The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

DALE MEDICAL CENTER 126 HOSPITAL AVE OZARK, AL 36360 April 12, 2017
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records (MR), policy and interviews it was determined the nursing care plan, a part of the interdisciplinary plan of care, failed to:

1. Include long term goals.

2. Include specify interventions for each problem which included the frequency of the intervention and the discipline/staff responsible for the intervention.

3. Include updates regarding patients failing to participate in group activities.

This affected 3 of 4 medical records reviewed and had the potential to affect all patients served in the facility. This affected MR # 1, # 2, and # 3.

Findings include:

Policy:
Subject: Treatment Planning
Purpose: " To provide a plan of care that is individualized and specific to the needs of the patient.
Policy: Each patient shall have an individualized treatment plan based on the patient's presenting problems, emotional and behavioral status, physical health, strengths and weaknesses...
Each discipline is responsible for documenting his/her role and interventions in the plan of care...
Each problem should have a short and a long term goal. Goals should indicate a target date for accomplishment and should be stated in positive terms...
Long term goals should indicate discharge criteria as applicable...
Each problem should have interventions which describe how the staff will assist the patient in meeting his/her goals. Interventions should indicate the frequency of the intervention and the discipline/staff responsible for the intervention."


1. MR # 1 was admitted to the facility 1/17/17 with diagnoses of Unspecified Mood Disorder, Intellectual Disability, Personality Disorder and Bipolar Disorder.

The 1/17/17 Treatment Plan lists problems/behavioral as:
1. Aggressive Behavior
2. Manic Behavior

Problems/Physical:
3. Potential for Injury Related to Aggressive Behavior

The Care Plan Interventions created 1/17/17 failed to include Long Term Goals.
The Care Plan Interventions created 1/17/17 failed to include a target date for Short Term Goals.

The specific interventions failed to have a frequency the intervention was to be completed by staff.

The interventions were not updated after being created 1/17/17 through the continued hospitalization [DATE].

The Master Treatment Plan Review Summary dated 3/29/17 failed to include any documentation of discussion by the treatment team regarding refusal of group therapy, recreational therapy with the Recreation Therapist and the MHT (Mental Health Technicians) on the following dates 3/23/17, 3/25/17, 3/26/17, 3/27/17 and 3/28/17. There was no documentation of individual therapy being conducted with MR # 1 after continued refusal to participate in groups.

The Master Treatment Plan Review Summary dated 4/5/17 failed to include any documentation of discussion by the treatment team regarding refusal of group therapy, recreational therapy with the Recreation Therapist and the MHT (Mental Health Technicians) on the following dates 3/30/17, 3/31/17, 4/1/17, 4/2/17, and 4/5/17. There was no documentation of individual therapy being conducted with MR # 1 after continued refusal to participate in groups.

In an interview with Employee Identifier (EI) # 2, the Chief Nursing Officer and EI # 3 Counselor Supervisor New Day on 4/11/17 at 3:38 PM the above information was confirmed. EI # 3 stated that the social workers and counselors communicated with the patients often but did not document individual counseling sessions. EI # 3 also stated they discussed missed or refused groups in the Treatment Plan Review but it was not documented.

2. MR # 2 was admitted to the facility 3/22/17 with diagnoses of Depression and Psychosis.

The Care Plan Interventions created failed to include Long Term Goals.
The Care Plan Interventions created failed to include a target date for Short Term Goals.

The specific interventions failed to have a frequency the intervention was to be completed by staff.

MR # 2 refused Group Therapy, Recreational Therapy with the Recreation Therapist and the MHT (Mental Health Technicians) on the following dates 3/25/17, 3/27/17, 3/28/17, 3/29/17, 3/30/17, 3/31/17, 4/2/17, 4/3/17 and 4/5/17. There was no documentation of individual therapy being conducted with MR # 2 after continued refusal to participate in groups.

There was no documentation of discussion in the Treatment Plan Review Summary regarding the refusals to participate in groups.

In an interview with EI # 5, Quality Assurance/Risk, on 4/11/17 at 3:45 PM, the information was confirmed.





3. Medical Record (MR) # 3 was admitted on [DATE] with diagnosis to include Schizophrenia, Paranoid Type.

A review of the care plan revealed there were no long term goals for MR # 3.

On 4/11/17 at 3:55 PM, in an interview with Employee Identifier (EI) # 5, Quality Assurance/Risk, the above finding was confirmed. EI # 5 stated the hospital was using the discharge plan for the patient as a long term goal.