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Based on record review, policy review, and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient centered short term goals for (8) of eight (8) active patients (A1, A2, 3, A4, A5, A6, A7 and A8). The lack of observable, measurable, behavioral patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient needs.

Findings Include:

A. Specific Patient Findings:

1. Patient A1 admitted on 3/17/16 had listed on the MTP dated 3/18/16 for the problem, "Psychotic Behaviors", the following short term goals: "[Patient] will identify own delusional beliefs that [he/she] is hearing voices that other people cannot hear" and "[Patient] will identify how delusional beliefs have negatively impacted [his/her] life."

2. Patient A2 admitted on 3/9/16 had listed on the MTP dated 3/11/16 for the problem, "Mood Lability with Suicidal and Homicidal Ideations", the following short term goals: "[Patient] will report any suicidal thoughts/impulses to staff prior to acting on them" and "[Patient] will demonstrate two (2) therapeutic activities to decrease depressive, agitated and suicidal/homicidal thinking and sad/aggressive feelings."

3. Patient A3 admitted on 3/18/16 had listed on the MTP dated 3/20/16 for the problem, "Depression with Suicidal Ideation", the following short term goals: "[Patient] will report any suicidal thoughts/impulses to staff prior to acting on them" and "[Patient] will demonstrate use of at least one (1) cognitive strategies [sic] to replace suicidal thoughts or self-destructive behaviors."

4. Patient A4 admitted on 3/14/16 had listed on the MTP dated 3/16/16 for the problem, "Depression with Suicidal Ideation", the following short term goals: "[Patient] will report any suicidal thought and impulses to staff prior to acting on them" and "[Patient] will allow unit staff to assist/remind [his/her] with ADL and personal hygiene needs to prevent further deterioration."

5. Patient A5 admitted on 3/16/16 had listed on the MTP dated 3/18/16 for the problem, "Depression with Suicidal Ideation", the following short term goals: "[Patient] will report any suicidal thoughts/impulses to staff prior to acting on them" and [Patient] will identify one (1) negative thoughts [sic] and replace with one (1) positive thoughts [sic]."

6. Patient A6 admitted on 3/15/16 had listed on the MTP dated 3/17/16 for the problem, "Mood Lability with Suicidal and Homicidal Ideations", the short term goal: "[Patient] will report any suicidal and/or homicidal thoughts and impulses to harm [himself/herself], to staff prior to acting on them."

7. Patient A7 admitted on 3/8/16 had listed on the MTP dated 3/10/16 for the problem, "Mood Lability with both suicidal and homicidal ideation", the short term goal "[Patient] will report any suicidal or homicidal thoughts to staff prior to acting on them."

8. Patient A8 admitted on 3/16/16 had listed on the MTP dated 3/18/16 for the problem, "Aggressive Behaviors", the short term goal "[Patient] will identify one (1) example of how relationship with staff and peers contribute to [his/her] anger control problems."

B. Policy Review

Review of hospital policy "Interdisciplinary Treatment Plan" No. CS.001 Section 3. Individual Treatment Plans c. iii. Short Term Goal revealed the following requirements:"

1. This is a behavioral statement of the goals that are stepping stones to the long term goals. Goals should be written as patient-centered using patient's name for individualization.

2. Short term goals should be directly related to the problems identified in the assessments and throughout the patients [sic] hospitalization;

3. Each goal will be written as observable and measurable behavior to the achieved....

C. Interviews

1. In an interview on 3/22/16 at 9:00 AM, the Director of Nursing, CEO, and Clinical Director concurred that patient short term goals were not listed in observable measurable, behavioral terms.

2. In an interview on 3/22/16 at 10:00 AM, RN1 concurred that patient short term goals were not listed in observable, measurable, behavioral terms.

3. In an interview on 3/23/16 at 10:00 AM, the Medical Director acknowledged understanding of the need for observable, measurable, patient specific short term goals.

Based on record review, document review, and interview the Medical Director failed to ensure the development of Master Treatment Plans (MTPs) that identified patient centered short term goals for (8) of eight (8) active patients (A1, A2, A3, A4, A5, A6, A7, and A8). The lack of observable, measurable, behavioral patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient needs.

Interview

In an interview on 3/23/16 at 10:00 AM the Medical Director acknowledged understanding of the need for observable, measurable, patient specific short term goals.