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Based on staff interview and record review, the facility failed to provide social work evaluation of high risk psychosocial issues requiring early treatment planning and interventions; and recommendations for eight (A1, A3, A4, B1, B4, B8, B14 and B16) of eight sample patients; which include social work roles in treatment and discharge planning. The Psychosocial assessments were not sufficiently individualized to address patient specific problems. This resulted in an absence of professional social work treatment services for 8 of 8 patients in the sample.

Findings are:

A. Record Review

1. Patient A1: The Psychosocial Assessment of 12/30/09 listed SW role in TX/DC planning as "Family contact, Discharge planning, and referral to Comm. [community] resources."

2. Patient A3: The Psychosocial Assessment of 1/8/10 listed SW role in TX/DC Planning as "Family contact, Discharge Planning."

3. Patient A4: The Psychosocial Assessment of 1/6/10 listed SW role in TX/DC Planning as "Family contact, Discharge planning and Referral to community resources."

4. Patient B1: The Psychosocial Assessment of 1/12/10 listed SW role in TX/DC Planning as "Family contact, coordination of care/opp, Discharge planning, Referral to Comm. Resources."

5. Patient B4: The Psychosocial Assessment of 1/7/10 listed SW role as "Family contact, Coordination of care/opp, Discharge planning, Community resource."

6. Patient B8: The Psychosocial Assessment for admission on 7/28/09 listed SW role in TX/DC planning as "Coordination of care/opp [sic], Discharge planning, Referral to comm. [community] resource." For the current admission of 1/8/10, the "Psychosocial Assessment - Readmission update" did not have any SW conclusions, treatment and discharge recommendations.

7. Patient B14: The Psychosocial Assessment of 12/28/09 listed SW role in TX/DC planning as "Discharge Planning."

8. Patient B16: The Psychosocial Assessment of 1/11/10 listed SW role in TX/DC Planning as: "Family contact, Coordination of care/opp [sic], Discharge planning, Referral to comm. [community] Resource."

B. Interview

In an interview on 1/12/10 at 2:00 p.m., the Director of Social Services acknowledged that the Social work Treatment and Assessments are not sufficiently individualized and that the social work "Conclusions and Recommendations are weak."

Based on record review and interview, the hospital failed to provide psychiatric evaluations that described memory functioning in measurable, behavioral terms for 7 of 8 active sample patients (A1, A3, A4, B1, B4, B8 and B16). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings are:

A. Record Review

1. In the psychiatric assessment for Patient A1, dated 12/29/09, memory testing in the mental status examination was described as "immediate retention and recent and remote memories appear to be severely impaired."

2. In the psychiatric assessment for Patient A3, dated 1/08/10, the only reference to memory was a description by the daughter that "he (the patient) has become increasingly confused with memory problems at home."

3. In the psychiatric assessment for Patient A4, dated 1/05/10, there was no estimation of memory included in the mental status exam.

4. In the psychiatric assessment for Patient B1, dated 1/11/10, there was no mention of memory testing.

5. In the psychiatric assessment for Patient B4, dated 1/06/10, there was no mention of memory testing.

6. In the psychiatric assessment for Patient B8, dated 1/09/10, there was no mention of memory testing.

7. In the psychiatric assessment for Patient B16, dated 1/09/10, there was no mention of memory testing.

B. Interview

In an interview on 1/12/109 at approximately 5:30 p.m., the Director of Quality Improvement acknowledged information about memory testing was either vague and/or omitted.

Based on record review and interview, it was determined that the physician did not include an inventory of specific patient assets as part of the admission psychiatric evaluation for 4 of 8 sample patients (A1, A3, A4, and B8). This failure results in lack of physician generated information to guide the development of patient treatment plans.

A. Record Review

1. In the psychiatric assessment for patient A1, dated 12/29/09, assets were simply listed "good family support."

2. In the psychiatric assessment for patient A3, dated 1/08/10, no assets were listed.

3. In the psychiatric assessment for patients A4, dated 1/05/10, assets were simply listed "adequate verbal skills."

4. In the psychiatric assessment for patients B8, dated 1/09/10, assets were simply listed "adequate verbal skills."

B. Interview

In an interview on 1/12/109 at approximately 5:30 p.m., the Director of Quality Improvement acknowledged that information about patient assets was either vague or omitted.

Based on record review and interview, it was determined that the physician did not include an inventory of specific patient assets as part of the admission psychiatric evaluation for 4 of 8 sample patients (A1, A3, A4, and B8). This failure results in lack of physician generated information to guide the development of patient treatment plans.

A. Record Review

1. In the psychiatric assessment for patient A1, dated 12/29/09, assets were simply listed "good family support."

2. In the psychiatric assessment for patient A3, dated 1/08/10, no assets were listed.

3. In the psychiatric assessment for patients A4, dated 1/05/10, assets were simply listed "adequate verbal skills."

4. In the psychiatric assessment for patients B8, dated 1/09/10, assets were simply listed "adequate verbal skills."

B. Interview

In an interview on 1/12/109 at approximately 5:30 p.m., the Director of Quality Improvement acknowledged that information about patient assets was either vague or omitted.

Based on record reviews and interviews the facility failed to describe the specific focus of treatment for each preprinted modality listed on the treatment plans in seven (7) of eight (8) sample records reviewed (A1, A3, B1, B4, B8, B14 and B16). This failure to document specific treatment approaches on the plan interferes with the assurance of consistency of approach to each patient's problems and can result in prolonged hospitalization for patients.

Findings:

A: Record Review:

1. Patient A1: For the Problem "Altered Endocrine Function," the identified interventions in the Treatment Plan (dated12/28/09) were: "Physician to assess patient daily for ongoing medical needs. RN to assess patient daily to evaluate endocrine issues, Monitor blood glucose level, administer sliding scale as indicated, Monitor patient food intake & compliance with ADA diet, Educate patient related Diabetes and nutritional requirements....".

For the Problem "Altered Neuro Function" the identified interventions were: "Physician to assess patient daily for medical needs. RN to assess patient daily to evaluate neurological status. Orient daily to ([left blank])...".

2, Patient A3: For the Problem "Altered Mus/Skel Function" the identified Interventions in the Treatment Plan (dated 1/07/10) were: "Physician to assess daily ongoing medical needs. RN to assess patient's risk for fall, Assist patient with ([left blank] )..."
For the Problem "Altered Neuro Function," the listed: Interventions were: "Physician to assess patient daily for medical needs. RN to assess patient daily to evaluate neurological status. Orient daily to ([left blank])..."

3. Patient B1: For the Problem "Cardiac," the Identified Interventions in the treatment plan (dated 1/11/10) were 1): "Physician to assess daily for ongoing medical needs, RN to assess daily to evaluate cardiac status and patient perception of effectiveness of medications. Monitor VS every ([left blank]), Patient education related to effects and side effects of medications administered to treat illness...."
For the Problem "Altered Endocrine Function" (the listed Interventions were: "Physician to assess patient daily for ongoing medical needs. RN to assess patient daily to evaluate endocrine issues, Monitor blood glucose level, administer sliding scale as indicated, Monitor patient food intake & compliance with ADA diet, Educate patient related Diabetes and nutritional requirements...."
For the Problem "Altered Gastro Function" the listed Interventions were: "Physician to assess daily for ongoing medical needs. RN to assess patient daily to evaluate gastric status. RN will provide daily patient education of effects and side effects of medication to treat illness....". [Patient has no specific "Gastric" or "Endocrine" illnesses diagnosed.]

4. Patient B4: For the Problem "Cardiac" the identified Interventions in the Treatment Plan (dated 1/07/10) were: "Physician to assess daily for ongoing medical needs, RN to assess daily to evaluate cardiac status and patient perception of effectiveness of medications. Monitor VS every ([left blank]), Patient education related to effects and side effects of medications administered to treat illness...."
For the Problem "EENT" the interventions were: "Physician to assess patient daily for ongoing medical needs, RN to assess patient daily to evaluate EENT status, Patient education of effects and side effects of medications to treat illness..." [The only finding in the Physical Examination (dated 1/11/10) related to EENT is "Absent teeth"].
For the Problem "Altered Gastro Function" the Interventions were: "Physician to assess daily for ongoing medical needs. RN to assess patient daily to evaluate gastric status. RN will provide daily patient education of effects and side effects of medication to treat illness...."
For the Problem "Altered Musculoskeletal Status" the Interventions were: "Physician to assess daily ongoing medical needs. RN to assess patient's risk for fall, Assist patient with ([left blank])..."
For the Problem "Altered Neuro Function to improve neurological function" the Interventions were: "Physician to assess patient daily for medical needs. RN to assess patient daily to evaluate neurological status. Orient daily to ([left blank])...,"

5. Patient B8: For the Problem "Cardiac": the identified interventions in the treatment plan (dated 1/08/10) were: "Physician to assess daily for ongoing medical needs, RN to assess daily to evaluate cardiac status and patient perception of effectiveness of medications. Monitor VS every ([left blank]), Patient education related to effects and side effects of medications administered to treat illness...."
For the Problem "EENT" the interventions on the plan were: "Physician to assess patient daily for ongoing medical needs, RN to assess patient daily to evaluate EENT status, Patient education of effects and side effects of medications to treat illness...." [No EENT problems were identified in the Physical Examination (dated 1/9/10)]
For the Problem "Sleep disturbances," the Interventions were: "Physician-Patient education of techniques to enhance sleep, RN to assess patient's sleep pattern nightly, Provide environment conducive to sleep by reducing stimuli one hour prior to bed time, Administer prescribed medications at bedtime to facilitate sleep, Assist pt. describing stressful experiences contributing to sleep problem, Assist the patient in exploring alternative methods of facilitating sleep, Encourage decrease in daytime sleep by participating in therapeutic activities, Encourage list of strategies used to improve sleep/applying successful ones, assist patient establish a daily bedtime routine." [Since the problem of Obstructive Sleep Apnea, which the patient had by diagnosis, was not listed on the plan, the interventions did not address Obstructive sleep apnea but rather were general sleep hygiene, which would not improve Obstructive sleep apnea.

6. Patient B14: For the Problem "Cardiac" the identified Interventions in the Treatment Plan (dated 12/27/09) were: "Physician to assess daily for ongoing medical needs, RN to assess daily to evaluate cardiac status and patient perception of effectiveness of medications. Monitor VS every ([left blank] ), Patient education related to effects and side effects of medications administered to treat illness...."
For the Problem "Altered Endocrine Function" the Interventions were: "Physician to assess patient daily for ongoing medical needs. RN to assess patient daily to evaluate endocrine issues, Monitor blood glucose level, administer sliding scale as indicated, Monitor patient food intake & compliance with ADA diet, Educate patient related Diabetes and nutritional requirements...."

7. Patient B16: For the Problem "Altered Mus/Skel Function" the identified Interventions in the Treatment Plan (dated 1/9/10) were: "Physician to assess daily ongoing medical needs. RN to assess patient's risk for fall, Assist patient with ([left bank])..."
For the Problem "Altered Nutrition" the Interventions were: "Physician to assess appetite, RN to assess appetite, determine the effectiveness of patient education and perception of effectiveness of medications. Patient education related to nutritional needs, Patient education related to effects and side effects of medications administered to treat illness, Encourage patient to attend nutrition group, Monitor patient for 2 hours after the meal, Weigh patient ([left blank]) (frequency), Nutritional consult and counseling, Monitor fluid/nutritional intake at meals, Monitor laboratory serum values and notify physician of significant values".
For the Problem "Altered Resp Function" the Interventions were: "Physician to assess patient daily for ongoing medical needs. RN to assess patient for daily to evaluate respiratory status, Provide medications as needed, Provide O2 at ([left blank]) LPM, Monitor O2 saturation every ([left blank]), Provide patient education for improving respiratory status...."
For the Problem "Sleep Disturbance" the Interventions were: "Physician-Patient education of techniques to enhance sleep, RN to assess patient's sleep pattern nightly, Provide environment conducive to sleep by reducing stimuli one hour prior to bed time, Administer prescribed medications at bedtime to facilitate sleep, Assist pt. describing stressful experiences contributing to sleep problem, Assist the patient in exploring alternative methods of facilitating sleep, Encourage decrease in daytime sleep by participating in therapeutic activities, Encourage list of strategies used to improve sleep/applying successful ones, assist patient establish a daily bedtime routine". [The interventions do not address Obstructive sleep apnea other than to address general sleep hygiene and behaviors.]
For the Problem "Altered integument function" the Interventions were: Physician to assess daily for ongoing medical needs. RN to assess daily to evaluate integumentary status. Encourage adequate nutrition & hydration, Encourage pt. to change position to enhance circulation...." [The Physical examination (dated 1/9/10)indicates "SKIN: Fairly stable." No skin problems were diagnosed.]

B. Interview:

1. In an interview conducted on 1/12/10 at 2pm, the Director of Social Services acknowledged and agreed the treatment plans were non specific and "unclear."

2. In an interview conducted on 1/13/10 at 8:30am, the Clinical Director acknowledged and "agree with you 100%" that the "treatment plans are not specific referring to the treatment plans of patients A1, A3 and B16.

Based on record review and interview it was determined the hospital failed to ensure that medical and nursing staff members responsible for treatment modalities were specifically identified by name for 8 of 8 sample patients (A1, A3, A4, B1, B4, B8, B14 and B16). This results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings are:

A. Record Review

Review of the Master Treatment Plans for all 8 sample patient's records revealed that the names of physicians and nurses responsible for specific interventions were not present.

B. Interview

In an interview 1/12/10 at 5:30 p.m., the Director of Quality Improvement acknowledged that the names of staff responsible for treatment interventions were consistently absent from the treatment plans.

Based on record review and interview it was determined the Clinical [Medical] Director failed: 1) to ensure that the treatment plans for eight (8) of eight (8) patients (A1, A3, A4, B1, B4, B8, B14, B16) were individualized, with appropriate problem lists and interventions, and 2) to monitor the inclusion of the names of personnel responsible for specific interventions on the treatment plans for eight (8) of eight (8) patients (A1, A3, A4, B1, B4, B8, B14, B16). This failure resulted in patient-specific problems not being addressed on the plans, and interventions that were not individualized for each patient, and staff not being identified as responsible for carrying out listed interventions. In addition, the Clinical Director was not able to produce documentation to show that reviews of two records of patients who had died in the hospital had taken place (D1 and D2).

Findings are:

A. The review of 8 of 8 sample records (A1,A3,A4,B1,B4,B8,B14 and B16) revealed that the facility failed to address problems identified in the Clinical assessment of the Psychiatrist and the Medical Physician in the treatment plan; since these problems were not addressed, there were no goals or modalities in place to effect treatment outcome; OR the problems identified on the plan were too generic and not individualized; OR problems were listed on the plan that were not identified as problems for a particular patient in that patient's assessments. Failure to specify patient-specific problems on Master Treatment Plan results in lack of guidance to staff in providing individualized, coordinated treatment and can result in prolonged hospitalization for patients. Refer to B118.

B. The record reviews and interviews revealed the facility failed to describe the specific focus of treatment for each preprinted modality listed on the treatment plans in seven (7) of eight (8) sample records reviewed (A1, A3, B1, B4, B8, B14 and B16). This failure to document specific treatment approaches on the plan interferes with the assurance of consistency of approach to each patient's problems and can result in prolonged hospitalization for patients. Refer to B122.

C. The record review and interview revealed that the hospital failed to ensure that medical and nursing staff members responsible for treatment modalities were specifically identified by name for 8 of 8 sample patients (A1, A3, A4, B1, B4, B8, B14 and B16). This results in the facility's inability to monitor staff accountability for specific treatment modalities. Refer to B123.

D. In an interview conducted on 1/13/10 at 8:30am, the Clinical director acknowledged and agreed, that the Clinical Director failed to keep any record of the reviews conducted by him on two (2) death (D1 and D2) records reviewed by him.

Based on record review and interview, it was determined the Director of Nursing failed to monitor the inclusion of the names of nursing personnel responsible for specific nursing interventions.

Findings are:

A. Record Review
Review of the Master Treatment Plans for all 8 of 8 sample patients (A1, A3, A4, B1, B4, B8, B14 and B16) revealed that responsible nursing staff were not identified by name on any of the treatment plans.

B. Interview
During a discussion of treatment plans with the Director of Nursing and the Director of Quality Improvement on 1/13/10 at approximately 11:00 a.m., they both acknowledged that responsible nursing staff was not specified by name.