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HOLLISWOOD HOSPITAL,THE
INDIVIDUAL COMPREHENSIVE TREATMENT PLAN
Tag No.: B0118
Based on record review and interview, the facility failed to provide a Master Treatment Plan that addressed the problem of multiple incidences of seclusion/restraints (8 incidents between 9/1/11 and 9/14/11) for 1 of 1 active sample patient (D26) whose record was reviewed for seclusion/restraint policy/procedure compliance. There were no goals or modalities on the treatment plan to affect a more favorable behavioral outcome before using seclusion or restraint. This failure resulted in patient D26 being hospitalized without all interventions for recovery being provided to her in a timely fashion, potentially delaying her improvement. Failure to provide treatment plans that reflect patient's current needs can result in patients not having adequate treatment.
Findings include:
A. Record Review
1. Facility policy, number THH-V-5.5, titled "Treatment Plans", not dated, states, "The purpose of the treatment plan is to identify the patient ' s problem areas, identify goals to be achieved during the patient stay and the modalities of treatment of treatment that will be used to achieve these goals." ... "Additional problems should be added"..Additional objectives or methods can be written." "Subsequent formal treatment plan reviews will be completed every 7 days after the treatment plan."
2. Patient D26's Master Treatment Plan, dated 9/3/11, was last reviewed 9/8/11. The plan did not mention the patient's problem behaviors leading to multiple seclusions or restraints, nor were there alternative interventions to be used before or in place of restrictive interventions (seclusion or restraint).
B Interview
In an interview on 9/15/11 at 11:40a.m., MD1 was told about patient D26's frequent seclusion/restraints incidents (8 since 9/1/11) and the fact that the patient's behavioral problems leading to the seclusion or restraints were not clearly addressed on her Master Treatment Plan. MD1 stated that the treatment team was aware of the behavioral problems of D26 and the "treatment plan should be updated to include these problems."