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Based on record review and staff interview, it was determined that eight (8) of eight (8) patients (patients 1, 2, 3, 4, 5, 6, 7, and 8) the Psychiatric Evaluations failed to include assessment of patient assets in descriptive, not interpretive fashion. This failure results in no information about patient interests, accomplishments, etc. i.e., inherent patient assets that the other members of the multidisciplinary treatment team might utilize in the selection of treatment interventions while the patient is hospitalized.

Findings include:

A. Record Review

1. Patient 1: The Psychiatric Evaluation, dated 7/13/19, stated as assets "Access to housing / residential stability" and "Interpersonal relationships and supports."

2. Patient 2: The Psychiatric Evaluation, dated 7/04/19, stated as assets "Attempting to realize one's potential" and "[S/he] is asking for help."

3. Patient 3: The Psychiatric Evaluation, dated 7/6/19, stated as assets "Motivation and readiness for change" and "Attempting to realize one's potential."

4. Patient 4: The Psychiatric Evaluation, dated 7/17/19, stated as assets "Exercising self-direction" and "Interpersonal relationships and supports."

5. Patient 5: The Psychiatric Evaluation, dated 6/19/19, stated as assets "Manage surrounding demand and opportunity [sic]" and "Manage surrounding demand and opportunity [sic]" as the "Patient strength 2."

6. Patient 6: The annual Psychiatric Evaluation, dated 9/10/18, no patient assets were described.

7. Patient 7: The Psychiatric Evaluation, dated 9/21/18, stated as assets "Setting and pursuing goals" and "Managing surrounding demand and opportunity [sic]."

8. Patient 8: The annual Psychiatric Evaluation, dated 6/5/19, had no assets described.

B. Staff Interview:

On 7/30/19 at 9:35 a.m. in an interview with the facility's Clinical Director, the findings described in Section A above, were discussed. The Clinical Director agreed with the findings.

Based on record review and interview, the Clinical Director failed to ensure that Psychiatric Evaluations contain an assessment of patient assets in descriptive, not interpretive fashion. This failure results in no information about inherent attributes that might serve as a basis for involving the patient in therapeutic endeavors.
(Refer to B117)