HospitalInspections.org

Based on record review, document review and interview, the facility failed to identify the strengths and abilities of each patient on which to base the master treatment plan for six (6) of 10 active sample patients (R1, R4, R5, B1, B2, and B3). This failure diminishes the effectiveness of treatment interventions by not engaging the patient through the use of their strengths and awareness of their disabilities.

Findings include:

A. Record Review

1. Patient R1 admitted on 3/31/17 had no master treatment plan completed as of 3:45 P.M. on 4/10/17.

2. Patient R4 admitted on 3/30/17 had no master treatment plan completed as of 3:45 P.M. on 4/10/17.

3. Patient R5 admitted on 3/30/17 had no master treatment plan completed as of 3:45 P.M. on 4/10/17.

4. Patient B1 admitted on 3/29/17 had no master treatment plan completed as of 3:45 P.M. on 4/10/17.

5. Patient B2 admitted on 3/30/17 had no master treatment plan completed as of 3:45 P.M. on 4/10/17.

6. Patient B3 admitted on 3/31/17 had no master treatment plan completed as of 3:45 P.M. on 4/10/17.

B. Document Review

The facility policy 45.007 titled "Treatment Planning" (last reviewed 12/16) states, "The master treatment planning session shall be held within seven (7) days of admission. As a team, those in attendance shall: Identify additional strengths and assets."

C. Interviews

1. On 4/10/17 at 1:00 P.M., the Survey Coordinator acknowledged that the treatment plans were not present.

2. The Director of Nursing on 4/11/17 at 3:00 P.M. stated, "I agree with you 100%. We are deficient."

3. The Director of Social Work on 4/11/17 at 1:40 P.M. stated, "They [treatment plans] should have been done a long time ago. There is nothing there. We are deficient and I am frustrated."

4. The Medical Director on 4/11/17 at 2:00 P.M. stated, "Of course, that is no excuse. We are deficient."

Based on record review, document review and interview, the facility failed to identify a diagnosis that served as the primary focus for the master treatment plans of six (6) of 10 active sample patients (R1, R4, R5, B1, B2 and B3). This practice compromised the staffs' ability to deliver clinically focused treatment.

Findings include:

A. Record Review

1. Patient R1 admitted on 3/31/17 had no master treatment plan as of 3:45 P.M. on 4/10/17.

2. Patient R4 admitted on 3/30/17 had no master treatment plan as of 3:45 P.M. on 4/10/17.

3. Patient R5 admitted on 3/30/17 had no master treatment plan as of 3:45 P.M. on 4/10/17.

4. Patient B1 admitted on 3/29/17 had no master treatment plan as of 3:45 P.M. on 4/10/17.

5. Patient B2 admitted on 3/30/17 had no master treatment plan as of 3:45 P.M. on 4/10/17.

6. Patient B3 admitted on 3/31/17 had no master treatment plan as of 3:45 P.M. on 4/10/17.

B. Document Review

The facility policy 45.007 titled "Treatment Planning" (reviewed 12/16) states, "As a team those in attendance shall: Review the DSM Diagnosis."

C. Interview

The Medical Director on 4/11/17 at 2:00 P.M. stated, "The plans are not there. We are deficient."