HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that physician goals for the patient and interventions included on the master treatment plan were individualized. Instead, the physician goals, objectives, descriptions, and frequency of interventions were identical for all 8 patients in the sample (A7, A10, A14, B4, B5, B13, C4, and C6). In addition, routine generic discipline functions and assessments were inappropriately labeled as interventions. This deficiency resulted in a lack of guidance for staff in providing individualized patient treatment.

Findings include:

A. Record review:

1. The treatment plan for patient A7 contained the following:
Goal: "[pt] will report significant reduction in symptoms and behaviors that impair functioning."

Objective: "To assess the consumer's need for medications based on the clinical presentation."
Description: "Psychiatric Evaluation/IP."
Frequency: "One time per admission"

Objective: "The attending physician will monitor the efficacy of medications and progress being made towards stabilization on a daily basis."
Description: "Psychiatric doctor services/Ongoing evaluation."
Frequency: "One time per day"

Objective: "To assess the consumer's physical health and well-being"
Description: "Initial H&P"
Frequency: "One time per admission"


2. The treatment plan for patient A10 contained the following:
Goal: "[pt.] will report significant reduction in symptoms and behaviors that impair functioning."

Objective: "To assess the consumer's need for medications based on the clinical presentation."
Description: "Psychiatric Evaluation/IP."
Frequency: "One time per admission"

Objective: "The attending physician will monitor the efficacy of medications and progress being made towards stabilization on a daily basis."
Description: "Psychiatric doctor services/Ongoing evaluation."
Frequency: "One time per day"

Objective: "To assess the consumer's physical health and well-being"
Description: "Initial H&P"
Frequency: "One time per admission"


3. The treatment plan for patient A14 contained the following:
Goal: "[pt.] will report significant reduction in symptoms and behaviors that impair functioning."

Objective: "To assess the consumer's need for medications based on the clinical presentation."
Description: "Psychiatric Evaluation/IP."
Frequency: "One time per admission"

Objective: "The attending physician will monitor the efficacy of medications and progress being made towards stabilization on a daily basis."
Description: "Psychiatric doctor services/Ongoing evaluation."
Frequency: "One time per day"

Objective: "To assess the consumer's physical health and well-being"
Description: "Initial H&P"
Frequency: "One time per admission"


4. The treatment plan for patient B4 contained the following:
Goal: "[pt.] will report significant reduction in symptoms and behaviors that impair functioning."

Objective: "To assess the consumer's need for medications based on the clinical presentation."
Description: "Psychiatric Evaluation/IP."
Frequency: "One time per admission"

Objective: "The attending physician will monitor the efficacy of medications and progress being made towards stabilization on a daily basis."
Description: "Psychiatric doctor services/Ongoing evaluation."
Frequency: "One time per day"

Objective: "To assess the consumer's physical health and well-being"
Description: "Initial H&P"
Frequency: "One time per admission"


5. The treatment plan for patient B5 contained the following:
Goal: "[pt.] will report significant reduction in symptoms and behaviors that impair functioning."

Objective: "To assess the consumer's need for medications based on the clinical presentation."
Description: "Psychiatric Evaluation/IP."
Frequency: "One time per admission"

Objective: "The attending physician will monitor the efficacy of medications and progress being made towards stabilization on a daily basis."
Description: "Psychiatric doctor services/Ongoing evaluation."
Frequency: "One time per day"

Objective: "To assess the consumer's physical health and well-being"
Description: "Initial H&P"
Frequency: "One time per admission"


6. The treatment plan for patient B13 contained the following:
Goal: "[pt.] will report significant reduction in symptoms and behaviors that impair functioning."

Objective: "To assess the consumer's need for medications based on the clinical presentation."
Description: "Psychiatric Evaluation/IP."
Frequency: "One time per admission"

Objective: "The attending physician will monitor the efficacy of medications and progress being made towards stabilization on a daily basis."
Description: "Psychiatric doctor services/Ongoing evaluation."
Frequency: "One time per day"

Objective: "To assess the consumer's physical health and well-being"
Description: "Initial H&P"
Frequency: "One time per admission"


7. The treatment plan for patient C4 contained the following:
Goal: "[pt.] will report significant reduction in symptoms and behaviors that impair functioning."

Objective: "To assess the consumer's need for medications based on the clinical presentation."
Description: "Psychiatric Evaluation/IP."
Frequency: "One time per admission"

Objective: "The attending physician will monitor the efficacy of medications and progress being made towards stabilization on a daily basis."
Description: "Psychiatric doctor services/Ongoing evaluation."
Frequency: "One time per day"

Objective: "To assess the consumer's physical health and well-being"
Description: "Initial H&P"
Frequency: "One time per admission"


8. The treatment plan for patient C6 contained the following:
Goal: "[pt.] will report significant reduction in symptoms and behaviors that impair functioning."

Objective: "To assess the consumer's need for medications based on the clinical presentation."
Description: "Psychiatric Evaluation/IP."
Frequency: "One time per admission"

Objective: "The attending physician will monitor the efficacy of medications and progress being made towards stabilization on a daily basis."
Description: "Psychiatric doctor services/Ongoing evaluation."
Frequency: "One time per day"

Objective: "To assess the consumer's physical health and well-being"
Description: "Initial H&P"
Frequency: "One time per admission"


B. Interview:

In an interview on 6/1/12 at 8:30am, the Medical Director acknowledged that the physician goals and interventions were not individualized.