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Based on a review of documents, the medical records maintained by the psychiatric hospital did not permit determination of the degree and intensity of the treatment provided to the individual furnished services at the institution. Further, based on review of documentation and interviews, it was determined that the extent of discharge planning for a particular patient was not able to be articulated through the patient record.

Findings were:

Based on a review of the clinical record of patient #1, the structure and content of the clinical record was not an accurate or complete representation of the patient ' s stay regarding admission and treatment, treatment goals, discharge planning, patient outcomes or follow-up care.

A review of the clinical record on 5-3-10 and 5-4-10 revealed that the patient ' s initial treatment plan was not implemented until 2-25-10, 5 days after her admission to Acadia Abilene.

A review of the clinical record on 5-3-10 and 5-4-10 revealed that the patient was not present during her initial treatment plan meeting with no indications as to the reason.

A review of the clinical record on 5-3-10 and 5-4-10 revealed that the initial Nursing Assessment (performed as part of the admission process) was not completed until 3-4-10 (patient admitted 2-20-10) and contained no documentation that the assessment had been attempted every 24 hours following her admission, per facility policy.

A review of the clinical record on 5-3-10 and 5-4-10 revealed an Educational Learning Assessment (performed as part of the admission process) that had not been completed and contained a single line drawn through the page.

A review of the clinical record on 5-3-10 and 5-4-10 revealed that the Initial Fall Risk Assessment (performed as part of the admission process) had been neither signed nor dated by the person who completed it.

A review of the clinical record on 5-3-10 and 5-4-10 revealed that the Nutritional Screening (performed as part of the admission process) had been completed by a Licensed Vocational Nurse. This screening was not completed nor co-signed by a Registered nurse as per requirements, nor was there any indication that the patient's nutritional needs were later reviewed by a Registered Dietician.

A review of the clinical record on 5-3-10 and 5-4-10 revealed that the Initial Pain Assessment (performed as part of the admission process) had been completed by a Licensed Vocational Nurse. This assessment was neither complted nor countersigned by a Registered Nurse as per requirements.

A review of the clinical record on 5-3-10 and 5-4-10 revealed that the Skin Assessment (performed as part of the admission process) had been completed by a Licensed Vocational Nurse. This assessment was not completed by nor countersiggned by a Registered Nurse, who was responsible for the skin assessment as well as other assessments as noted above.

A review of the clinical record on 5-3-10 and 5-4-10 revealed that 5 of 25 patient Observation Record sheets were incomplete for the following time spans: 0815 to 0945 on 2-22-10, 0700 to 0715 on 3-4-10, 2315 to 2330 on 3-6-10, 2330 to 0000 on 3-7-10 and 2315 to 0000 on 3-13-10. As the patient had been on special precautions during this time frame, it could not be determined during the missing time-spans what the condition nor whereabouts of the patient were during these time periods.

Based on a review of the clinical record on 5-3-10 and 5-4-10, there was no consent signed by the patient for 1 of 4 psychoactive medications she was receiving (perphenazine).

A review of the patient ' s medication administration records on 5-3-10 and 5-4-10 revealed that the patient did not receive 9 of her 9 scheduled morning medications (to be given at 9:00 am) on 3-16-10 (patient did not discharge from facility until 11:30 am) with no documentation as to why the medications were not given.

A review of the clinical record on 5-3-10 and 5-4-10 revealed that 6 of 9 Case Management progress notes contained only a brief note stating that the patient refused to attend group therapy but contained no assessment data regarding the patient ' s appearance, mood, insight and judgment, speech, affect, observed behavior or thoughts.

A review of the clinical record on 5-3-10 and 5-4-10 revealed a document titled " Discharge Plan " (dated 3-16-10, the date of the patient ' s discharge) that stated Referrals & Appointments " *to be arranged by APS* " . There was no documentation of patient involvement in the development and/or implementation of her discharge plan, as is required under Texas State regulations found at 25 TAC 404.154(14).

The above was confirmed in an exit conference with the facility Administrator and other administrative staff on the afternoon of 5-4-10 in the facility conference room.

Based on a review of documents, progress notes were not recorded by others significantly involved in active treatment modalities.

Findings were:

A review of the clinical record on 5-3-10 and 5-4-10 revealed that 6 of 9 Case Management progress notes contained only a brief note stating that the patient refused to attend group therapy but contained no assessment data regarding the patient ' s appearance, mood, insight and judgment, speech, affect, observed behavior or thoughts.

The above was confirmed in an exit conference with the facility Administrator and other administrative staff on the afternoon of 5-4-10 in the facility conference room.

Based on a review of documentation and interviews, it was determined that there was no documented evidence that discharge planning for patient #1 was completed with the patient's input and the recommendations of the Indisciplinary Treatment Team as found in the various assessments and recommendation incumbent upon the members of that team to make in relation to the patient's aftercare needs. There was no indication in wither documentation or interview that discharge planning had begun early in the patient's treatment in the facility and there was no evidence found to suggest that appropriate aftercare needs or arrangements had been made prior to the last two or three days of the patient's hospitalization.

Findings were:

A review of the clinical record for patient #1 on 5-3-10 and 5-4-10 revealed no documentation that follow-up or after care had been addressed by the facility staff until 3-15-10. Physician ' s Daily Progress Note dated 3-15-10 states, in part, " Disch planning - NH will not take pt back, options being assessed. " The patient ' s Integrative Discharge Plan, dated 3-16-10 (date of discharge) states, in part, " Referrals & Appointments " *to be arranged by APS* " . (Note: APS standards for "Adult Protective Services" a part of the Texas State Agency of the Department of Family and Protective Services, assigned to deal with the realities of adult abuse, neglect, and exploitation.)

There was no other documentation found to suggest that post-hospitalization needs for follow-up treatment were considered.

The above was confirmed in an exit conference with the facility Administrator and other administrative staff on the afternoon of 5-4-10 in the facility conference room.