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Based on document review and interview, it was determined, for 6 of 10 patients (Pt's #1, 2, 4, 6, 8, and 10) in the inpatient psychiatry mental health unit ( 5 A/G), the Hospital failed to ensure patient participation in the treatment plan. This has the potential to affect all patients in the inpatient psychiatry mental health unit.

Findings include:

1. On 10/28/2015 at approximately 4:00 PM the Illinois "Mental Health and Developmental Disabilities (405 ILCS 5/) Mental Health and Developmental Code" was reviewed. Under Article I. Rights Sec. 2-102 "The recipient's preferences regarding emergency interventions under, subsection (d) of Section 2-200 shall be noted in the recipient's treatment plan".

2. On 10/26/2015 and 10/27/2015 the following clinical records were reviewed with the Director of Psychiatric Services ( E #2). The section under "Patient's preferred treatment in the event of a psychiatric crisis:" on the Hospital "INPATIENT PSYCHIATRIC TREATMENT PLAN" form was not completed.

Patients include:

- Pt #1 was admitted on 9/2/2015 with a diagnosis of schizoaffective disorder and was discharged on 9/16/2015. The patient preference was not indicated.

- Pt #2 was admitted on 10/18/2015 with a diagnosis of schizoaffective disorder. The patient preference was not indicated.

- Pt #4 was admitted on 10/23/2015 with a diagnosis of bipolar disorder. The patient preference was not indicated.

- Pt #6 was admitted on 10/23/2015 with a diagnosis of anxiety disorder. The patient preference was not indicated.

- Pt #8 was admitted 8/20/2015 with a diagnosis of dementia with behavioral disturbances and was discharged on 9/10/2015. The patient preference was not indicated.

- Pt #10 was admitted 9/18/2015 with a diagnosis of major depressive disorder and discharged on 9/19/2015. The patient prefence was not indicated.

3. The Director of Psychiatric Service (E #2) stated during an interview on 10/27/2015 at approximately 3:00 PM, the patient's preferred treatment was not a requirement to be completed but was the facilities attempt to provide good care.

Based on document review and interview, it was determined for 10 of 10 patients (Pt. #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) in the Inpatient Psychiatric Unit (5 A/G), the Hospital failed to ensure the treatment plan was complete. This has the potential to affect all patients in the inpatient psychiatric mental health unit.

Findings include:

1. On 10/28/2015 at approximately 4:15 PM the "Mental Health and Developmental Disabilities (405 ILCS 5/) Mental Health and Developmental Code" was reviewed. Under Chapter III Admission, Transfer and Discharge Procedures for the Mentally Ill
Section 3-209 indicates "Within three days of admission under this Chapter, a treatment plan shall be prepared for each recipient of service and entered into his or her record".

2. On 10/27/2015 at approximately 2:00 PM the policy titled "Patient Care Policy/Procedure Psychiatry Services: Treatment Services indicates "Interdisciplinary treatment plans are developed within 3 days of admission".

3. On 10/26/2015 and 10/27/2015 the following clinical records were reviewed with the Director of Psychiatric Services ( E #2). "THE INPATIENT PSYCHIATRIC TREATMENT PLAN" was not dated, timed or authenticated by the physician.

- Pt #1 was admitted on 9/2/2015 with a diagnosis of schizoaffective disorder and was discharged on 9/16/2015.

- Pt #2 was admitted on 10/18/2015 with a diagnosis of schizoaffective disorder.

- Pt #3 was admitted 9/4/2015 with a diagnosis of schizoaffective disorder and was discharged on 10/26/2015.

- Pt #4 was admitted on 10/23/2015 with a diagnosis of bipolar disorder.

- Pt #5 was admitted on 10/12/2015 with a diagnosis of major depressive disorder .

- Pt #6 was admitted on 10/23/2015 with a diagnosis of anxiety disorder.

- Pt #7 was admitted on 9/9/2015 with a diagnosis of bipolar disorder and was discharged on 9/29/2015.

- Pt #8 was admitted on 8/20/2015 with a diagnosis of dementia with behavioral disturbances and was discharged on 9/10/2015.

- Pt #9 was admitted on 7/30/2015 with a diagnosis of schizoaffective disorder and discharged on 8/12/2015.

- Pt #10 was admitted 9/18/2015 with a diagnosis of major depressive disorder and discharged on 9/19/2015.

4. An interview was conducted with the Director of Psychiatric Services (E #2) on 10/27/2015 at approximately 2:00 PM. E #2 stated when the physician completes a history and physical this includes the plan of care and treatment. I am not sure we need to indicate the plan of care on the Inpatient Psychiatric Treatment Plan.