HospitalInspections.org

Based on record review and interview, the facility failed to provide 6 of 6 active sample patients (A1, A2, A3, A4, A5 and A6) with treatment plans that delineated individualized treatment modalities. Instead, interventions on the preprinted treatment plans included a list of nine generic "INTERVENTIONS" which were statements selected by the person completing the plan. Some of these intervention choices were routine tasks that are performed on every patient while others allowed for a choice of a type of therapy. This resulted in a treatment plan that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient A1 was admitted 5/23/11. Her treatment plan, updated 8/18/11, selected such routine, generic discipline functions as "Monitor, record and report vegetative symptoms including nutrition, sleep and energy" and "Engage the patient in a calm manner as well as providing a reduced stimuli environment." Also selected was "Medication management and administration/med compliance" with no further explanation. These were not individualized further for the specific patient.

2. Patient A2 was admitted 8/22/11. His treatment plan, dated 8/25/11, selected such routine, generic discipline functions as "Monitor, record and report mood fluctuations, daily activity, thought process, physical complaints" and "Engage the patient in a calm manner and gently confront impulsive/socially inappropriate behavior." Also selected were "Medication management and administration/med compliance" and "Encourage appropriate self expression and participation in groups or social activities." These were not individualized further for the specific patient.

3. Patient A3 was admitted 7/22/11. His treatment plan, updated 8/23/11, selected such routine, generic discipline functions as "Monitor, record and report vegetative symptoms including nutrition, sleep and energy" and "Monitor, record and report mood fluctuations, daily activity, thought process, physical complaints." Also selected was "Medication management and administration/med compliance" with no further explanation. These were not individualized further for the specific patient.

4. Patient A4 was admitted 7/20/11. Her initial treatment plan of 7/22/11 selected "Monitor, record and report anxiety level, thought process, physical complaints" and "Medication management and administration/med compliance" with no further explanation. These are routine staff functions and were not individualized further for the specific patient.

5. Patient A5 was admitted 8/3/11. His treatment plan update of 8/22/11 selected "Monitor, record and report vegetative symptoms including nutrition, sleep and energy" and "Monitor, record and report anxiety level, thought process, physical complaints" which are routine ward tasks. Also selected were "Medication management and administration/med compliance" and "Offer individualized tx (treatment): Low Stim (stimulus) Environment" with no further explanation. These are routine staff functions and were not individualized further for the specific patient.

6. Patient A6 was admitted 7/24/11. His treatment plan of 8/24/11 selected "Monitor, record and report vegetative symptoms including nutrition, sleep and energy" and "Monitor, record and report anxiety level, thought process, physical complaints" which are routine ward tasks. Also selected were "Medication management and administration/med compliance" and "Other: Geriatric Programming" with no further explanation. These are routine staff functions and were not individualized further for the specific patient.

B. Staff Interview

The Medical Director was interviewed on 8/25/11 at 10:45a.m.. He agreed that the interventions on the treatment plans were very non-specific and stated that the staff have struggled with how to write treatment plans.

Based on record review and interview, the facility failed to ensure that the staff members responsible for each intervention on the Master Treatment Plans were specifically identified in 6 of 6 treatment plans (A1, A2, A3, A4, A5, and A6). This failure resulted in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented, thereby possibly leading to missed patient treatment, response, and outcomes.

Findings include:

A. Record Review

1. The assigned disciplines for interventions on treatment plans utilized the following hospital designed code system: "1=MD, 2= Nursing, 3= HT (Hospital Therapist), 4= Social Work, 5 = OT, 6= TR, 7=Dietary, 8= Other." "Other" was designated as the mental health technician. A listing "#1-8" meant that all of the disciplines from #1 to 8 were responsible.

2. Review of the multidisciplinary treatment plans (dates in parentheses) revealed that they did not delineate the names and responsibilities of treatment team members but used the hospital designed code system:

2a. Patient A1 (8/18/11); Patient A2 (8/25/11); Patient A3 (8/23/11); Patient A5 (8/22/11); listed #1 to 8 coded staff members responsible for the following intervention: "Monitor, record and report vegetative symptoms including nutrition, sleep and energy;" #1=MD, 6= TR and 8= MHT staff members were responsible to "Engage the patient in a calm manner and gently confront impulsive/socially inappropriate behavior."

2b. Patient A4 (7/22/11); Patient A6 (8/24/11) listed #1 to 8 coded staff members responsible for the following intervention: "Monitor, record and report vegetative symptoms including nutrition, sleep and energy"; #1 to 6 coded staff members were responsible for the following intervention: "Monitor, record and report mood fluctuations, daily activity, thought process, physical complaints."

B. Staff Interview

1. In an interview with the Hospital Therapist on 8/25/11 at approximately 9:30AM, she agreed that no one discipline or name was listed on the patient interventions.

2. In an interview with RN I on 8/25/11 at approximately 9:50AM, she concurred that the interventions were not specific and the person(s) responsible were not identified by name.