|5100.15 CONTENTS OF TREATMENT PLANS|
(a) A comprehensive individualized plan of treatment shall:
(2) Be based upon diagnostic evaluation which includes examination of the medical, psychological, social, cultural, behavioral, familial, educational, vocational, and developmental aspects of the patients situation.
Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a comprehensive individualized plan of treatment was based upon medical and psychological aspects of the patients situation for one of one medical records reviewed (MR1).
Review of facility policy and procedure "Treatment Plan" reviewed January 2018, revealed "1. Each patient shall have an individualized treatment plan that is based on assessments of his/her clinical needs. ... 3. ... c. all disciplines, medical, nursing, social service, occupational therapy and recreational therapy may add specific objectives and interventions to the treatment plan. ..."
1. Review of MR1 on February 04, 2020, revealed a physician order on August 30, 2019, "Forced Medication: Zyprexa inj 10 mg IM (intramuscular) 3 times a day prn for anxiety, may give if pt refuses PO zyprexa". Further review of the Treatment Plan revealed no documentation or discussion of the forced medication use.
Interview with EMP2 on February 4, 2020, at 10:00 AM confirmed the above findings.
| ||Plan of Correction - To be completed: 03/31/2020|
1) A single point education lesson is being developed regarding the process and documentation for forced medications which contents will include:
a) The necessity for the Psychiatrist to document the justification for a forced medication order in the patient's Treatment Plan.
b) The discussion with the patient regarding the order for the forced medication order will also be reflected in the Treatment Plan.
2) Communication of the changes is being provided by the Behavioral Health Management Team during daily huddles beginning 2/17/2020.
3) The single point education lesson for the Treatment Team which includes the Psychiatrists, Registered Nurses, Social Worker and Case Manager will be reviewed and completed by 3/31/2020.
4) Because of the infrequency, all patient records with forced medication orders will be monitored by the Behavioral Health Management Team. The monitoring will begin on 4/01/2020 and continue until 10/01/2020 to ensure compliance.
5) The Behavioral Health Manager has responsibility of this plan and the compliance results will be reported to the Performance Improvement Oversight Committee on a monthly basis.