HospitalInspections.org

Based on record review and interview, the Director of Social Services failed to ensure that the Master Treatment Plans of 6 of 8 active sample patients (A1, A5, A9, A10, A11 and A13) included social work interventions that were individualized for the patients. The listed interventions on the MTPs of these patients were non-specific generic social work functions. This failure hampers staff's ability to provide individualized patient care.

Findings include:

A. Record Review

1. Patient A1 (MTP dated 6/15/11)

For the identified problem of "Disturbed sensory perception AEB (as evidenced by) hallucinations, mania, delusions, constant singing, insomnia, poor intake food & hydration RT (related to) Dx (diagnosis) of dementia," the generic social work interventions were "Gather history & assess level of function; (CIA during 1st 72 hrs (hours)"; "Develop multidisciplinary treatment Integration (MTI) Plan in 72 hrs)"; "Engage Pt's (patient's) family/significant other in continued support and participation of tx (treatment)"; "Provide Psychotherapy Group session daily"; "Provide Indiv. (individual) therapy PRN (as needed)"; "Complete D/C (discharge) planning" and "Contact family weekly to provide status report of progress or lack thereof.":

2. Patient A5 (MTP dated 6/28/11)

For the problem, "Altered thought processes R/T (related to) MDD (Major Depressive Disorder) and GAD (generalized anxiety disorder) AEB (as evidenced by): uncontrollable crying, worrying, expression of grief, increased anxiety, fatigue, trembling," the generic social work interventions were: "gather history and assess level of function"; "develop Multidisciplinary Treatment Integration plan within 72 hours"; "provide psychotherapy group daily" and "provide individual therapy PRN (as needed)."

3. Patient A9 (MTP dated 6/15/11)

For the problem, "Disturbed thought process R/T diagnosis Schizophrenia AEB: inappropriate affect, delusions of grandeur, sleep disturbance, impaired insight, impaired judgment, impaired impulse," the generic social work interventions were: "Gather history and assess level of functioning"; "develop multidisciplinary Treatment Integration Plan within 72 hours"; "provide psychotherapy group sessions daily" and "provide individual therapy PRN."

4. Patient A10 (MTP dated 6/22/11)

For the identified problem of "Alterations in Thought Processes R/T Dementia, agitation, aggression," the generic social work interventions were identical to those for Patient A1.

5. Patient A11 (MTP dated 6/13/11)

For the problem, "disturbed thought processes AEB pt's increased anxiety regarding colostomy bag, and obsessed with cutting his catheter," the generic social work interventions were: "Gather history and assess level of functioning"; "develop multidisciplinary Treatment Integration Plan within 72 hours"; "provide psychotherapy group sessions daily" and "provide individual therapy PRN."

6. Patient A13 (MTP dated 6/21/11)

For problem, "altered thought processes R/T (related to) dementia AEB increased confusion, agitation, and hallucinations," the generic social work interventions were: "Gather history and assess level of functioning"; "develop multidisciplinary Treatment Integration Plan within 72 hours"; "provide psychotherapy group sessions daily"; "provide individual therapy PRN" and "complete d/c planning."

B. Staff Interviews

During an interview on 6/28/11 at 1:15p.m., the Director of Social Work acknowledged that social work interventions on the above patient's treatment plans were generic social work functions and were identical or very similar for the patients.