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VIOLATION: Director of Nursing - Responsibilities Tag No: A1702
Based on interview and record review, the facility failed to follow monitor nursing care furnished, Patient #1 was not provided the physician ordered, individual therapy treatment.

Findings include:

Review of the facility provided policy (dated 6/2020) Provision of Care, Treatment and Services reflected, "The treatment plan is the tool used by the physician and multi-disciplinary treatment team to implement the physician ordered services and move the patient toward the expected outcomes and goals ...The nursing staff is responsible for developing the initial Treatment Plan within twenty-four (24) hours of admission(TAC 411.47)1."

Review of Patient #1's physicians order dated 8/23/21 reflected, "THERAPY ORDERS: Group Therapy, CD Assessment, Individual therapy."

Review of the Patient #1's nurse's note dated 8/23/20, reflected, " ...Expresses interest in speaking with therapist 1:1 ..."

During an interview on the morning of 1/20/21, in the facility conference room, Staff #2, Director of Clinical Services stated, "We use group therapy ...If the doctor ordered it, we should have given it." Staff #2 confirmed there was no record of Patient #1 having received individual treatments.