HospitalInspections.org

Based on policy review, document review, and interview the Critical Access Hospital (CAH) failed to ensure patients had a complete individual comprehensive treatment plan with treatment interventions, short term goals, and long-term goals for 4 of 4 Patient (Patient 1, 2, 3 and 4). This deficient practices has the potential to place patients at risk for deterioration of current illness and harm.

Findings Include:

Review of facility policy titled, "Treatment Planning and Documentation of Patient Care" Revised 04/03/23 showed "POLICY" It is the policy of Girard Medical Center Senior Behavioral Health Inpatient Services (SBH) that each patient is provided with individualized, planned, and appropriate interventions that are designed to meet the patient's need for treatment. The patient's response to care is regularly monitored and treatment reassessed to determine effectiveness and to enable the individual to feel a sense of achievement.

... The Comprehensive Interdisciplinary Treatment Plan

Treatment Plans for Identified Problems

A. Long- and Short-Term Goals - Long- and short-term goals are specified on the problem treatment plan. Each active problem from the problem list should be identified and interventions elaborated.

B. Long Term Goals (LTGS)

i. Long-term goals are the expected outcomes of the treatment process. They are the same as the discharge criteria or treatment outcomes. If the patient is likely to be transferred to another level of care for services as a part of treating the current episode of illness, the time required to accomplish this should be the time frame for the long-term goals.

ii. Long term goals are always stated in measurable, descriptive terms. Measurable means that the expectation is behaviorally stated and can be observed or measured. For example, an individual with severe depressive symptoms may have functional impairments and acuity evidenced by an inability to function at home or work, sleeping more than 12 hours per day, not eating regularly, subjective feelings of hopelessness and worthlessness, lack of concentration, lack of enjoyment in activities. The long-term goals would be related to these symptoms or impairments such as "Patient will report improved feelings of wellbeing for three days, will eat regular meals, will sleep 8 -10 hours per day, and will be observed and report improved concentration."

iii. Long term goals are always "patient behaviors." This is updated as appropriate through the treatment plan review. Each long-term goal serves as one criterion for discharge from the inpatient program.

C. Short Term Goals

i. Short term goals or objectives specify what small changes or steps in the treatment process the patient must achieve in order to accomplish the long-term goals.

ii. Objectives are always stated in specific behavioral expectations that relate to long term goals. Objectives can be measured and easily observed. Objectives are always expectations of the patient, not activities that staff would conduct. In addition, short term goals are related or linked to the types of interventions to be used to achieve those goals.

iii. Objectives have target dates that are small timeframes to allow for the next step in the treatment process. These dates may be revised as appropriate through the treatment plan review. There can be more than one objective related to each long-term goal.

Patient 1

Review of Patient 1's discharged medical record showed a 83-year-old admitted voluntarily on 10/16/22. The patient was admitted for dementia with aggressive behavior. The medical history showed Basal Cell Carcinoma (skin cancer that develops on the skin exposed to the sun) of the nose, chronic atrial fibrillation (irregular and rapid heart rhythm), Tachy Brady (period of fast and slow heart rates) syndrome, and Benign prostatic hypertrophy (noncancer growth of prostate tissue).

Review of the master treatment plan (MTP), initiated on 10/17/22, showed treatment for the following problems cognitive deficits (decline in memory), placement and the potential for injury related to falls, seclusion, restraint.

The MTP does not include short term and long-term goals or nursing interventions.

Review of a document titled "SBH IP (Senior Behavioral Health Interdisciplinary Plan) Master Treatment Plan" dated 10/17/22 showed an active psychiatric and medical problem list that included 1. Cognitive deficits; 2. Placement; 3. Potential injury related to falls, seclusion, and restraints.

The facility failed to show individualized long-term goals and short-term goals that are observable and measurable for the problem list.

Patient 2

Review of Patient 2's discharged medical record showed a 89-year-old patient admitted voluntarily on 11/15/22. The patient was admitted for increased agitation with verbal and physical aggression. The psychological diagnosis showed Dementia (memory loss) with physical aggression and violence and depression. The medical history showed Parkinson's (brain disorder that causes unintended or uncontrollable movements), dry eye syndrome, seasonal allergic rhinitis, constipation, osteoarthritis (degeneration of the joint) of the right knee, benign prostatic hypertrophy (noncancer growth of prostate tissue), chronic back pain, seizure disorder (disorder of the brain), chronic pain, and Vitamin B deficiency.

The master treatment plan initiated on 11/16/22 showed treatment for the following problems, major depressive disorder (MDD) with psychotic features, and Parkinson's dementia with behavioral disturbances.

Review of a document titled "SBH IP Master Treatment Plan" dated 11/16/22 showed an active psychiatric and medical problem list that included 1. Cognitive deficits; and 2. Potential injury related to falls, seclusion, and restraints.

The facility failed to show individualized long-term goals and short-term goals that are observable and measurable for the problem list.

Patient 3

Review of Patient 3's discharged medical record showed a 92-year-old patient admitted voluntarily on 03/17/23. The patient was admitted for dementia with related behavior problems. The medical history showed hypertension (elevated blood pressure), dry eyes, hyperlipidemia (excess of lipids or fats in your blood), urinary tract infections, diabetes, gastroesophageal reflux disease (back flow of stomach acid in your mouth and esophagus), anemia, and chronic kidney disease (progressive damage and loss of function in the kidneys).

The master treatment plan initiated on 03/17/23 showed treatment for the following problems, major depressive disorder recurrent with psychotic features, generalized anxiety, unspecified dementia with behavioral disturbances, restlessness, and agitation.

The nursing care plan does not include long term and short-term goals or interventions.

Review of a document titled "SBH IP Master Treatment Plan" dated 03/17/23 showed an active psychiatric and medical problem list that included 1. Risk of Harm to Self or Other; and 2. Potential injury related to falls, seclusion, and restraints.

The facility failed to show individualized long-term goals and short-term goals that are observable and measurable for the problem list.

Patient 4

Review of Patient 4's current medical records show a 77-year-old admitted voluntarily on 03/17/23. The psychological diagnosis is Dementia with related physical aggression and behaviors. The medical history showed hypertension, Diabetes, Hypothyroidism, Vitamin D deficiency, chronic sinusitis (inflammation of the tissues in your sinuses), hyperlipidemia, and osteoarthritis.

Review of the master treatment plan initiated on 03/17/23 showed treatment for the following problems, Major depressive disorder recurrent with psychotic features, unspecified dementia with behavioral disturbance and restless and agitation, no changes to medical regimen during the initial team meeting.

Review of the nursing care plan initiated on 03/17/23 showed the following problems, risk for violence, risk of falls, long term care required and alteration in blood glucose levels.

Review of the nursing care plan showed a problem list with goals listed, however, the goals are not designated as long term or short-term goals and does not include nursing interventions.

Review of a document titled "SBH IP Master Treatment Plan" dated 03/17/23 showed an active psychiatric and medical problem list that included 1. Risk of Harm to Self or other; 2. Cognitive deficits; and 3. Potential injury related to falls, seclusion, and restraints.

The facility failed to show individualized long-term goals and short-term goals that are observable and measurable for the problem list.

During an interview on 04/06/23 at 1:15 PM Staff C, Program Director stated "Care plans are on the Nursing Flow sheet. The goals from these are included in the MTP and the Tx Plan Review which are updated every 7 days."

The facility failed to provide documentation of long-term and short-term goals in the patient's medical record per policy.