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Based on medical record review and staff interview it was determined that the facility failed to describe the responsible physician and nursing responsibilities in the behavioral and medical components of the Comprehensive Treatment Plan of eight (8) of eight (8) active sample patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4).

These failures resulted in treatment plans that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include

I Medical Record review:

1. Patient A1: The Comprehensive Treatment Plan which consisted of both a behavioral and medical care components dated 3/16/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "alteration in comfort," "dyspepsia," "sleep difficulty", "Pain", and "GERD (gastric esophageal reflux disease" yet lacked a description of any physician involvement and no identified nursing plan of care was present in the behavioral component.

2. Patient A2: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 3/8/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "dyspepsia," HIV", "impaired skin integrity", "nicotine dependence", "pain", "sleep difficulty", "immune deficiency disorder", "risk for falls" and "decreased cardiac output - edema" lacked a description of any physician involvement and no identified nursing plan of care in both the behavioral and medical components.

3. Patient A3: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 3/12/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "hepatitis C", "pain", "sleep [sic]", "impaired skin integrity", "seizures" ,and "alternation in comfort-acute" lacked description of any physician involvement and no identified nursing plan of care was present in the behavioral component.

4. Patient A4: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 2/26/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "hypertension", "fall risk", "sleep difficulty" ,"herpes", "Hepatitis C", "imbalance nutrition " and "risk for infection" lacked description of any physician involvement and no identified nursing plan of care was present in the behavioral component.

5. Patient B1: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 2/29/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "asthma", "eczema", "overweight" and "insomnia" lacked a description of physician involvement and no identified nursing plan of care was present in the behavioral component.

6. Patient B2: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 2/25/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "tachycardia", "hypertension", "BLE (bilateral lower extremity) edema", "seasonal allergies", "risk for bleeding", "sleep difficulty " , "risk for falls", "urinary retention" and "impaired skin integrity" lacked description of any physician involvement and no identified nursing plan of care in the behavioral component.

7. Patient B3: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 2/24/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "constipation", "HIV", "HTN (hypertension,", "GERD", "sleep difficulty", "neuropathy", "imbalance nutrition", and "vitamin D deficiency" lacked description of any physician involvement and no identified nursing plan of care in the behavioral component.

8. Patient B4: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 3/21/16 lacked any physician involvement in the medical care plan component focused on "insomnia", "nicotine dependence", "constipation", "edema", "alternation in comfort" and "inadequate breathing" lacked description of any physician involvement and no identified nursing plan of care in the behavioral component.


II. Staff interview:

1. On 3/21/16 at 1:30 PM the CEO was shown several of the findings described in Section I above. She agreed with the findings.

2. On 3/23/16 at 9:30 AM the facility CEO and the Director of Hospital Operations were interviewed. The focus was the findings describe in Section I above, they both concurred with the findings.

Based on interview and medical record review, the Medical Director failed to ensure that the Comprehensive Treatment Plan which has both behavioral and medical components for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4) included physician interventions that were individualized and that specified the form or the frequency of treatment. No physician interventions were included in these treatment plans. This results in Treatment Plans that do not reflect what the psychiatrist and/or the other medical staff will be doing during the patient's hospitalization.

Findings include:

A. Record review

1. No specific interventions for the psychiatrist were included in the behavioral and/or the medical care components of the Comprehensive Treatment Plan (CTP). Patient A1 (CTP dated 3/16/16), Patient A2 (CTP dated 3/8/16), Patient A3 (CTP dated 3/12/16), Patient A4 (CTP dated 2/26/16), Patient B1 (CTP dated 2/29/16), Patient B2 (CTP dated 2/25/16) and Patient B3 (CTP dated 2/24/16) and Patient B4 (CTP dated 3/21/16).

1. Patient A1: The Comprehensive Treatment Plan which consisted of both a behavioral and medical care components dated 3/16/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "alteration in comfort," "dyspepsia," "sleep difficulty", "Pain" and "GERD (gastric esophageal reflux disease" yet lacked a description of any physician involvement and no identified nursing plan of care was present in the behavioral component.

2. Patient A2: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 3/8/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "dyspepsia", "HIV", "impaired skin integrity", "nicotine dependence", "pain", "sleep difficulty", "immune deficiency disorder", "risk for falls" and "decreased cardiac output - edema" lacked a description of any physician involvement and no identified nursing plan of care in both the behavioral and medical components.

3. Patient A3: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 3/12/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "hepatitis C", "pain", "sleep [sic]", "impaired skin integrity", "seizures" and "alternation in comfort-acute" lacked description of any physician involvement and no identified nursing plan of care was present in the behavioral component.

4. Patient A4: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 2/26/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "hypertension", "fall risk", "sleep difficulty" ,"herpes", "Hepatitis C", "imbalance nutrition" and "risk for infection" lacked description of any physician involvement and no identified nursing plan of care was present in the behavioral component.

5. Patient B1: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 2/29/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "asthma", "eczema", "overweight" and "insomnia" lacked a description of physician involvement and no identified nursing plan of care was present in the behavioral component.

6. Patient B2: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 2/25/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "tachycardia", "hypertension", "BLE (bilateral lower extremity) edema", "seasonal allergies", "risk for bleeding", "sleep difficulty", "risk for falls", "urinary retention" and "impaired skin integrity" lacked description of any physician involvement and no identified nursing plan of care in the behavioral component.

7. Patient B3: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 2/24/16 lacked any statement of involvement by the psychiatrist other than "Responsible for overall care." The medical care plan component focused on "constipation", "HIV", "HTN (hypertension,", "GERD", "sleep difficulty", "neuropathy", "imbalance nutrition" and "vitamin D deficiency" lacked description of any physician involvement and no identified nursing plan of care in the behavioral component.

8. Patient B4: The Comprehensive Treatment Plan which consisted of both behavioral and medical components dated 3/21/16 lacked any physician involvement in the medical care plan component focused on "insomnia", "nicotine dependence", "constipation", "edema", "alternation in comfort" and "inadequate breathing" lacked description of any physician involvement and no identified nursing plan of care in the behavioral component.


II. Staff interview:

1. On 3/21/16 at 1:30 PM the CEO was shown several of the findings described in Section I above. She agreed with the findings.

2. On 3/23/16 at 9:30 AM the facility CEO and the Director of Hospital Operations were interviewed. The focus was the findings describe in Section I above, they both concurred with the findings.

Based on record review and staff interview, it was determined that the Director of Nursing (DON) failed to monitor and take corrective action to ensure that individualized treatment plans were develop in the behavioral component of the Comprehensive Treatment Plan that clearly delineated active treatment oriented nursing interventions to address specific patient psychiatric problems and assist patients to accomplishment treatment goals for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). There were no nursing goals or interventions addressing the psychiatric diagnosis of the patients. Failure to document individualized nursing interventions on patient's treatment plans hampers the staff's ability to assure consistency of treatment and can result in failure to deliver effective psychiatric care. The findings include:

A. Record review

1. No specific interventions for nursing were included in the behavioral care plan of the Comprehensive Treatment Plan. Patient A1 (CTP dated 3/16/16).Patient A2 (CTP dated 3/8/16).Patient A3 (CTP dated 3/12/16).Patient A4 (CTP dated 2/26/16). Patient B1 (CTP dated 2/29/16) PatientB2 (CTP dated 2/25/16). Patient B3 (CTP dated 2/24/16). Patient B4 (CTP dated 3/21/16).




B. Staff interview(s)

1. On 3/22/16 at 1:00 P.M. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed. The focus was the findings described in Section I above - absence of the nursing interventions in addressing psychiatric problems in the "Behavioral treatment care plan." They stated that nursing staff addresses the medical problems in the Medical care plan component and the other clinicians address their efforts in the Behavioral component.

2. On 3/21/16 at 09:50 AM RN #1 was interviewed. She stated that nurses document their efforts in the Medical care plan component of the Comprehensive Treatment Plan and not in the Behavioral component.