HospitalInspections.org

Based on interview and record review the facility failed to provide completed treatment plans for four (4) out of six (6) patients reviewed for treatment plans to address medical needs and interventions. (Patients #1, 2, 3, and 4)

Findings Included:

Review of Patient #1's Psychiatric evaluation reflected a 51 year old female, admitted on 11/16/15 at 12:22 p.m., with a diagnosis of Schizoaffective Disorder, Suicidal Ideations, Borderline Personality Disorder, Chronic Obstructive Pulmonary Disease, Hypertension, and Diabetes Mellitus Type 2 without complication, Constipation.

Review of Patient #1's Treatment Plan dated 11/19/15 did not reflect the Problem: Alteration in Elimination.

Review Patient #2's History and Physical dated 9/10/15 reflected an 18 year old female admitted for PTSD, Depression, and Suicidal Ideation.

Review of Patient #2's Treatment Plan for Risk for Seizures reflected a check for a history of seizures. There were no goals checked or interventions in place.

Review of Patient #3's History and Physical dated 9/7/15 reflected a 59 year old female admitted for Major Depression, and Suicidal Ideation, Hypertension, and Arthritis.

Review of Patient #3's Treatment Plan for Alteration in Comfort reflected a check for Chronic Pain C3 (cervical) and T9 (thoracic) discs. There were no goals checked or interventions in place.

Review of Patient #4's History and Physical dated 9/5/15 reflected a 19 year old female admitted for Depression, and Suicidal Ideation, Seizures.
Review of Patient #4's Treatment Plan for Risk for Seizures was checked for a history of seizures. There were no goals checked or interventions in place.

During an interview on 1/11/16 at 1:30 p.m. in the Administrative office, Staff #1, Chief Nurse Officer stated the facility was not aware of Patient #1 history of constipation. Staff #1 stated the constipation would have been on the treatment plan and interventions put into place.


Review of the facility provided Policy, SUBJECT: Multidisciplinary Treatment Planning #PC.18 (revised 5/13) reflected:
...The treatment plan is individualized and based on the needs, liability ...and directed toward restoring and maintain optimal levels of physical and psychological functioning. Care is planned and provided in an interdisciplinary, collaborative manner by qualified staff members.
Treatment Plan
1. Treatment plan content ...is based on the findings of the Admission Assessment, History and Physical Examination ...and other pertinent information.

During an interview on 1/12/16 at 9:00 a.m. Staff #4 confirmed the findings and stated treatment plans will be the Quality program in 2016; and the facility had not started the program yet.