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Based on record review, staff interview and policy review, the facility failed to update interventions or problems on the master treatment plans for 2 of 11 active sample patients (A4 and A6). This resulted in a failure to progress to a less restrictive environment.

Findings include:

A. Record Review

1. The master treatment plan for patient A4 was dated 8/5/09. There has been no comprehensive Treatment Plan update since that admission. The following were listed as interventions for care on the master treatment plan dated 8/4/09: "Attending psychiatrist will assess for aggression, agitation, poor impulse control daily and evaluate meds and side effects as needed. Social worker will meet with patient to discuss placement options and develop aftercare plan." There were no nursing interventions listed.

Despite ongoing problems A4 exhibited with aggression towards patients and staff, the updates for A4 failed to document any changes in goals, only listing lack of progress towards original goals. From January through April 2011, there was only one intervention change in the weekly update. Refer to B125 Part B for these details.

2. The master treatment plan for patient A6 was dated 9/28/10. The only documentation for A6 was related to progress towards original goals.

B. Staff Interview

On 4/28/11 at 11:45a.m. the Director of Nursing was asked to provide the most recent treatment plan, and she said, "Those submitted were the only treatment plans for both [A4] and [A6]."

C. Policy Review

Hospital policy "Treatment Planning" effective 10/97 and revised on 4/28/2011, stated on page 2 that the "the treatment plan should be a fluid document in that changes to the plan may be made at any time. This may include both the elimination and addition of goals and objectives. The Updated Treatment Plan should be formulated at least every 7 days that the patient remains in treatment." Page 4 stated, "Physicians also must initiate changes to interventions contained on the Master Treatment Plan or the Updated Treatment Plan if, after four successive days, there is no improvement in the patient's condition."