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Based on record review and interviews, the facility failed to provide sufficient psychiatric medical staff to function as an acute psychiatric hospital for 50 (fifty) certified acute psychiatric care beds. Most patients on acute psychiatric care units were therefore being treated at a residential rather than acute level of care. This failure places patients at risk of not receiving medical care at the acute level they require. (Refer to B102)

Based on record review and interview, it was determined that the facility failed to ensure that the staff member responsible for each intervention was specifically identified in 2 of 8 active sample patient master treatment plans (A2 and A3). This failure results in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented.

Findings include:

A. Record Review

1. Patient A2's Master Treatment Plan dated 11/12/12 had one "Rehabilitation" intervention for Objective 1. There was no name, signature or title present to identify the staff responsible for this intervention.

2. Patient A3's Master Treatment Plan dated 11/12/12 had one "Clinical" intervention for Objective 1. There was no name, signature or title present to identify the staff responsible for this intervention.

Patient A3 had one "Group" intervention for Objective 1. There was no name, signature or title present to identify the staff responsible for this intervention.

B. Interview

In an interview on 11/13/12 at 3:00PM, the Clinical Director agreed with the findings and stated, "That is an error. They should have been signed."