HospitalInspections.org

Based on record review and staff interview, the facility failed to develop Master Treatment Plans that included a substantiated diagnosis for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 9, 11, 12, and 13). The absence of a substantiated diagnosis (or diagnoses) on the treatment plan compromises the treatment team's ability to deliver clinically focused treatment.


Findings include:


A. Record Review


The MTPs (dates in parentheses) for the following patients did not contain substantiated diagnoses: Patient 1 (10/16/16), Patient 2 (10/24/16), Patient 3 (10/20/16), Patient 4 (10/21/16, revised 10/22/16), Patient 9 (10/21/16), Patient 11 (10/5/16), Patient 12 (10/20/16), and Patient 13 (10/5/16, revised 10/11/16).


B. Staff Interview


1. During an interview with MD1, the attending psychiatrist for these patients, on 10/25/16 at 9:00 a.m., he acknowledged that no diagnoses were documented on the MTP's for Patients 1, 2, 3, 4, 9, 11, 12, and 13.


2. During an interview with the Medical Director on 10/25/16 at 12:00 p.m., he acknowledged that no diagnoses were documented on the MTP's for Patients 1, 2, 3, 4, 9, 11, 12, and 13.