HospitalInspections.org

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the reason a patient refused to sign their Initial Treatment Plan on admission (MR7); the facility failed to ensure there was a documented reason a patient refused to sign their Weekly Treatment Plan (MR7 and MR9); and the facility failed to ensure a patients 30 day Treatment Plan review was completed 30-Day, 60-Day, 90-Day and 120-Day's (MR7, MR8 and MR9).

Findings include:

Review on January 9, 2025, of the facility's "Treatment Planning and Team Policy", last revision date May 11, 2020, revealed "...IV. Procedure ...4. Multidisciplinary Team meetings ...Patient/representative involvement is reflected by the patient/representative signature on the plan ..."

Review on January 9, 2025, of the facility's "30 Day Summaries", original effective date September 14, 2022, revealed "Purpose: The purpose of the 30 day review is to summarize a patient's treatment course and continued treatment planning. Policy: It is the policy of the Behavioral health [sic] Services (BHS) for Older Adults patient summary will be completed every 30 days on all patients who are on the unit for 30 or more. Procedure: 1. Thirty day summaries will be completed on all BHS patients who are on the unit greater than 30 days. 2. The summary will be reviewed by the treatment team and discussed with the patient and / or his / her legal guardian. 3. If the 30 day falls on a weekend or holiday, the 30 day review will be completed on the business day before or after the 30,h [sic] day. 4. The thirty day summary will be completed in addition to weekly revisions of the Master Treatment Plan. "

Review on January 9, 2025, of the facility's "BH Treatment Plan Update Form B" last revised May 2021, revealed a line for the date of review due at a minimum weekly. There are nine sections listing the following information: Updates to Problems/Goals As Identified In The Master Treatment Plan Initial Data Form; lined sections indicating the Problem number, Short Term Goals number, Progress Toward Short-term Goals: and blocks for the facility to check if Unchanged Resolved Revised. The tenth section lists New Problems identified and/or changes in medications or discharge date? With boxes to check Yes No (specify below). The eleventh section is identified as Justification for Continued Stay ...The twelfth section is Patient/Guardian Statement. I have reviewed Revisions and/or Additions to my treatment plan. I have asked questions of the staff and have received explanations regarding treatment. (If patient refuses to sign, or if clinically contraindicated please explain). There is a line for the Patient signature, Date, Time and Refused to sign, a line for Reason for refusal and a line for Guardian/DPOA signature, date and time.

Review on January 9, 2025, of the facility's "BHAddendumtoMasterTreatmentPlan [sic]" last reviewed May 2021, revealed lines for the Date, PatientName [sic], ResultsofRe-Examination [sic], Review/ResultsofTreatmentPlansfromadmissiontocurrent [sic] and ReasonsforContinuedStay [sic]. On the second page there are lines for TreatmentPlancurrentlyineffect,includingastatementthattheplanpresentstheleastrestrictive [sic] alternative consistent with adequate treatment for the condition: a line for Certificationthatthe currentTreatmentPlancanbeprovidedintheBehavioralHealthUnit [sic]. A line for The30 day treatmentplanhasbeenreviewedwithmeandIhavebeengiventheopportunitytoparticipate [sic] in planning my care during my hospitalization. A line for the Patient Signature, Date Time. A check box indicating DidnotSign [sic] Reasondidnotsign [sic] Guardian/DPOA signature, date and time.

1. Review of MR7 on January 9, 2025, revealed this patient was admitted to the facility on July 24, 2024, for evaluation and treatment of a mental health disorder. MR7 was discharged on October 23, 2024.

Review on January 9, 2025, of MR7's Initial Treatment Plan revealed the facility's Treatment Team met on July 24, 2024. Documentation on MR7's Initial Treatment Plan revealed this patient refused to sign this form. There was no documentation indicating the reason MR7 refused to sign the Initial Treatment Plan form.

Review of MR7 on January 9, 2025, revealed the facility held this patient's Treatment Plan review on September 4, 2024. There was no documentation MR7 was provided an opportunity to review, ask questions and signed this Weekly Treatment Plan Form B.

Review of MR7's Weekly Treatment Plan Update Form B on January 9, 2025, revealed this patient refused to sign these weekly updated forms on the following dates:
July 31, 2024.
August 7, 2024.
August 14 and 29, 2024.
September 11 and 18, 2024.
October 2, 16 and 9, 2024.

There was no documentation indicating the reason MR7 refused to sign the Weekly Treatment Plan Update Form B.

Review of MR7 on January 9, 2025, revealed the facility completed a 30-Day Treatment Plan Review of this patient on August 21, 2024, and a 60-Day Treatment Plan Review on September 21, 2024. Further review revealed this patient refused to participate in the 30-Day and 60-Day Treatment Plan Review. There was no documentation indicating the reason MR7 refused to participate in the 30-day Treatment Plan review or the 60-Day Treatment Plan Review.

Interview with EMP1 on January 9, 2025, confirmed the above findings at the time of the medical record review.

2. Review of MR8 on January 9, 2025, revealed this patient was admitted to the facility on June 1, 2024, for evaluation and treatment of a mental health disorder. MR8 was discharged on October 28, 2024.
Review of MR8's 30-Day Treatment Plan Review on January 9, 2025, revealed the facility completed a 30-Day review of this patient on July 1, 2024. Further review revealed this patient refused to participate. There was no documentation indicating the reason MR8 refused to participate in this patient's 30-day Treatment Plan review.

Review of MR8 on January 9, 2025, revealed this patient's 60-Day Treatment Plan review was to be completed on August 1, 2024; the 90-Day Treatment Plan review was to be completed on September 1, 2024, and the 120-Day Treatment Plan review was to be completed on October 1, 2024. There was no documentation in MR8 indicating this patient's 60-Day, 90-Day and 120-Day Treatment Plan reviews were completed.

Interview with EMP1 on January 9, 2025, confirmed the above findings at the time of the medical record review.

3. Review of MR9 on January 9, 2025, revealed this patient was admitted to the facility on August 8, 2024, for evaluation and treatment of a mental health disorder. MR9 was discharged November 15, 2024.

Review of MR9's Weekly Treatment Plan Update Form B on January 9, 2025, revealed this patient refused to sign these weekly updated forms on the following dates:
August 19 and 28, 2024.
September 3, 16, 23 and 30, 2024.
October 7, 21 and 28, 2024.
November 11, 2024.

Review of MR9 on January 9, 2025, revealed this patient's 30-Day Treatment Plan Review was to be completed on September 8, 2024; the 60-Day Treatment Plan Review was to be completed on October 8, 2024, the 90-Day Treatment Plan Review was to be completed on November 8, 2024. There was no documentation in MR9 indicating this patient's 30-Day, 60-Day and 90-Day Treatment Plan reviews were completed.

Interview with EMP1 on January 9, 2025, confirmed the above findings at the time of the medical record review.