HospitalInspections.org

Based on record review and an interview, the hospital failed to ensure members of the multidisciplinary team complied with hospital policy for the development of individualized treatment plans. The deficient practice is evidenced by failure to have a master treatment plan signed by all members of the interdisciplinary team and the patient in 2 (#F1 & #F2) of 3 (#F1-#F3) reviewed master treatment plans.

Findings:
Review of the hospital policy number CS-02 titled, "Treatment Planning; Integrated/Multidisciplinary" last revised on 07/01/2024 revealed in part:
"Purpose:
To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided.
Policy:
The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessment process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs and identified by the patient, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care.
Procedure:
4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient's medical record."

Patient #F1:
Review of Patient #F1's medical record revealed she was admitted to the facility on 01/14/2025 at 4:30 AM from an outside referring facility emergency room for Schizophrenia.

Review of Patient #F1's Interdisciplinary Treatment Plan Master Sheet dated 01/14/2025 revealed it was not signed by the both Patient #F1 and the staff therapist and/or staff social worker. Further review revealed no documentation the patient was unable/unwilling to participate or refused to sign the treatment plan.

On 02/18/2025 at 2:18 PM, an interview was conducted with SF1DOQ. She reviewed the IDT Master Sheet dated 01/14/2025 in Patient #F1's medical record. She confirmed it was not signed by Patient #F1 and should have either been signed by the patient or documented "patient refused" or "patient unwilling/unable to participate" within 24 hours of admission to the facility. SF1DOQ also confirmed the IDT Master Sheet dated 01/14/2025 in Patient #F1's medical record was not signed by the therapist and/or social worker and should have been signed within 72 hours of the patient's admission to the facility.

Patient #F2:
Review of Patient #F2's medical record revealed she was admitted to the facility on 02/01/2025 at 4:05 AM from an outside referring facility emergency room for Major Depressive Disorder.

Review of Patient #F2's Interdisciplinary Treatment Plan Master Sheet dated 02/01/2025 revealed it was not signed by the staff therapist.

On 02/18/2025 at 2:20 PM, an interview was conducted with SF1DOQ. She reviewed the IDT Master Sheet dated 01/14/2025 in Patient #F2's medical record. SF1DOQ also confirmed the IDT Master Sheet dated 01/14/2025 in Patient #F2's medical record was not signed by the therapist and/or social worker and should have been signed within 72 hours of the patient's admission to the facility.