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Based on interview and record review, the facility failed to complete a treatment plan (a patient's specific hospitalization plan with treatment goals) for two of ten sampled patients (Patient 11 and Patient 14).

This failure had the potential for the staff to be unaware of how to meet Patient 11's and Patient 14's medical and psychological needs.

Findings:

a. Patient 11 was admitted on 6/12/25 with a diagnosis of adjustment disorder (a mental health condition involving significant emotional or behavioral symptoms in response to a change in their life) per Patient 11's face sheet (a document summarizing key information about a patient).

A review of Patient 11's Master Treatment Plan was conducted on 6/17/25. Patient 11's Master Treatment Plan was signed by a physician, a registered nurse, a social worker, and a psychologist, but individual sections were not completed. The section titled, Reason For Admission, was blank and not completed. The section titled, Substantiated Diagnosis, was blank and not completed. The section titled, Initial Problem List, was blank and not completed. The section titled, Strengths/Protective Factors, was blank and not completed. The section titled, Limitations/Stressors, was blank and not completed. The section titled, Initial Discharge Plan, was blank and not completed. The section titled, Post Discharge Goal(s), was blank and not completed. The section titled, Patient Involvement in Treatment Plan, was blank and not completed. The section titled, Patient/Guardian Statement, was blank and not completed.

b. Patient 14 was admitted on 5/9/25 with a diagnosis of major depressive disorder (a serious mental illness characterized by persistent feelings of sadness and loss of interest, and difficulty functioning in daily life) per Patient 14's facesheet.

A review of Patient 14's Master Treatment Plan was conducted on 6/18/25. Patient 14's Master Treatment Plan was not signed by the treatment team (the facility's team which could include a physician, a registered nurse, a social worker, and a psychologist). Patient 14 was discharged on 5/23/25, and the Master Treatment Plan remained unsigned.

An interview was conducted on 6/18/25 at 9:32 A.M. with Registered Nurse (RN) 15. RN 15 stated the RN admitting the patient would be expected to start completing the Master Treatment Plan with the physician. RN 15 stated that if the sections of the treatment plan were not completed or not signed, the treatment plan would be incomplete. RN 15 stated that the treatment plan indicated a patient's plan for treatment and goals while admitted in the facility.

An interview was conducted on 6/18/25 at 10:57 A.M. with Social Worker (SW) 12. SW 12 stated that if the Master Treatment Plan was blank with only signatures, it would be considered incomplete. SW 12 stated that if the Master Treatment Plan was filled but had no signatures, it would be considered incomplete.

An interview was conducted on 6/18/25 at 1:20 P.M. with Director of Nursing (DON). The DON stated that Nursing, Social Worker, or Case Management were expected to complete the Master Treatment Plan. The DON stated that Patient 11's Master Treatment Plan was not complete even though it was signed, because multiple sections were not filled. The DON stated that Patient 14's Master Treatment plan was not complete because it was not signed by the treatment team. The DON stated it was important for the Master Treatment Plan to be completed so everyone on the team was aware of Patient 11's and Patient's 14's situation. The DON stated that the Master Treatment Plan also helped in planning what Patient 11 and Patient 14 needed when it was time for discharge from the facility.

A review of the facility's policy titled, Interdisciplinary Treatment Plan, revised 11/2020, indicated " ...Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, the plan shall describe patient strengths and disabilities; goals and objectives of treatment; clinical interventions prescribed ...Treatment shall be planned, reviewed, and evaluated at regular intervals by representatives of each clinical discipline ...Minimally there will always be a Physician, Nurse and Social Services person present at every Treatment Team Meeting ...Purpose ...To provide a complete, individualized, plan of care based on an assessment of the patient's specific needs and problems ...To provide appropriate communication between team members that fosters consistency and continuity in the care of the patient ...To formulate a plan of care that meets the patient's objectives and needs ...Within eight (8) hours of admission, the RN will initiate the treatment plan ...Within 72 hours of admission, members of the treatment team shall further develop the Treatment Plan ..."

Based on interview and record review, the facility failed to ensure it followed their policy for one of three sampled patients (Patient 1) when licensed nurse (LN) 1 did not attempt to verbally de-escalate a behavioral situation prior to the use of an emergency medication.

This failure resulted in the administration of a medication that Patient 1 potentially did not need.

Findings:

According to the facility's History and Physical, Patient 1 was admitted to the facility on 4/28/25 with diagnoses that included "suicidal" and anxiety.

On 6/18/25 at 2:38 P.M., a concurrent interview and record review was conducted with LN 1. A record review for an order, "zyprexa (medication primarily used to manage certain serious mental health conditions) 5 mg (milligrams) SL (sublingual; placed under the tongue to dissolve) x1 (one time) now" dated 5/8/25 at 10:48 P.M., indicated LN 1 carried out the order for emergency administration. LN 1 stated that prior to the administration of an emergency medication, nurses must verbally attempt to de-escalate the situation. LN 1 stated he did not document that he verbally attempted to de-escalate the situation prior to administering the medication.

On 6/18/25 at 3:00 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that all nurses must follow their policy and attempt to de-escalate a situation prior to the administration of an emergency medication.

According to the facility policy titled Consent for Psychotropic Medications, dated 6/2024, "...prior to the administration of any emergency medication, verbal de-escalation is to be attempted..."