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ASPIRE BEHAVIORAL HEALTH OF CONROE, LLC
COMPLETE NEUROLOGICAL EXAM RECORDED AT TIME OF ADMISSION
Tag No.: B0109
Based on review of 7 of 21 records reviewed the admission data did not include an assessment patients neurological functioning.
Findings:
The need for a complete neurological examination could not be determined because a baseline neurological exam consisting of gross testing of cranial nerves II through XII was not conducted.
Patient # 1, 7, 9, 12, 15, 20, 21
EVALUATION ESTIMATES INTELLECTUAL/MEMORY FUNCTIONING
Tag No.: B0116
Based on review of 9 of 21 records reviewed the psychiatric evaluation did not include an assessment of intellectual and/or memory functioning.
Findings
Record review reflected intelligence was not assessed for 4 of 9 patients ( #3,6,7,12)
Memory functioning was not assessed for 8 of 9 patients ( # 3,5,6,9,12,15, 20,21)
EVALUATION INCLUDES INVENTORY OF ASSETS
Tag No.: B0117
In 5 of 21 records reviewed there was a failure to include an assessment of the patient's assets.
Findings:
In the 5 records the psychiatric evaluation did not include an assessment of the patients strengths ,a factor necessary for formulation of the treatment plan.
Patient's # 2,7,8,12,18
MONITOR/EVALUATE QUALITY/APPROPRIATENESS OF SERVICES
Tag No.: B0144
Based on review of medical staff rules and regulations and review of 1 of 21 clinical records, the medical director allowed admission of a patient who did not meet admission criteria required by the medical staff rules and regulations.
Findings:
Review of medical staff rules and regulations #2: admission of patients. 2.2 reflected the hospital shall not admit patients who:
2.2.8 unable to perform ADLs
3.2.11 Severely demented and unable to participate in group therapy or who are bedfast and unable to transfer self.
However. record review reflected patient #8, an 80 year old patient. was admitted from a nursing home on 11/10/2009 with severe dementia and behavioral problems. A CT scan of the brain revealed severe generalized atrophy with severe ischemia and a left occipital infarct. Many admission assessments could not be conducted due to the patients severe dementia and inability to respond appropriately respond to questions. The patient was unable to stand and tried to climb out of her bed or chair. She was total assist with ADLs and participated in no psychiatric treatment modalities. The only interventions on her treatment plan were:
1. Reality orientation
2. Give meds as ordered
3. Daily baths