HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to include the patient and family directly in the treatment planning process for 9 of 11 patients (#1-7 and #9-10). In addition, the facility failed to identify the assigned treatment team members responsible for treatment interventions for 11 of 11 sample patients. Identification of those staff members responsible for ensuring compliance with particular aspects of the patient's treatment plan are essential to the provision of care. Uncoordinated care in which clinical team members do not understand their assigned duties or the assigned duties of their colleagues can result in delay of the patient's discharge and recovery.

Findings were:

Facility policy #PR.10 entitled Patient Rights - Description & Procedure, last reviewed 3/13, included the following:
"16. The patient and family, when appropriate, have the right to be involved in all aspects of the patient's care. The right to take part in the development of an individualized treatment plan for his/her hospitalization and discharge. The patient has the right to request that the parent, legal guardian, conservator, or other person of his/her choice participate in the development of the treatment plan. The patient has the right to be informed of the reasons for denial of such a request. Staff must document in the medical record, that the parent guardian, conservator, or other person of his/her choice was contacted to participate ..."

Facility policy #PC.18 entitled Multidisciplinary Treatment Planning, last revised 5/13, included the following:
"Care is planned and provided in an interdisciplinary, collaborative manner by qualified staff members ...
The Treatment Plan contains the following:
a. List of all diagnosis for the patient with notation as to which diagnosis will be treated during the hospital stay. At least one mental illness diagnosis, any substance abuse disorder, and non-psychiatric conditions.
b. A list of problems and needs that are to be addressed during the patient's hospital stay.
c. Add to the treatment plan ...
iii. The ABH (Abilene Behavioral Health) staff responsible for providing or ensuring the provision of each treatment intervention ...
d. The treatment plan shall be signed by all members of the IDT (interdisciplinary team). If the patient is unable or unwilling to sign the Treatment Plan, the reason for or circumstances of such inability or unwillingness is documented in the patient's medical record ...
The Attending Physician is responsible for the overall integrity of the Treatment Plan and Reviews ...
c. Team members are prepared to discuss pertinent findings/events as related to the treatment plan ...
d. Team members are expected to be on time and fully prepared for each treatment plan meeting ..."

A review of patient records revealed that for 9 of 11 patients (#1-7 and #9-10), the facility failed to document the inclusion of the patient and his/her family or legally authorized representative directly in the treatment planning process. In addition, in each of 11 of 11 patient records, all members of the treatment team were not identified, and it was unclear if the treating physician actually participated in the meetings.

As an example, review of the multidisciplinary treatment plan for Patient #6, a 15-year-old-female, revealed no documented participation of the patient or her parent/legally authorized representative (LAR). There was no indication that the facility had informed the patient or the parent/LAR of the date and time of the treatment plan meeting. The only two individuals listed as members of the interdisciplinary team were an individual from social services and an individual from recreational therapy. There was no physician signature on the treatment plan.

The above findings were confirmed in an interview with the facility director of clinical services on the afternoon of 7/12/16 in a facility office. They were again confirmed in an exit interview with the facility CEO and other administrative staff on the afternoon of 7/12/16 in the facility conference room.

Based on review of facility documentation and staff interviews, the facility failed to include diagnoses on the treatment plans of 7 of 11 sample patients (#1-4, #6-7 and #11). This failure compromised the staff's ability to deliver clinically focused treatment.

Findings were:

Facility policy #PC.18 entitled Multidisciplinary Treatment Planning, last revised 5/13, included the following:
"Care is planned and provided in an interdisciplinary, collaborative manner by qualified staff members ...
The Treatment Plan contains the following:
a. List of all diagnosis for the patient with notation as to which diagnosis will be treated during the hospital stay. At least one mental illness diagnosis, any substance abuse disorder, and non-psychiatric conditions.

Review of treatment plans for patients #1-4, #6-7 and #11 revealed the area on the treatment plan for diagnoses was left completely blank. There was no other documentation of the diagnoses in the treatment plan.

These findings were confirmed with the individual responsible for facility risk management/performance improvement in an interview on the afternoon of 7/12/16 in a facility office.

There were again confirmed in an interview with the facility CEO and other administrative staff on the afternoon of 7/12/16 in the facility conference room.