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Based on medical record review, review of hospital documents and staff interview it was determined the hospital failed to ensure the patient and/or guardian was provided the right to participate in the development and implementation of their treatment plans. This failure impacted fourteen (14) of fourteen (14) patients reviewed (patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) and has the potential to violate the rights of all patients to participate in his or her plan of care. Findings include:

1. The State Agency received a complaint related to patient #1, who is a child. The complaint included an allegation the patient's parents called the hospital multiple times each day to check on the child's progress and leave messages for the physician to contact them. This physician (P#1) cared for the patient for eight (8) days. He did not order any medications during these eight (8) days and he did not return the parent's phone calls. The parents were told by hospital staff that physician #1 "did not talk to patient's parents."

2. Review of the medical record revealed physician #1 was the attending psychiatrist for patient #1, age 8, from 1/24/11 through 2/1/11. Review of the Child's History, completed by the mother on 1/24/11, revealed one of the questions was: "What things about your child and your family will help you through the problems your child is having?" The mother's recorded response was: "Getting (patient's) medicine stable would help her." The patient's diagnosis was noted as Depressive Disorder and Oppositional Defiant Disorder. No medications were ordered during the eight (8) days physician #1 cared for the patient. On 2/1/11 an order was written to transfer the patient to physician #2.

3. During the course of the survey, confidential interviews were conducted with multiple staff members from the Children's Unit where the patient was treated. All staff interviewed acknowledged chronic problems with avoidance of family contacts by physician #1. Two (2) staff members acknowledged they do tell families at admission that physician #1 doesn't contact families.

4. During these interviews all staff acknowledged being aware the family of patient #1 made requests to speak to physician #1. All staff was aware of the concern related to a lack of medication treatment. Multiple staff reported that notes were left on the chart asking physician #1 to call the family.

5. Interview was conducted with the Children's Unit Program Manager in the morning of 3/29/11. She stated the patient's mother contacted her by phone related to a concern that no medications were ordered for over a week and that physician #1 would not contact her to answer her questions related to the current plan of care and treatment. The Program Manager stated she failed to document the conversation in the record but did make arrangements for the care of patient #1 to be transferred to physician #2.

6. Interview was conducted with Physician #1 in the morning of 3/30/11. He acknowledged he was aware the family of patient #1 wanted to speak with him. He confirmed there was a note left on the chart related to this request. He also acknowledged that he didn't contact the family.

As a result the family of patient #1 was denied the opportunity to exercise their right to participate in treatment planning for their daughter.

7. The current Admission Handbook for the Children's Unit was provided for review. Review of the "Patient's Rights and Responsibilities," statement #5 revealed it states; "You have the right to help develop your treatment plan with staff. This written plan of care must be made a part of your record within three (3) days and must be reviewed at proper times during your hospital stay."

8. The Policy, "Master Treatment Plan", last revised 5/10, was provided for review. It states in part: "Presentation of the MTP (Master Treatment Plan) with guardian, significant other or family should take place as soon as possible following the MTP meeting."

9. Review of the 3/26/11 MTP for patient #2, age 12, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

10. Review of the 3/27/11 MTP for patient #3, age 9, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

11. Review of the record for patient #4, age 8, revealed he was admitted on 3/25/11. Review of the record on 3/30/11 revealed no MTP was developed. The record lacked any documentation reflecting the opportunity to participate had been provided to the patient or guardian.

12. Interview with the Dayshift Charge Nurse, in the morning of 3/30/11 revealed this patient's MTP was overlooked and had not been developed.

13. Review of the 3/26/11 MTP for patient #5, age 7, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

14. Review of the 3/22/11 MTP for patient #6, age 8, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

15. Review of the 3/28/11 MTP for patient #7, age 11, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

16. Review of the 3/28/11 MTP for patient #8, age 11, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

17. Review of the 3/23/11 MTP for patient #9, age 8, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

18. Review of the 3/26/11 MTP for patient #10, age 6, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

19. Review of the 3/25/11 MTP for patient #11, age 8, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

20. Review of the 3/25/11 MTP for patient #12, age 10, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

21. Review of the 3/26/11 MTP for patient #13, age 11, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

22. Review of the 3/19/11 MTP for patient #14, age 10, revealed no documentation the patient or patient's guardian participated. The record lacked any documentation reflecting the opportunity to participate was provided.

23. Interviews were conducted with both the Dayshift and Evening Charge Nurses during the morning and afternoon of 3/29/11. The Dayshift Charge Nurse was interviewed again while observations were conducted on the Children's Unit in the late morning on 3/30/11. Interview with the Dayshift Charge Nurse confirmed that currently the Children's Unit does not have a Treatment Plan Coordinator. They both confirmed that currently the MTP is reviewed with the patient and guardian at the time of discharge.

24. Interview was conducted with both the Nurse Executive and the Director of Quality/Risk Management in the early afternoon of 3/28/11 and the Children's Unit Program Manager in the morning of 3/29/11. These Master Treatment Plans were reviewed and discussed. All acknowledged the Children's Unit does not currently provide an opportunity for patients and guardians to attend and/or participate in the treatment planning meeting.

This failure to ensure patients are provided the right to participate in the development and implementation of their treatment plans is noted to be a continuation of noncompliance which was identified and cited during a complaint survey completed on 5/06/10.

25. When this continued noncompliance was discussed with the Nurse Executive and Director of Quality/Risk Management, they indicated there was a misunderstanding related to the prior deficiency.

Based on review of documents and staff interview, it was determined the hospital failed to ensure the QA/PI program is monitoring whether the guardian/family is offered the opportunity to participate in the treatment plan and whether the attending physician is participating in the development of the Master Treatment Plan (MTP). A failure to monitor previously identified deficient areas has resulted in continuing noncompliance in these areas and has the potential to negatively impact the quality of care rendered to all patients. Findings include:

1. During a complaint survey which ended on 5/6/10 the hospital was cited under Patient Rights for failing to provide the patient/guardian the right to participate in treatment planning and under Medical Staff for failure of the medical staff to enforce a requirement the physician participate in development of the MTP.

2. During the course of another complaint survey conducted 3/28/11 through 3/31/11 these same deficient practices were identified and recited.

3. Review of the hospital's Plan of Correction (PoC) from the previous survey, dated 5/6/10, indicated the Social Worker or Case Worker will make specific contact with the guardian/family member to enlist participation in the development of the patient's MTP; this activity will be monitored via chart reviews and the findings will be reported to the Performance Improvement Steering Committee monthly.

4. A review of the QA/PI Steering Committee Minutes for the past twelve (12) months failed to indicate any evidence the committee had received such reports after July of 2010.

5. During interview with the Director of Quality Management on 3/30/11 at 3:30 p.m. she confirmed these findings were last reported to the Steering Committee back in July of 2010.

6. The hospital's PoC from the same survey (as indicated above) indicated the attending physician will participate in the development of the patient's MTP. The Medical Director will perform chart reviews to ensure the attending physician's participation in the formulation of the MTP and these findings will be reported to the Performance Improvement Steering Committee monthly and reported to the quarterly Medical Staff Meetings.

7. A review of the Medical Staff Meeting Minutes and the QA/PI Steering Committee Minutes since that time failed to provide any evidence that these findings were reported as indicated in the PoC.

8. During interview with Director of Quality on 3/30/11 in the afternoon, she stated these findings have not been monitored and reported to the Performance Improvement Steering Committee nor to the quarterly meetings of the medical staff.

9. The 2011 Performance Improvement Plan indicated in part (under the sub-section titled Performance Improvement Steering Committee) "The PI Steering Committee is responsible for overall implementation and over-site of this plan ...... and acts on quality related information from the departments, committees of the hospital, the medical staff and retrospective review functions".

There was no evidence the Steering Committee received any QA/PI monitoring reports regarding the Attending Physicians' participation in the patient's MTP. There were no reports regarding whether the guardian/Family were being afforded the opportunity to participate in the patient treatment plans after July of 2010.

10. These findings were reviewed with the Director of Quality/Risk Manager on 3/31/11 in the a.m. and she agreed with the findings.

Based on medical record review, review of medical staff rules and regulations and staff interview it was determined the hospital medical staff failed to enforce the requirement for the physician to participate in the development of the Master Treatment Plan (MTP) and/or the treatment plan review for fourteen (14) of fourteen (14) patients reviewed (patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14). This failure creates a potential for the quality of care for all patients to be adversely affected. Findings include:

1. Review of the Medical Staff Rules and Regulations, last revised 10/09, revealed it included the following under "Multidisciplinary Master Treatment Plan: All physicians with active medical staff membership and privileges to admit and treat patients shall participate in the development of the master treatment plan."

2. Review of the 2/03/11 Treatment Plan Review for patient #1 revealed the Responsible Staff Signature and Progress sections for the physician were not completed.

3. Review of the 3/26/11 Master Treatment Plan (MTP) for patient #2 revealed the plan was not signed by the psychiatrist.

4. Review of the 3/27/11 MTP for patient #3 revealed the plan was not signed by the psychiatrist.

5. Review of the MTP for patient #4, who was admitted on 3/25/11, revealed the MTP had not been developed.

6. Review of the MTP for patient #4 with the Dayshift Charge Nurse on the Children's Unit in the late morning of 3/30/11. He acknowledged the MTP, which is to be developed within three (3) days of admission, was overlooked and was not done.

7. Review of the 3/26/11 MTP for patient #5 revealed the plan was not signed by the psychiatrist.

8. Review of the 3/22/11 MTP for patient #6 revealed the plan was not signed by the psychiatrist.

9. Review of the 3/28/11 MTP for patient #7 revealed the plan was not signed by the psychiatrist.

10. Review of the 3/28/11 MTP for patient #8 revealed the plan was not signed by the psychiatrist.

11. Review of the 3/23/11 MTP for patient #9 revealed the plan was not signed by the psychiatrist.

12. Review of the 3/26/11 MTP for patient #10 revealed the plan was not signed by the psychiatrist.

13. Review of the 3/25/11 MTP for patient #11 revealed the plan was not signed by the psychiatrist.

14. Review of the 3/25/11 MTP for patient #12 revealed the plan was not signed by the psychiatrist.

15. Review of the 3/26/11 MTP for patient #13 revealed the plan was not signed by the psychiatrist.

16. Review of the 3/19/11 MTP for patient #14 revealed the plan was not signed by the psychiatrist.

17. Review of the 3/26/11 Treatment Plan Review for patient #14 revealed the Responsible Staff Signature and Progress sections for the physician were not completed.

18. Interview was conducted with both the Nurse Executive and the Director of Quality/Risk Management in the early afternoon of 3/28/11 and the Children's Unit Program Manager in the morning of 3/29/11. These Master Treatment Plans were reviewed and discussed. All acknowledged the psychiatrists on the Children's Unit do not currently participate in the treatment planning meeting.

This failure of medical staff to enforce the requirement for the physician to participate in the development and/or review of treatment plans is noted to be a continuation of noncompliance which was identified and cited during a complaint survey completed on 5/06/10.

19. When this continued noncompliance was discussed with the Nurse Executive and Director of Quality/Risk Management, they indicated the lack of physician participation was a chronic problem.