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Based on interview and record review the facility failed to develop a comprehensive and individualized Plan of Care as directed by facility policy for six patients (#2, #4, #7, #21, #22 and #23) of 13 care plans reviewed. The facility census was 44.

Findings included:

1. Record review of the facility's policy titled, "Treatment Planning" dated 07/01/12, showed the following direction:
-It is the policy of [the] Hospital to provide each person admitted to the hospital's inpatient program a written, individualized, interdisciplinary treatment plan based on current assessments of the patient's clinical problems, needs and strengths that fosters communication between team members to promote consistency and continuity in the care of the patient.
-Patient goals and expected outcomes are written in behavioral, measurable and achievable terms, and include expected achievement dates.
-Specific treatment interventions are listed.
-Interventions for each appropriate discipline are included for each problem and include specific interventions with the specific focus of the interventions related to the problems.

2. Record review of discharged Patient #2's History and Physical (H&P) showed the patient was admitted to the facility on 07/05/12 with Bipolar Disorder, mixed (a psychiatric disorder characterized by extreme mood swings, ranging between episodes of acute mania and severe depression. Mixed bipolar disorder means the patient feels depression and manic at the same time), polysubstance abuse (multiple drugs), high blood pressure, restless leg syndrome and seasonal allergies.

Record review of the Master Treatment Plan (Care Plan) for Patient #2 showed the following:
- Problem #1: PI (Suicide precaution) and 96-hour hold (an involuntary admission) with short term goals and interventions;
- Problem #2: PSA (polysubstance abuse). No short term goals or interventions were care planned;
- Problem #3: HTN (high blood pressure). No short term goals or interventions were care planned.

The Care Plan failed to address bipolar disorder, restless leg syndrome, or seasonal allergies.

3. Record review of current Patient #4's H&P showed the patient had been admitted to the facility on 02/20/13 with mood symptoms, substance (drug) usage and suicidal ideation related to a history of rape and sexual abuse.

Record review of Patient #4's Care Plan showed the following:
- Problem #1: SI (Suicidal ideation,thinking about, considering, or planning to take one's own life) with one short term goal and one intervention;
- Problem #2: Constipation - with one short term goal and one intervention.

The Care Plan did not address sexual abuse or drug usage.

4. Record review of current Patient #7's Psychiatric Evaluation dated 02/20/13 showed the patient was admitted to the facility on 02/19/13 with Acute Psychosis (a mental disorder characterized by symptoms of delusions that indicate impaired contact with reality), alcohol and substance abuse (opioids [pain medication]), chronic back pain and hypertension (high blood pressure).

Record review of the Care Plan showed the following:
-Problem #1: Protective Hold/Seclusion with short term goals and interventions
-Problem #2: Alcohol and Opioid dependence with short term goals and interventions;
-Problem #3: Chronic Back Pain with short term goals. The Care Plan failed to address any interventions for these goals.

The Care Plan did not address psychosis or hypertension.

5. Record review of current Patient #21's H&P showed the patient was admitted on 02/18/13 with bipolar disorder, depressed mood, anxiety and a history of sexual abuse.

Record review of the Care Plan for Patient #21 showed the following:
- Problem #1: History of sexual abuse. The short term goal was, "Will identify two positive coping skills." The intervention was, "Monitor for safety."
This interventions' focus was not specifically related to the problem of sexual abuse.
-A second short term goal was, "Will adhere to medication regimen (routine.)" Interventions included, "Conduct room checks, administer Revia (medication used to suppress impulses) for impulsivity and chapstick for dry lips."
The intervention was not specific or individualized for the problem of a history of sexual abuse.
-A second issue listed under Problem #1 was, "Allegations made toward patient in reference to making inappropriate comments toward a peer about sex."
Short term goals included, "Will adhere to medication regimen." Interventions included, "Conduct room checks and administer meds (medications) as ordered."

The goal and interventions were not individualized or specific for the problem of a history of sexual abuse.

6. Record review of current Patient #22's H&P showed the patient was admitted on 02/21/13 with bipolar disorder and attention deficit with hyperactivity (combination of problems, such as difficulty sustaining attention, hyperactivity and impulsive behavior.)

Record review of the Care Plan for Patient #22 showed the following:
-Problem #3: Migraine headaches by history. A short term goal was, "Patient will demonstrate/utilize non-medication interventions to nurse or physician by day three." The interventions for this goal included: "Medical consult regarding possible UTI (urinary tract infection), burning on urination, repeat UA (urine test) and order medications and titrate dosage as needed (increase in drug dosage to a level that provides the optimal therapeutic (desirable) effect."
The goals/interventions were not appropriate for this patient's identified problem of migraine headaches.

7. Record review of current Patient #23's H&P showed the patient was admitted on 02/25/13 with psychosis and obsessive compulsive disorder (anxiety disorder with uncontrollable thoughts and fears, which cause repetitive behaviors). The patient has a history of cystic fibrosis (inherited disorder, which affects cells that produce mucous, sweat, and digestive juices.)

Record review of the Care Plan for Patient #23 showed the following:
-Problem #3: Eating disorder and cystic fibrosis. Staff listed three individual goals; Patient will consume at least 50% of two meals per day. Patient will maintain weight at 129 pounds for five days. Patient will have no episodes of self-induced vomiting for three days.

The goals had no date when the staff initiated (date goal identified) the goal or a target date (date for resolution) as directed in the facility policy. The care plan did not contain an intervention to weigh the patient. Without weighing the patient the staff would be unable to know if the patient maintained her weight at 129 pounds.

8. During an interview on 02/25/12 at 10:45 AM, Staff V, Registered Nurse (RN) Department Manager reviewed the care plans for Patients #21 and #22 and stated that some of the goals and interventions were not specific enough as related to the problems identified.


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Based on interview, record review and policy review the facility failed to ensure that Discharge Summary's were completed by a physician in charge of the patient's care or a qualified designee with primary knowledge of the patient's treatment plan for 10 patients (#1, #2, #3, #7, #25, #26, #27, #28, #29, and #30) of eleven records reviewed. The facility census was 44.

Findings included:

1. Record review of the facility's document titled,"Medical Staff Rules and Regulations", undated and unsigned but provided by the facility as Policy and Procedure of the Medical Staff for Discharge Summary, showed the following direction:
- Medical Records: The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient, this record shall include: Discharge Summary.
- Under the supervision of a physician, the medical staff allows credentialed Nurse/Therapist Extenders; including qualified RNs [Registered Nurses], MS [Master of Science] Social Workers, Nurse Practitioners [a level of nursing practice that utilizes extended and expanded skills, experience and knowledge in assessment, planning, implementation, diagnosis and evaluation of the care required] and Physician Assistants to dictate discharge summaries.
- Allied/Affiliate Staff: Non-physician staff members who have been credentialed according to the Medical Staff Bylaws may: Initiate therapy only to the extent established by the Medical Staff, but not beyond the scope of the Allied/Affiliate Health Professional's license, certification or other legal credentials.

2. Record review of a document from the Missouri Division of Professional Registration titled, "Coalition for Nurses in Advanced Practice" undated, showed the following:
- Credentialing and privileging are processes that are used by hospitals and health care organizations to ensure that their customers and the public are treated by licensed professionals who have been educated, trained, certified and/or licensed to perform certain medical and health care tasks. These two processes also provide a measure of confidence by the facility that the health care professionals are able to provide a high level of care and avoid malpractice.

3. Record review of the Missouri Division of Professional Registration licensee search showed that Staff X, RN, is licensed by the State of Missouri as a Registered Nurse and is not an Advanced Practice Nurse.

4. Record review of Patient #1's Discharge Summary showed he was discharged from the facility on 12/21/12. The Discharge Summary contained discharge psychiatric diagnoses, discharge medications and discharge prognosis. The document was dictated and signed by Staff X, RN.

5. Record review of Patient #2's Discharge Summary showed he was discharged from the facility on 07/09/12. The Discharge Summary contained discharge psychiatric diagnoses, discharge medications and discharge prognosis. The document was dictated and signed by Staff X, RN.

6. Record review of Patient #3's Discharge Summary showed the patient was discharged from the facility on 08/23/12. The Discharge Summary contained discharge psychiatric diagnoses, discharge medications and discharge prognosis. The document was dictated and signed by Staff X, RN.

7. Record review of Patient #7's Discharge Summary showed Patient #7 was discharged from the facility on 01/13/13. The Discharge Summary contained discharge diagnosis, discharge medications and discharge prognosis. The document was dictated and signed by Staff X, RN.

8. Record review of Patient #25's Discharge Summary showed Patient #25 was discharged from the facility on 11/13/12. The Discharge Summary contained discharge psychiatric diagnoses, discharge medications and discharge prognosis. The document was dictated and signed by Staff X, RN.

9. Record review of Patient #26's Discharge Summary showed Patient #26 was discharged from the facility on 11/21/12. The Discharge Summary contained discharge psychiatric diagnoses, discharge medications and discharge prognosis. The document was dictated and signed by Staff X, RN.

10. Record review of Patient #27's Discharge Summary showed Patient #27 was discharged from the facility on 12/07/12. The Discharge Summary contained discharge psychiatric diagnoses, discharge medications and discharge prognosis. The document was dictated and signed by Staff X, RN.

11. Record review of Patient #28's Discharge Summary showed Patient #28 was discharged from the facility on 12/17/12. The Discharge Summary contained discharge psychiatric diagnoses, discharge medications and discharge prognosis. The document was dictated and signed by Staff X, RN.

12. Record review of Patient #29's Discharge Summary showed Patient #29 was discharged from the facility on 12/20/12. The Discharge Summary contained discharge psychiatric diagnoses, discharge medications and discharge prognosis. The document was dictated and signed by Staff X, RN.

13. Record review of Patient #30's Discharge Summary showed Patient #30 was discharged from the facility on 09/24/12. The Discharge Summary contained discharge psychiatric diagnoses, discharge medications and discharge prognosis. The document was dictated and signed by Staff X, RN.

14. During an interview on 02/25/13 at 3:10 PM, Staff G, Director of Medical Records, stated that Staff X, RN, was not an employee of the facility and Staff X did not have a contract or agreement with the facility. Staff G stated that Staff X was a nurse who worked for physician Staff Z, MD (medical doctor) and that she dictated the Discharge Summary's for the physician. Staff G stated that she did not transcribe for the physician but actually dictated the Discharge Summary and the physician cosigned afterward. Staff G stated that Staff X was credentialed and privileged by the Medical Staff. She stated that Staff X was not an advanced practice nurse, practitioner or a Physician Assistant. Staff G could not provide evidence of a credentialing file for Staff X. Staff G stated that Staff X did not come to the facility and round (to visit those patients for whom a physician is responsible) with the physician so did not have professional knowledge of the patients or their discharge status.

15. During an interview on 02/27/13 at 12:30 PM, Staff A, Chief Executive Officer (CEO), reviewed the regulation regarding Discharge Summary's. He acknowledged that Staff X, RN, was a nurse working for Staff Z, MD, and not an employee of the facility by contract or agreement and was not an advanced practice nurse or Physician assistant qualified to dictate Discharge Summary's containing psychiatric diagnoses, medications or prognosis. He stated Staff X was working outside of her scope of practice by dictating discharge summaries.


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