HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that the social services section of the individualized interdisciplinary treatment plan was developed and implemented based on the social workers assessment/evaluation of the patient. This was noted for 1 of 7 patients whose medical record was reviewed for the social workers completion of the individualized interdisciplinary treatment plan out of a total sample of 14 patients. Findings:
Patient #2: Medical record review revealed that the patient was admitted to the hospital on 7/01/10 and discharged from the hospital on 7/08/10. Review of the Psychiatric Evaluation dated 7/02/10 revealed that the patient's Axis I diagnosis was "Schizoaffective D/O, mixed, last episode depressed, severe". Review of the medical record revealed no documentation to indicate that the social worker had assessed/evaluated the patient during the patient's hospitalization.
Review of the "Psychosocial Assessment" form found in the chart of Patient #2 revealed no documented evidence the form had been initiated by the social worker as all sections were left blank.
In a face to face interview on 07/21/10 at 3:30 p.m., Social Worker S3 verified Patient #2 did not have a Psychosocial Assessment performed during her admit of 07/01/10 because she (S3) had been on vacation during that time. Further the Social Worker indicated the Multidisciplinary Treatment Plan is developed using the information obtained in the assessments performed by the Psychiatrist, Medical Physician, RN, Social Worker, and Recreational Therapist.
Review of Policy 1.37 titled "Treatment Plans" originated 2009 and submitted as the one currently in use, revealed "The Master Treatment Plan is based on the assessment of the patient's presenting problems, physical health, emotional and behavioral problems, cognitive functioning, and social functioning".

Based on record review and interview, the hospital failed to ensure a transfer agreement was in place for the provision of immediate medical and surgical services for patient care as needed. Findings:

Review of the hospital's transfer agreements revealed no documented evidence of a transfer agreement with a medical facility providing medical and surgical care. This finding was confirmed by the hospital's owner, S2 on 7/28/2010 at 9:15 a.m. S2 further indicated the hospital's practice had been to have patients cleared medically before accepting them for psychiatric treatment. S2 indicated the hospital had not obtained a transfer agreement for medical and surgical treatment because they had felt the medical screening would have been sufficient to determine no medical/surgical needs would surface.

Based on record review and interview, the hospital failed to ensure 1) that psychotherapy was provided by a social worker in accordance with hospital policy and patient treatment plans for 8 of 14 sampled patients (#2, #3, #7, #8, #9, #10, #11, #14); 2) that Social Services were provided by a social worker for 17 of 46 weekdays reviewed for the provision of Social Services (5/31/2010, 6/03/2010, 6/04/2010, 6/11/2010, 6/14/2010, 6/15/2010, 6/22/2010, 6/25/2010, 7/05/2010, 7/06/2010, 7/07/2010, 7/08/2010, 7/12/2010, 7/16/2010, 7/19/2010, 7/23/2010, and 7/26/2010); and 3) that a Psychosocial Assessment was performed as per hospital policy for 1 of 14 sampled patients (#2). Findings:

1) failing to ensure psychotherapy was provided by a social worker in accordance with hospital policy and patient treatment plans for 9 of 14 sampled patients (#2, #3, #6, #7, #8, #9, #10, #11, #14).

Patient #2:
Review of Patient #2's medical record revealed a treatment plan dated 7/2/2010 for the problem of "Gravely disabled related to mood disturbance". Review of the Preliminary Treatment Plan initiated by the psychiatrist revealed Patient #2 was to have a full range of services. Review of the hospital policy titled, "Social Work Plan of Services, Continuum of Care, # 5.24" presented by the hospital as their current policy revealed in part, "Group Therapy, held daily, is a regular part of the program, and each patient is expected to attend." Further review of the medical record for Patient #2 revealed no documented evidence the patient had been seen by the social worker for the entire hospital stay of 07/02/10 through 07/08/10.

Patient #3:
Review of Patient #3's medical record revealed a treatment plan dated 7/24/2010 for the problem of "Depressed Mood related to history of mental illness, pain with clinical interventions which included "Provide group therapy daily x 3 hours. SW (Social Worker)." Further review revealed no documented evidence Patient #3 was provided psychosocial group therapy by the Social Worker on 7/26/2010 (Monday). (Patient #3 remained in-patient at the time of the survey.) This finding was confirmed by Social Worker S3 on 7/27/2010 at 3:50 p.m.

Patient #7:
Review of Patient #7's medical record revealed a treatment plan dated 6/12/2010 for the problem of "Ineffective individual coping related to grief and loss issues, alcohol dependence, and disturbances in normal functioning," with clinical interventions which included "Provide group therapy daily x 3 hour. SW". Further review revealed no documented evidence Patient #7 was provided psychosocial group therapy by the Social Worker on Monday 6/14/2010 or Tuesday 6/15/2010. (Patient #7 was discharged on 6/16/2010). This finding was confirmed by Social Worker S3 on 7/27/2010 at 3:50 p.m.

Patient #8:
Review of Patient #8's medical record revealed a treatment plan dated 5/31/2010 for the problem of "Depressed Mood" with clinical interventions which included "Provide group therapy daily x 3 hour. SW." Further review revealed no documented evidence Patient #8 was provided psychosocial group therapy by the Social Worker on Thursday 6/03/2010, Friday 6/04/2010, Wednesday 6/14/2010, and Thursday 6/15/2010.

Patient #9:
Review of Patient #9's medical record revealed a treatment plan dated 6/21/2010 for the problem of "Potential for relapse in use of alcohol and/or drug related to the patients use of THC (marijuana) and ETOH (alcohol)" with clinical interventions which included "Educate patient about chemical dependency in group x 3 hour. SW." Further review revealed no documented evidence Patient #9 was provided psychosocial group therapy by the Social Worker on Tuesday 6/22/2010 and Friday 6/25/2010 (Patient #9 was discharged on 6/26/2010). This finding was confirmed by Social Worker S3 on 7/27/2010 at 3:50 p.m.

Patient #10:
Review of Patient #10's medical record revealed a treatment plan dated 7/15/2010 for the problem of "Potential for relapse in use of alcohol and/or drug use related the patient's use of opiates and Depressed mood related to history of mental illness, physical illness, medication non-compliance" with clinical interventions which included "Educate patient about chemical dependency in group x 3 hour. SW." and "Provide group therapy daily x 3 hours. S.W."" Further review revealed no documented evidence Patient #10 was provided psychosocial group therapy by the Social Worker on Friday 7/16/2010 and Monday 7/19/2010. (Patient #10 was discharged on 7/23/2010.) This finding was confirmed by Social Worker S3 on 7/27/2010 at 3:50 p.m.

Patient #11:
Review of Patient #11's medical record revealed a treatment plan dated 6/02/2010 for the problem of "Ineffective individual coping" with clinical interventions which included "Provide group therapy daily x 3 hour. SW." Further review revealed no documented evidence Patient #11 was provided psychosocial group therapy by the Social Worker on Thursday 6/03/2010 and Friday 6/04/2010. (Patient #11 was discharged on 6/08/2010) This finding was confirmed by Social Worker S3 on 7/27/2010 at 3:50 p.m.

Patient #14:
Review of Patient #14's medical record revealed a treatment plan dated 5/20/2010 for the problem of "Ineffective individual coping" with clinical interventions which included "Provide group therapy daily x 3 hour. SW." Further review revealed no documented evidence Patient #14 was provided psychosocial group therapy by the Social Worker on Monday 5/24/2010. (Patient #14 was discharged on 5/25/2010). This finding was confirmed by Social Worker S3 on 7/27/2010 at 3:50 p.m.

2) failing to ensure Social Services was provided for 17 of 46 weekdays reviewed for provision of Social Services (5/31/2010, 6/03/2010, 6/04/2010, 6/11/2010, 6/14/2010, 6/15/2010, 6/22/2010, 6/25/2010, 7/05/2010, 7/06/2010, 7/07/2010, 7/08/2010, 7/12/2010, 7/16/2010, 7/19/2010, 7/23/2010, and 7/26/2010).

Review of the hospital policy titled, "Social Work Plan of Services, Continuum of Care, # 5.24" presented by the hospital as their current policy revealed in part, "Group Therapy, held daily, is a regular part of the program, and each patient is expected to attend."

Review of the hospital's Social Worker's Time Cards and the hospital's Census report revealed the following:
Monday 5/31/2010 there was no Social Worker on duty with a hospital census of 2.
Thursday 6/03/2010 there was no Social Worker on duty with a hospital census of 2.
Friday 6/04/2010 there was no Social Worker on duty with a hospital census of 2.
Friday 6/11/2010 there was no Social Worker on duty with a hospital census of 2.
Monday 6/14/2010 there was no Social Worker on duty with a hospital census of 2.
Tuesday 6/15/2010 there was no Social Worker on duty with a hospital census of 2.
Tuesday 6/22/2010 there was no Social Worker on duty with a hospital census of 1.
Friday 6/25/2010 there was no Social Worker on duty with a hospital census of 1.
Monday 7/05/2010 there was no Social Worker on duty with a hospital census of 2.
Tuesday 7/06/2010 there was no Social Worker on duty with a hospital census of 1.
Wednesday 7/07/2010 there was no Social Worker on duty with a hospital census of 1.
Thursday 7/08/2010 there was no Social Worker on duty with a hospital census of 1.
Monday 7/12/2010 there was no Social Worker on duty with a hospital census of 2.
Friday 7/16/2010 there was no Social Worker on duty with a hospital census of 3.
Monday 7/19/2010 there was no Social Worker on duty with a hospital census of 3.
Friday 7/23/2010 there was no Social Worker on duty with a hospital census of 2.
Monday 7/26/2010 there was no Social Worker on duty with a hospital census of 2.

During a face to face interview on 7/27/2010 at 3:50 p.m., Social Worker S3 indicated there was no Social Worker on duty in her absence on the dates listed above. S3 further indicated all patients were to have Psychosocial therapy provided by the Social Worker on a daily basis Monday through Friday as part of their treatment plan according to hospital policy. S3 confirmed that no Psychosocial therapy had been provided to patients in the hospital on the dates of 5/31/2010, 6/03/2010, 6/04/2010, 6/11/2010, 6/14/2010, 6/15/2010, 6/22/2010, 6/25/2010, 7/05/2010, 7/06/2010, 7/07/2010, 7/08/2010, 7/12/2010, 7/16/2010, 7/19/2010, 7/23/2010, and 7/26/2010.

3) failing to ensure a Psychosocial Assessment was performed as per hospital policy for 1 of 15 sampled patients (#2). Findings:

Medical record review revealed that the patient was admitted to the hospital on 7/01/10 and discharged from the hospital on 7/08/10. Review of the Psychiatric Evaluation dated 7/02/10 revealed that the patient ' s Axis I diagnosis was Schizoaffective D/O, mixed, last episode depressed, severe " . Review of the medical record revealed no documentation to indicate that the social worker had assessed/evaluated the patient.
Review of the " Psychosocial Assessment " found in the chart of Patient #2 revealed no documented evidence the form had been initiated by the social worker as all sections were left blank.
In a face to face interview on 07/21/10 at 3:30pm Social Worker S3 verified Patient #2 did not have a Psychosocial Assessment performed during her admit of 07/01/10 because she (S3) had been on vacation during that time. Further the Social Worker indicated the Multidisciplinary Treatment Plan is developed using the information obtained in the assessments performed by the Psychiatrist, Medical Physician, RN, Social Worker, and Recreational Therapist.
Review of Policy 1.37 titled " Treatment Plans " originated 2009 and submitted as the one currently in use, revealed " The Master Treatment Plan is based on the assessment of the patient ' s presenting problems, physical health, emotional and behavioral problems, cognitive functioning, and social functioning " .