2/14/12 at 3:45PM, the Medical Director acknowledged the above findings.

Based on record review and interviews, the facility failed to provide a Master Treatment Plan (MTP) that included specific modalities that corresponded to the listed problems and goals for 7 of 8 active sample patients (4E, 8E, 16E, 22E, 9W, 15W, and 22W). The modalities identified in the MTPs were generic instead of being individualized for patients. This deficiency results in treatment plans that do not reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment.

Findings:

Record review:

1. Patient 4E: admitted 2/07/12. MTP dated 2/07/12 documented Medical Staff "interventions" Modalities) as: "Psychiatric evaluation, Prescribe meds, Monitor effectiveness." These are generic professional medical functions not specific to the patient. The documented Nursing Service interventions were: "Nursing assessment to identify medical issues;" "Educate on psychotropic meds." These are generic nursing functions not specific to the patient. The documented Social Service interventions were: "Psychosocial assessment"; "Contact family for baseline behavior." These are generic Social Service functions.

2. Patient 8E: admitted 2/06/12. MTP dated 2/06/12 documented Medical staff interventions as: "Psychiatric assessment, Physical review to identify individual needs"; "Prescribe Meds, monitor effectiveness"; "order labs, monitor results." These are generic professional medical functions not specific to the patient. The documented nursing interventions were: "health screen, nursing assessment to identify medical needs," "monitor VS, monitor for med compliance, adverse effects." These are generic professional nursing functions not specific to the patient. The documented Social Service interventions were: "Psychosocial assessment, Tx (Treatment) meetings to monitor progress/compliance" These are generic professional Social Service functions not specific to the patient.

3. Patient 16E: admitted 2/09/12. MTP dated 2/09/12 documented Medical Staff "interventions" as: "Will conduct an H&P (History and Physical) and neuro (neurologic) system review"; "will meet with [pt. name] and clarify Dx (Diagnosis) and prescribe meds and Tx, and progress daily." These are generic professional medical functions and not specific to the patient. The documented Nursing Service interventions were: "Will conduct a review of nursing assessment to identify health concerns," "Provide med education on the benefits of med compliance." These are generic professional nursing functions and not specific to the patient.

4. Patient 22E: admitted on 2/04/12. MTP dated 2/04/12 documented Medical Staff interventions as: "Dictate an H&P and perform a neuro system and prescribe meds and Tx." This is a generic professional medical function not specific to the patient. The documented nursing interventions were: "Conduct a review of nursing assessment to identify health concerns," "Provide 1:1 to educate on benefits of med compliance." These are generic professional nursing functions not specific to the patient. The documented Social Services interventions were: "Psychosocial assessment," "Family contact." These are generic professional social service functions and not specific to the patient.

5. Patient 9W: admitted 2/09/12. MTP dated 2/09/12 documented Medical Staff interventions as: "MD will meet with client to clarify DX (diagnosis)," "H&P assessment," "Meds and Labs." These are generic professional medical functions not specific to the patient. The documented nursing interventions were: "Nurse physical assessment to determine health care needs," "Monitor for change in behavior," "Provide a safe therapeutic milieu." These are generic professional nursing functions not specific to the patient.

6. Patient 15W: admitted 2/01/12. MTP dated 2/02/12 documented Social Service interventions as: "Psychosocial assessment," "Family contact for collateral information." These are generic professional social service functions and not specific to the patient.

7. Patient 24W: admitted 2/04/12. MTP dated 2/05/12 documented Medical Staff interventions as: "Will conduct a psychiatric evaluation to assess the severity of psychosis and will dictate an H&P and complete neuro system review." This is a generic professional medical function not specific to the patient. The documented nursing interventions were: "Will review the nursing assessment to identify health concerns"; "Will provide med education on the benefits of compliance with Tx and meds." These are generic professional nursing functions and not specific to the patient. The documented Social Services interventions were: "Psychosocial assessments," "Family contact to determine baseline." These are generic professional social service functions and not specific to the patient.

Interviews

In an interview with RNA on 2/14/12 at 1PM the RNA acknowledged that treatment modalities listed on the master treatment plan tended to be generic and/or were routine staff functions (e.g. "Complete assessments") listed as interventions.

In an interview with Director of Nursing (DON) on 2/14/12 at 2PM the DON agreed that the use of generic treatment modalities is an ongoing problem.

In an interview with the Hospital Medical Director on 2/14/12 at 3:45PM, the Medical Director acknowledged the above findings.

Based on record review and interview, the facility failed to ensure that the name and discipline of the staff persons responsible for specific aspects of care were listed on the Master Treatment Plans for 5 of 8 active sample patients (1E, 8E, 16E, 15W and 24W). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Patient 1E: Admitted 2/07/12, MTP dated 2/07/12: the responsible staff for social work interventions listed responsible person as "counselor".

Patient 8E: Admitted 2/06/12, MTP dated 2/06/12: the responsible staff for social work interventions listed responsible person as "therapist".

Patient 16E: Admitted 2/04/12, MTP dated 2/04/12: the responsible staff for social work interventions listed responsible person as "therapist".

Patient 15W: Admitted 2/01/12, MTP dated 2/01/12: the responsible staff for social work interventions listed responsible person as "unit staff".

Patient 24W: Admitted 2/05/12, MTP dated 2/05/12: no responsible staff were listed for nursing or for medical staff interventions.

Interview:

In an interview with the Director of Social Work on 2/14/12 at 4:15PM, the Social Work Director acknowledged the above findings.