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CENTERS INC, THE
COMPLETE NEUROLOGICAL EXAM RECORDED AT TIME OF ADMISSION
Tag No.: B0109
Based on interview and record review for eight (8) of eight (8) sample patients (4, 5, 6, 8, 9, 10, 11 and 12), the facility failed to document a descriptive neurological examination indicating what tests were performed to assess memory functioning. This restricts clinicians' ability to measure change in baseline function, thus affecting patient care.
Findings include:
A. Record Review
1. Patient 4-The psychiatric evaluation (1/9/17) stated "Memory: Limited."
2. Patient 5-The psychiatric evaluation (1/16/17) stated "Memory: Gross Memory Deficits." No additional information documented.
3. Patient 6-The psychiatric evaluation (1/11/17) stated "Memory: Poor Short-Term."
4. Patient 8-The psychiatric evaluation (1/14/17) stated "Memory: Intact."
5. Patient 9-The psychiatric evaluation (1/12/17) stated "Memory: Poor Short-Term."
6. Patient 10-The psychiatric evaluation (1/10/17) stated "Memory: Limited."
7. Patient 11-The psychiatric evaluation (10/5/17) stated "Memory: Gross Memory Deficits." No additional information documented.
8. Patient 12-The psychiatric evaluation (1/10/17) stated "Memory: N/A (Non-applicable)."
B. Interview
During interview on 1/18/17 at 11:50 a.m., the Clinical Director acknowledged the above findings.
EVALUATION INCLUDES INVENTORY OF ASSETS
Tag No.: B0117
Based on record review and interview, there was failure to note patient assets (personal attributes) in the psychiatric assessment in descriptive, not interpretive, fashion for three (3) of eight (8) sample patients (4, 11 and 12). This lack of patient information inhibits the treatment team's ability to use this individual patient information in formulating treatment plans.
Findings include:
A. Record Review
1. Patient 4-The psychiatric evaluation (1/9/17) identified assets as "Good Health."
2. Patient 11-The psychiatric evaluation (10/5/17) identified assets as "None noted."
3. Patient 12-The psychiatric evaluation (1/12/17) identified assets as "Good Health."
B. Interview
During interview on 1/18/17 at 11:50 a.m., the Clinical Director acknowledged the above findings.