CMS-HCA-Florida-Brandon-Hospital

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, staff interview and review of policy and procedures it was determined the facility failed to ensure a registered nurse supervised and evaluated the care of each patient for two (#1, #4) of five patients sampled.

Findings included:

Review of the facility policy, Fall Prevention Plan, states all employees are expected to participate in the reduction of patient falls. Interventions may be initiated by either clinical or non-clinical staff, as appropriate, and will include the patient and family as appropriate. Section II - Assessment/Reassessment: ...(2) the following factors should be used to determine the patient's fall risk: Auditory and/or visual impairment, congestive heart failure. Section III - Fall Prevention Interventions states patients determined to be at risk for fall will also have the following interventions implemented based on the assessment of the patient: ...(c) the patient should not be left unattended when assisting them to the bathroom, the bedside commode, or the shower; ...(f) if video-monitoring is used, bed alarms are not to be used; ...(g) Patient Safety Attendants (sitters): the use of patient safety attendants and/or use of restrictive devices (i.e., restraint, Posey bed) should be evaluated and approved by the Director/designee/House Supervisor for implementation, continuation and resources available, i.e. family, private agency, or staff.

1. Review of patient #1's Emergency Patient Record, dated 4/13/2019, indicated the patient was [AGE] years old, legally blind, and hard of hearing. The stated complaint included, CHF (congestive heart failure) and SOB (shortness of breath). Review of the subjective assessment included trouble breathing since yesterday. Review of the nursing fall risk assessment stated the patient was not at high risk for falls.

Interview on 5/1/2019 at 11:45 a.m., with the Risk Manager, confirmed the findings and stated patient #1 should have been assessed to be at risk for falls.

2. Review of the medical record for patient #4 revealed the patient was admitted on [DATE] for urological complaint. Review of the nursing fall risk assessment, dated 2/28/2019 at 5:01 am, revealed the patient was identified with generalized weakness, the patient was hard of hearing and was a high risk for falls. Nursing documentation revealed a bed exit alarm was implemented. Review of the nursing shift assessment, dated 2/28/2019 at 7:58 am, revealed nursing assessed the patient to be a high risk for falls. Documentation stated interventions in place were a bed exit alarm, diversion, and supervision/assistance with ambulation.

Review of the nursing notes, dated 2/28/2019 at 9:15 am, revealed the nurse assisted the patient to the bathroom and told the patient to call for assistance back to bed. The nurse documented she left the room to administer another patient's medication and heard a loud thud from the patient's room. Review of the policy revealed the patient should not be left unattended when assisting them to the bathroom, the bedside commode, or the shower.

The nursing note further stated the patient attempted to ambulate back to bed and slipped on a napkin and fell hitting his elbow. The patient was assessed and treatment was provided. The physician and administrator were notified. Nursing documentation at 10:00 am revealed a post-fall assessment was completed with documentation that no fall protocols were in place at the time of the fall. Review of the record revealed no additional fall interventions were implemented post-fall. Review of the policy revealed the use of patient safety attendants and/or use of restrictive devices (i.e., restraint, Posey bed) should be evaluated and approved by the Director/designee/House Supervisor for implementation, continuation and resources available.

Review of the nursing fall risk assessment on 2/28/2019 at 8:00 pm revealed the patient was identified as a high fall risk and interventions in place were supervision/assistance, bed exit alarm, and virtual sitter. Review of the policy, Fall Prevention Plan, states the virtual sitter is a system that uses cameras, sensors and central monitoring stations to alert staff to patient movement and activities that place them at high risk for fall. If video-monitoring is used, bed alarms are not to be used. An interview was conducted with the Director of Risk Management on 5/01/2019 at 3:00 pm at which time she confirmed the patient was located on a unit that had one room with a virtual sitter but the patient was not in that room at the time of the fall.

Review of the record revealed nursing conducted fall risk assessment of the patient each shift but there were no additional fall interventions put into place other than the supervision/assistance and bed exit alarm. Review of nursing note, dated 3/01/2019 at 8:24 pm, stated the patient was educated multiple times during the shift about the need to use the call light for assistance, bed alarm in use and assistance provided with ambulation. On 3/01/2019 at 9:24 pm nursing documented the patient was non-compliant during the shift, bed exit alarming in the patient's room multiple times since the start of the shift. The patient refused to use the call light. Review of the record revealed no evidence nursing attempted any other interventions.

Review of the nursing shift assessment, dated 3/02/2019 at 8:00 am, stated the patient was a high risk for falls, he was able to comprehend and follow directions, the bed exit alarm was in place, required supervised assistance and his gait was weak and unsteady. Review of the record revealed Physical Therapy treatment was provided at 1:45 pm and documentation revealed the patient was left supine in bed with the call light in reach and the RN (Registered Nurse) was notified of the patient's status at the end of the session. Review of the nursing note, dated 3/02/2019 at 3:05 pm, stated a loud crash was heard from the patient's room, the patient was found lying of the floor and that he slipped and fell when attempting to use the bedside commode. The patient stated he hit his head and couldn't move his leg. Review of the record revealed the patient sustained injury which required surgical repair.

An interview and review of the record was conducted on 5/01/2019 at 3:00 pm with the Director of Risk Management and the Director of Quality Management at which time the above findings were confirmed.

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Based on review of medical records, review of policy and procedure, ambulance report review, review of bed census reports and staff interviews it was determined the facility failed to ensure an individual which presented to the facility and was determined to have an emergency medical condition was not provided stabilizing treatment as required within the capabilities of the staff and facilities available at the hospital, for one (#9) of twenty-two patients sampled prior

to discharge.

Findings included:

Review of the facility policy, EMTALA - Medical Screening and Stabilization, last revised 2/26/2016, states in part, ...7. Stabilizing Treatment Within Hospital Capability ...c. Stabilizing Treatment and individuals whose EMC's are resolved. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, including diagnostic work -up and/or treatment could reasonably be performed as an outpatient or later as an inpatient, provide the individual is given a plan for appropriate follow-up care with discharge instructions. The EMC that caused the individual to present to the DED must be relieved or eliminated, but the underlying medical condition may persist. Hospitals are expected within reason to assist/provide discharged individuals the necessary information to secure follow-up care to prevent relapse or worsening of the medical condition upon release form the hospital.

Review of the County Fire Rescue Medical Encounter Report Form dated 4/30/2018 was reviewed. The report indicated that EMS arrived to the scene where patient #9 was located at 23:16. The patient medications were listed as Zoloft (medication used to treat depression), Amoxicillin (Antibiotic-medication used to treat infections), Haldol (Anti-psychotic medication used to treat schizophrenia), and Geodan (Anti-psychotic drug used to treat schizophrenia and Bi-Polar disorder). Review of the narrative revealed that EMS was dispatched because Patient #9 was complaining of a headache. The EMS personnel documented upon arrival patient #9 did not appear to be in any distress. Further review revealed upon contact the patient reported that he has had a headache for approximately 2 hours. Patient reported that he has a psychiatric history and has been non complaint with his medication for approximately 2 weeks, causing him to have random suicidal thoughts. The patient was able to walk to the rescue under his own power, sat on the stretcher, secured with straps, and loaded in the rescue without incident. Further review revealed that patient #9 was transported to Brandon Regional Hospital without incident, and full report was given to the ED staff nurse.

Review of the medical record for patient #9 revealed the patient arrived to the facility's ED (Emergency Department) on 4/30/2018 at 11:34 pm via EMS (Emergency Medical Services). Review of the record revealed a physician performed a MSE at 11:38 pm. The physician documented the patient had a past medical history of schizophrenia, depression and anxiety. The physician documented the patient presented with suicidal ideation's with no stated plan, the patient's affect was depressed, flat and he was suicidal.

Review of the physician orders revealed on 4/30/2018 at 11:37 pm the physician ordered a consultation with the Behavioral Health Unit Intake Coordinator. Review of the record revealed the physician completed the Certificate of Professional Initiating Involuntary Examination on 4/30/2018 at 11:48 pm. Review of the Certificate of Professional Initiating Involuntary Examination dated 4/30/2018 at 2348, revealed in part, ...Criteria: there is reason to believe person has mental illness ...Diagnosis of Mental illness is ...Depression ...AND BECAUSE OF MENTAL ILLNESS ...Person is unable to determine for himself/herself whether examination is necessary ...and either there is substantial likelihood that without care or treatment the person will cause serious bodily harm to self.

Documentation revealed the physician medically cleared the patient on 5/01/2018 at 1:14 am. Review of the facility's in-patient Behavioral Health Unit midnight census for 5/01/2018 was 18 with a capacity of 25. The unit had the capability and capacity to admit the patient.

Review of the medical record revealed nursing documentation, dated 5/01/2018 at 1:46 am, which stated telephone communication, with an independent organization used to assist in bed placement for patients with behavioral health diagnosis, requesting a bed for the patient. Documentation stated the BA (Baker Act) paperwork was also faxed at that time. Review of the record revealed no evidence the ED staff requested bed placement on their behavioral health unit. Review of the nursing documentation on 5/01/2018 at 4:31 am revealed the organization used to assist with bed placement was called again regarding placement of the patient. Documentation stated the patient will be on hold for 12 hours in the ED because he has no insurance.

Review of the physician documentation at 6:02 am on 5/1/2018 stated the patient was pending bed assignment by the organization and the patient's status was unchanged. At 6:23 am the physician documented the patient's continued care was transferred to the oncoming ED physician and the patient's complaints and labs were discussed.

Review of the medical record revealed the ED physician documented at 9:07 am on 5/1/2018 that the patient was seen by the licensed mental health worker and the ED physician was asked by the licensed mental health worker to rescind the Baker Act per her telephone conversation with the psychiatrist. Documentation by the ED physician stated he told the licensed mental health worker the patient should be seen by the psychiatrist for further evaluation.

Review of the Behavioral Health intake specialist note, dated 5/01/2018 at 12:22 pm, stated she met with the patient for a brief assessment. She stated the patient felt alright and denied all suicidal ideation, homicidal ideation, auditory or visual hallucinations. He stated I guess I can be let go. Documentation stated the patient will be provided community resources and a bus pass. The patient was discussed with the on-call psychiatrist.

Review of the record revealed the psychiatrist evaluated the patient on 5/01/2018, no time noted.

The psychiatric consult note, stated in part, Reason for Consult: Evaluate patient with Baker act ...history of Present illness: Patient is well known.. Presents with suicidal ideation, once had a good night's sleep ... deny any suicidal ideation and requested to be discharged . ...Denies any intent to harm himself or others. Has been appropriate with ER staff. ...Mental Status Exam: awake alert, and oriented x4 ...thought process: coherent and goal directed ...thought content: within normal limits. Short term: intact. Long term: intact...Insight/Judgement: insight intact, judgement intact. Assessment and Plan ...Will lift Baker act, Patient psychiatrically cleared for discharge. No discharge prescriptions were written.

Review of the ED physician documentation on 5/01/2018 at 12:51 pm validated that Patient #9 was evaluated by the psychiatrist and the Baker Act was rescinded. The patient was discharged from the facility at 12:50 pm.

An interview was conducted on 6/22/2018 at 3:45 pm with the Risk Manager/Director of Patient Safety, BHU (Behavioral Health Unit) Program Director and Behavioral Health Unit Director. The BHU Director and Program Director confirmed the BHU had capacity and capability.

The facility staff failed to ensure that their own policy and procedure was followed as evidenced by the facility staff failed to ensure that Patient #9's discharge instructions included discussion regarding the reason for his noncompliance with his psychiatric medications prior to discharge. As patient stated to EMS that he was noncompliant with his meds which caused him to have random suicidal ideations; and it was determined by the ED physician that on 4/30/2018 the patient had an emergency psychiatric medical condition. There were no prescriptions given to the patient upon discharge. There was no discussion whether or not the patient had remaining psychiatric medication at home or if he had access to his psychiatric medication upon discharge.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview it was determined the facility failed to ensure the nursing staff provided care and services to meet the needs of 1 (#2) of 10 sampled patients.

Findings included:

Patient #2 was admitted on [DATE] at 7:00 a.m., with uncontrolled high blood pressure, severe nausea and vomiting, and abdominal pain.

The Physician Orders for Patient #2 dated 8/21/16 at 9:35 a.m., and signed by the attending physician included orders for Catapres 0.1 mg (milligram) tablet every 4 hours as needed for systolic blood pressure greater than 160 or diastolic blood pressure greater than 90. On 8/21/16 at 1:41 p.m., the same physician signed an order to administer Apresoline 10 mg IV (intravenously) every 4 hours as needed to Patient #2 for systolic blood pressure greater than 160 or diastolic blood pressure greater than 90.

The record for Patient #2 revealed the following blood pressure readings on 8/21/16: 177/88 at 10:44 a.m. and 201/92 at 12:16 p.m. The review of the Medication Administration Record (MAR) failed to reveal evidence of the administration of Catapres 0.1 mg tablet or any documentation of reasons the medication was not administered as ordered. The MAR did show documentation of the administration of Apresoline 10 mg IV at 2:08 p.m. on 8/21/16. Patient #2's blood pressure readings following the dose of blood pressure medicine were: 177/88 at 3:20 p.m.; 161/74 at 4:10 p.m.; 148/96 at 7:55 p.m.; and at 162/79 at 11:19 p.m. The review of the MAR failed to reveal evidence of the administration of a repeat dose of Apresoline or documentation of reasons the medication was not administered as ordered. On 8/22/16 at 8:12 p.m. Patient #2's blood pressure was 135/99. The MAR failed to reveal evidence of the administration of either Catapres or Apresoline, or documentation of the reasons why the medication was not administered as ordered. On 8/25/16 blood pressure readings for Patient #2 included 169/81 at 7:30 p.m.; 168/80 at 7:45 p.m.; 164/73 at 8:00 p.m.; 164/75 at 8:25 p.m.; and 187/84 at 9:47 p.m. The MAR failed to reveal evidence of the administration of either Catapres or Apresoline, or documentation of the reasons why the medication was not administered as ordered.

The History and Physical examination dated 8/21/16 at 1:50 p.m., and signed by the attending physician included documentation Patient #2 underwent a CT scan of the abdomen and pelvis while in the ED that showed Patient #2 had a rectal fecal impaction. The review of the record failed to reveal any evidence of medical or nursing intervention for the rectal impaction between 8/21/16 at 10:09 a.m., the time of her arrival on the nursing unit, until 8/24/16 at 11:03 when she was administered a rectal suppository.

The History and Physical examination dated 8/21/16 at 1:50 p.m., included documentation Patient #2 was admitted with severe nausea and vomiting secondary to [DIAGNOSES REDACTED] caused by her accelerated hypertension. The Admission [Nursing] assessment dated [DATE] at 3:20 p.m., and signed by the RN included documentation Patient #2's neurological status and GI/Nutrition status were Within Defined Parameters (WDP) indicating the nurse had assessed both organ systems and found no abnormalities.

The Admission Assessment included documentation Patient #2 was 4 feet 11 inches tall and weighed 110 pounds, 8 ounces on 8/21/16 at 3:20 p.m. Her Body Mass Index was computed at 22.2 indicating her height and weight were within normal proportions. On 9/2/16 at 10:12 a.m. Patient #2 was discovered to be 5 feet 4 inches tall, not 4 feet 11 inches tall.

A Swallow Test was performed on 8/23/16 at 1:10 p.m. The documentation included Patient #2 had a history of bulimia since [AGE]. The dysphagia evaluation was limited to liquids only due to the patient's refusal to accept anything other than liquids.

The Consultation Note dated 8/25/16 at 10:22 a.m., and signed by the consulting surgeon included documentation Patient #2's general appearance was cachectic and emaciated, indicating Patient #2 appeared to have a wasted, malnourished, chronically ill appearance. A review of the entire record for Patient #2 failed to reveal any evidence her dietary intake was being monitored.

The Adult Nutrition assessment dated [DATE] at 10:58 a.m. and signed by the Registered Dietician indicated Patient #2 was seen and evaluated by a Registered Dietician for the first time because she had been unable to take anything by mouth for three consecutive days. The documentation included the patient's height was 4 feet 11 inches and her weight was 125 pounds. Her BMI was calculated at 25.2 indicating Patient #2 was overweight. The Registered Dietician recommended Patient #2 start liquid tube feedings due to being at high risk of malnutrition.

The review of the facility policy Assessment/Reassessment, policy #2.600.048, revised 8/2/16 was reviewed on 10/12/16. Page 3 included documentation indicating each discipline is responsible for the appropriate assessment and reassessment of patients under their care. Page 6 indicated nutritional screening is part of the patient admission assessment completed by the RN to determine if the patient's nutritional and hydration status are appropriate. The nutritional screening included determining if the patient had been eating poorly due to poor appetite for 5 days or more. Based on the result of the nutrition screen, the RN can order a dietician consult.

An interview and record review was conducted with the RN Quality Management Coordinator and the RN Clinical Applications Director on 10/12/16 at 2:00 p.m. They confirmed the following findings:

1. The nursing staff failed to ensure Patient #2 received blood pressure medication in compliance with the physician ordered plan of treatment.

2. The nursing staff failed to appropriately assess the neurologic and GI/nutritional status of Patient #2 in light of her documented diagnoses of [DIAGNOSES REDACTED]

3. The nursing staff failed to intervene appropriately to initiate treatment for the rectal fecal impaction on a timely basis.

4. The nursing staff failed to ensure accurate measurements were used to compute the patient's body mass index, an indicator of nutritional status. Patient #2's BMI calculated as 18.9, indicating Patient #2 was less than half a pound away from being classified underweight (18.5 pounds) when her BMI was calculated using her accurate height of 5 feet 4 inches 1. instead of the height of 4 feet 11 inches documented by the RN performing the admission assessment on 8/21/16, and the Registered Dietician on 8/27/16.

5. As a result of the inaccurate nutritional assessment at the time of her admission, the nursing staff failed to order a consultation with the dietician on a timely basis.

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Based on record review, policy review and staff interview, the facility failed to ensure safety met the needs of one (#9) of ten sampled patients in the Emergency Department (ED).

Findings include:

Patient #9's Assessment Data dated 3/27/14 at 5:32 p.m. and signed by the ED RN indicated safety precautions had been implemented due to the patient expressing suicidal ideation. The documentation indicated a sitter was with the patient, the patient was placed in a psychiatric safe room and the sharps box was secured. The patient was triaged at level 2.

The Certificate of Professional Initiating Involuntary Examination dated 3/27/14 at 8:00 p.m. and signed by the ED physician indicated the patient was being placed under the Baker Act. The supporting evidence indicated the patient was actively suicidal and had taken an overdose of medication.

The Emergency Provider Report dated 3/27/14 at 5:13 p.m. included documentation by the ED physician indicating at an unstated time after the patient was medically cleared, the patient obtained access to his home medications. The ED physician documented he presumed the home medications were brought in by the patient's friend. The ED physician documented the patient took about 20 or more pills of each home medications. He was admitted to MICU (Medical Intensive Care Unit).

A detailed review of the electronic medical record with the facility staff failed to reveal evidence of a nursing reassessment of the patient between the last documented entries at 7:36 p.m. and the patient's transfer to MICU at 11:07 p.m. With the exception of the ED physician documentation regarding the taking of the medications while under suicide precautions with a sitter present, there was no documentation of the time the event occurred or the names of the home medications the patient ingested.

Assessment/Reassessment, Number: 2.600.048, revised 9/17/13 was reviewed on 3/31/14. Page 21, 2) f. Emergency Department indicated patients are reassessed based on the triage priority. Nursing care is evaluated on a continual basis to determine the progress or lack of progress toward patient outcomes. Reevaluation is documented and the plan of care is revised as appropriate. Reevaluation shall include recheck of any abnormal vital signs, any change in status and that there is no change in status from any previous evaluation. The documentation included the frequency of reassessments based on the triage priority. Emergent (Priority 1-2)-ongoing reevaluations are performed as warranted by the dynamic status of the patient's response to treatment.

Safety Technician Utilization, Number 2.600.047, revised 11/2001, was reviewed on 3/31/14. The Purpose was To provide a safe patient care environment for patient's [sic] at risk for injury to self or others, elopement or falls. Page 5, Suicide Safe Environment Readiness Checklist included documentation indicating the registered nurse must be responsible to implement the following precautions immediately. The list of precautions included if visitors are allowed they must store their belongings in lockers provided and are not allowed to give any items to the patient.

An interview was conducted with the ED Nurse Manager. In response to questions, he stated there were no lockers in which to store visitors' belongings. He indicated the ED had safes that were large enough to store visitors' belongings. He confirmed the findings there was no evidence in the medical record indicating the time the patient's visitor arrived, no indication the visitor's personal belongings were secured and no evidence the visitor was educated regarding not providing the patient with any items. He confirmed the finding the facility policies regarding patient safety and reassessment were not followed by the RN assigned to the care of patient.

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Based on policy review, record review and staff interviews, it was determined the facility failed to administer medications as ordered and per policy, for 4 (#1, #4, #6, #8) of 10 sampled patients.

Findings include:

1. The facility' policy, Medication Administration Times with effective date, 07/01/2013 states, the definition of Time Critical Medications are medications identified in this policy that due to the medication or the patient's diagnosis must be given at the exact time or within 30 minutes before or after the scheduled time. Time Critical scheduled medications are Medications with a dosing schedule of every 4 hours or more frequent .

2. A review of the medical record for patient #4 revealed the Physician order dated 3/16/14 Ipratropium/Albuterol Sulfate 0.5-3mg/3ml ampule Neb per dose inhaler every 4 hours . A review of the electronic Medication Administration Record (e-MAR) revealed the scheduled medication was to be administered by Respiratory Therapy. On 3/17/14 the MAR revealed zero of two doses were administered outside the 30 minute scheduled time-frame. On 3/18/14 the MAR revealed five of six doses were administered outside the 30 minute scheduled time-frame. On 3/19/14 the MAR revealed two of six doses were administered outside the 30 minute scheduled time-frame. These findings were confirmed by Staff A.

3. A review of the medical record for patient #8 revealed the Physician order dated 02/06/14 Ipratropium/Albuterol Sulfate 0.5-3mg/3ml ampule Neb per dose inhaler every 4 hours . A review of the electronic Medication Administration Record (e-MAR) revealed the scheduled medication was to be administered by Respiratory Therapy. On 02/6/14 the e-MAR revealed zero of one dose was administered outside the 30 minute scheduled time-frame. On 02/07/14 the e-MAR revealed two of six doses were administered outside the 30 minute scheduled time-frame. On 2/8/14 the e-MAR revealed two of five doses were administered outside the 30 minute scheduled time-frame. These findings were confirmed by Staff A.

4. Review of the electronic medical record for patient #1 revealed orders indicating the patient left the floor three times a week mid morning to receive dialysis on a different floor in the hospital. Review of his orders also revealed the patient was to receive a breathing treatment (ipratr-albuterol 3 milliliters, every four hours while awake) scheduled to be given at 0800, 1200, 1600, and 2000.

Review of the electronic medication administration record for this patient revealed on 03/11/14, 03/13/14, and 03/18/14 , for the 1200 dose of the breathing treatment, the medication had not been given and the documented reason was patient not available. Interview with the Unit Director, staff A, on 03/20/14 at 9:50 a.m., revealed the patient left the floor about 10 a.m. for dialysis and he wasn't available on the floor for the Respiratory Therapist (RT) to administer the breathing treatment. She provided an order to hold all blood pressure medications prior to dialysis, but there was no doctors order to hold, or not give, the breathing treatments related to being off of the floor for up to four hours to receive dialysis. She confirmed there were no notes by either the nurses or the RT indicating the doctor had been made aware of the missed breathing treatments due to the patient being off the floor three times during the week.

Further review revealed the Ipratr-Albuterol 3 ml every four hours was not being given within thirty minutes of scheduled time, per the policy. On 03/17/14 and 03/18/14 two of four doses were administered outside of the thirty minute time frame. On 03/19/14 one of four doses were administered outside of the thirty minute time frame.

5. Review of the medical record for patient # 6 revealed physician orders upon admission on 02/09/14 that included the use of an Incentive Spirometer and an Acapella device. Orders included deep breaths and coughs ten times a day.

The order for the Acapella device was acknowledged by the Respiratory Therapist on 02/09/14 at 13:24 p.m., but did not include the frequency of use and description of what the physician expected (deep breaths and coughs ten times a day.)

Review of the electronic record did not reveal either nursing or RT documented the patient's use of the breathing devices.

Interview with the Director of Respiratory Services, on 03/20/14 at 12:00 p.m., confirmed that after educating the patient on the use of both the Incentive Spirometer and the Acapella device, there should be documentation that the patient was using the device, per the order 'ten times a day.'

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Based on record review, policy review and staff interview, it was determined the facility failed to ensure polices regarding assessment and reassessment, discharge documentation and pain management were followed for 1 (#1) of 10 sampled patients.

Findings include:

Patient #1 was taken to the facilities Emergency Department (ED) on 12/4/13 at approximately 10:30 a.m. The chief complaint was left foot pain. Vital signs were recorded at that time and again at 11:59 a.m. There was no further documentation of vital signs. The last timed documentation was medication administration at 1:07 p.m. The time of discharge was not documented, but was after 1:07 p.m.

The facility policy ED Vital Signs, # 3.780.006, revised 11/13, requires that vital signs be recorded at the time of discharge. There was no evidence that the facility complied with their policy.

The facility policy Pain Management # 2.600.154, revised 10/13, requires that pain intensity is to be measured using an age appropriate pain scale and that there is a reassessment within one hour of pain relief intervention. Review of triage documentation at 10:38 a.m. revealed that the intensity of the pain was not documented. The nurse documented that 5 milligrams of Morphine was administered at 11:25 a.m. There was no documentation of a pain assessment at that time. A pain assessment was documented at 11:55 a.m., noting the pain level to be 5 on a 0 - 10 scale. It could not be determined if the morphine had relieved the pain since there was no prior assessment. The nurse documented that oxycodone was administered at 1:07 p.m. There was no pain assessment documented at that time and no assessment following the administration of the pain medication. There was no documentation of the pain level at the time of discharge.

Review of the physicians medical screening examination revealed that the ambulance personnel had documented that patient #1's blood glucose was 328. At 11:00 a.m. a lab report revealed the blood glucose was 213. The ED physician documented that the patient had received a morning dose of insulin. The physician ordered 10 Units of regular insulin, which was administered at 1:07 p.m. Review of nursing documentation revealed there was no documentation of reassessment of the patient's blood glucose after the insulin was administered. The facility's policy Assessment/Reassessment #2.600.048, revised 9/13 requires that patients are to be reevaluated and plan of care revised prior to discharge from the ED. The reevaluation is to include recheck of any abnormal vital signs, any change in status and to determine there is no change in status from any previous evaluation. The nurse failed to reevaluate the blood glucose after the insulin was administered and before the patient was discharged .

Review of the medical record for patent #1 from another facility revealed that the patient arrived via ambulance on 12/4/13 at approximately 3:45 p.m. The patient reported his blood glucose to be below 30. One - half amp of 50% dextrose was administered in the ambulance. The blood glucose was found to be 38 in the ED. The patient required admission to the Intensive Care Unit.

The Clinical Nurse Coordinator or Progressive Care was present during the review of the medical record on 1/15/14 beginning at approximately 10:30 a.m. and confirmed the above findings, with the exception of documentation from the other facility.

The facility's policy ED Discharge Process, no number, dated 10/13 requires the following information to be documented at the time of discharge: an assessment of the patient's ambulatory status, functional status, and ability to perform Activities of Daily Living; reassessment, including vital signs prior to discharge and correct disposition status Review of the medical record revealed there was no discharge disposition documentation in the record of patent #1. The Clinical Nurse Coordinator of the ED was interviewed on 1/15/14 at approximately 3:00 p.m. He confirmed that the nurse failed to document the discharge disposition as required. The patient had arrived via ambulance. The Clinical Nurse coordinator could not determine by what conveyance the patient was transported home.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined the Registered Nurses failed to ensure diabetic medication and care was provided to meet the patients' needs and hypertension medication and neuro vascular checks were not provided as ordered by the physician for 5 (#1, #3, #4, #5, #8) of 10 sampled patients.

Findings include:

1. Patient #1 presented to the Emergency Department (ED) on 7/15/13 following a fall at the Assisted Living Facility (ALF), where she was resided. The patient was found to have a fractured pelvis and a mild subdural hematoma. Review of laboratory results revealed a blood glucose of 304. The ED physician documented the patient had acute hyperglycemia. The patient was admitted .

Review of the list of home medications revealed no documentation of any medication to treat diabetes. Further review of the medical record revealed the ALF had provided a copy of the Medication Administration Record (MAR) that indicated the patient was receiving levemir insulin. This was not added to the home medication list by nursing for medication reconciliation and therefore not considered by the physician for continuation in the hospital. The insulin was not ordered initially for the patient.

A nurse performed a point of care blood glucose test at 11:44 a.m. on 7/16/13 and noted the blood glucose was 210. There was no documentation of any action taken in response to the elevated blood glucose. An order for sliding scale insulin was entered at 3:53 p.m. and 3 units of insulin were administered at that time.

Review of the blood glucose monitoring revealed at 4:06 p.m. on 7/19/13 the blood glucose was 314. According to the sliding scale insulin order, the patient should have received 5 units of insulin. Review of the MAR revealed the nurse administered 6 units in error. The Clinical Nurse Coordinator (CNC)was present during the record review on 9/17/13 at approximately 11:00 a.m. and confirmed the above findings.

2. Patient #3 was admitted on [DATE] with the diagnosis of type II diabetes. The physician ordered point of care blood glucose monitoring before meals and at night. Review of documentation of blood glucose monitoring revealed the nurse failed to document a blood glucose result before lunch on 7/19/13. The CNC was present during the review of the record on 9/17/13 at approximately:00 p.m. and confirmed the finding.

3. Patient #4 was admitted on [DATE] with the diagnosis of uncontrolled diabetes. The physician ordered point of care blood glucose monitoring with sliding scale insulin coverage before meals and at night. Review of the glucose monitoring revealed at 11 a.m. on 9/17/13 the blood glucose was 314. Based on the sliding scale insulin order the patient should have received 8 units of regular insulin. Review of the MAR revealed the nurse administered 10 units in error.

4. Patient #5 was admitted on [DATE] with the diagnosis of left sided weakness and hypertension. The physician ordered Apressoline 10 milligrams intravenously every 4 hours as needed for systolic blood pressure over 150. Review of vital signs revealed the blood pressure was 196/84 at 10:48 a.m. on 9/15/13. The patient had been ordered Vasotec on a routine basis and this medication was administered at that time. The nurse failed to reassess the blood pressure following the Vasotec until 2:53 p.m.,which was approximately 3 hours later. The blood pressure was documented as 194/84. There was no intervention for the elevated blood pressure until 6:37 p.m. Apressoline 10 milligrams was administered intravenously. There was no explanation as to why another 3 1/2 hours passed before the Apressoline was administered.

5. Patient #8 was admitted on [DATE] with a fractured left femoral head fracture. The patient was taken to surgery for repair of the fracture on 9/16/13. Following the surgery, the physician ordered neuro vascular checks every hour x 2 and then every 4 hours x 24 hours. Review of documentation of the checks revealed there was no check performed from 8 a.m. until 3:40 p.m. on 9/17/13. This was greater than 7 1/2 hours between checks.

The CNC was present during the review of the records for patients #4,#5, #8 on 9/18/13 between 10 a.m. and 2 p.m. and confirmed the above findings.

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Based on clinical record review, facility document review, staff interview and policy review, it was determined the facility failed to comply with the requirement to accept an appropriate transfer of a patient when services were available at the facility for 1 (#21) of 21 sampled patients. This practice may result in a delay in the provision of required care for the patient.

Findings include:

Patient #21 was seen and evaluated at facility #1 (transferring facility) emergency department (ED) on 1/21/13. A review of facility #1's Emergency Department (ED) physician's notes revealed the patient was evaluated at 7:34 am. Based on the CT results the patient was diagnosed with a Subdural Hematoma. A review of the Computerized Tomography (CT) of Brain revealed the patient had right frontal parenchymal as well as Subdural hemorrhage.

An entry at 10:17 am revealed the physician had decided to transfer the patient citing the reason as trauma, needing higher level of care, condition critical.

An entry made at 11:01 am revealed the physician had spoken to the facility #2's (receiving facility ED physician and presented him with the case and need to transfer. Facility #1 ED's physician documented that Facility #2's ED physician commented that he would have to clear it with the Neurosurgeon before he would accept the patient. ED Physician #1 informed ED Physician #2 that it is an EMTALA violation to contact him (neurosurgeon) and delay or refuse transport. ED physician #2 told him he didn't want the patient shoved down his throat and would not accept until he spoke with the neurosurgeon. ED Physician #1 had not received a call back from ED physician #2 and proceeded to transfer patient to facility #3 (facility that actually received the patient ). At 11:30 am the patient was transferred to facility #3.

A review of Facility #2's Transfer Request Form, dated 1/21/13 revealed initially the ED Physician had denied the transfer of patient #21. After the Administrator on Duty spoke to the physician than the patient had been accepted for transfer, but had already been transferred to Facility #3.

A review of Facility #2's policy, EMTALA- Duty to accept, policy #1.780.007, approved 2/6/12, revealed a hospital with specialized capabilities or facilities shall accept from a transferring hospital an appropriate transfer of an individual with an emergency medical condition (EMC) who requires specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. Further review of the policy page 2 of 3, revealed only the chief executive officer (CEO) or his/her designee and the emergency physician in consultation with the appropriate hospital representative have the right to accept or refuse to accept the transfer of an individual on behalf of the receiving hospital.

An interview was conducted on 2/8/13 at 5:00 pm with the Chief Nursing officer (CNO), the Assistant Chief Nursing Officer (ACNO)/Interim ED Director and the Director of Risk Management. During the interview the above incident was confirmed. When questioned on the chain of events the CNO responded that on 1/21/13 the hospital had received a request for transfer from Facility #1. The Facility's ED physician did not want to accept transfer until he had spoken to the Neurosurgeon on call. The Neurosurgeon did not want to accept the patient because the facility was not the closest facility for transfer. The incident was escalated to the Administrator on call (AOC) who spoke to the Neurosurgeon. The facility than agreed to accept transfer but it was too late the patient had already been transferred to Facility #3.

On 1/22/13 The ED Medical Director spoke to the ED physician and physician was taken off duty until an EMTALA refresher course was completed. This was completed on 1/24/13.

On 1/23/13 the Neurosurgeon was taken off the call schedule until he spoke with the CEO and was reeducated on EMTALA on 1/25/13. On 1/24/13 the Facility self-reported the EMTALA violation. The facility is currently auditing all patients who have left without medical screening examination, transfers in and out.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined the registered nurse failed to supervise and evaluate care related to assessments and interventions for pain management, propofol sedation and use of restraint for 3 (#1, # 3, #10) of 10 sampled patients. This practices does not ensure patient care goals are met.

Findings include:

The facility's policy Pain Management #2.600.154 revised 11/12 requires the responsibility of the nurse is to assess the patient, medicate the patient according to his/her self-report, assess the effectiveness of the pain relief measures and obtain orders for additional pain medication if needed. The policy states that a score of 4 or more is considered inadequate pain control. The patient is to be reassessed within one hour after the pain relieving intervention.

1. Patient #1 was admitted on [DATE] with the chief complaint of abdominal pain. The Emergency Department (ED) physician's clinical impression was pancreatitis. Review of pain assessment documentation by nursing revealed the patient reported the pain level to be 10 on a 0-10 pain scale at 5:10 p.m. Review of the Medication Administration Record (MAR) revealed the patient received Dilaudid 2 milligrams (mg) intravenously (IV) at 5:10 p.m. The reassessment at 5:47 p.m. revealed the pain had been relieved with the patient reporting a pain level of 1.

The pain assessment documented at 6:30 revealed the pain level was at 10. Two mg of Dilaudid was administered at 6:35 p.m. according to the MAR. The next assessment at 7:40 p.m. revealed a pain level of 8. Review of the MAR revealed no pain medication was administered. There was no evidence the physician was notified that the medication given at 6:35 p.m. was not effective. The patient was not assessed for pain again until 9:50 p.m., over three hours later. The patient reported the pain level at 9 on the 0-10 pain scale. The next assessment documented at 1:50 a.m. on 9/12/12 revealed the pain level was reported as 7. The patient received two mg of Dilaudid at 2:09 a.m. At 3:09 a.m., the pain level was documented as 2. The next pain assessment was documented at 7:25 a.m. with the level being reported at 8. No pain medication was administered. The next assessment at 9:09 a.m. revealed the pain level was now 9 on the 0-10 scale. The MAR revealed 1 mg of Dilaudid was administered. The reassessment at 9:46 a.m. revealed the pain level at 3. On 9/13/12 at 4:46 a.m. the nurse documented the patient reported pain at 10. Dilaudid 2 mg was administered. Reassessment at 5:19 a.m. revealed the pain level was still 10. Reassessment at 5:32 a.m. revealed the pain level was still unacceptable at 6. There was no documentation that the physician was notified that the Dilaudid was not effective and no additional medication was administered. Pain management was not implemented by nursing per policy.

2. Patient #3 was admitted on [DATE] with the diagnosis of lung cancer. Review of the pain assessments by nursing revealed the patient reported pain as a level 6 on 1/8/13. Review of the MAR revealed no pain medication was administered at that time. The next assessment at 11:45 a.m. revealed the pain level was 7. Vicodin was administered at 11:45 a.m. The reassessment at 12:40 p.m. revealed a pain level of 2. There was no explanation documented for the delay in providing the necessary pain medication.

3. Patient #10 was admitted on [DATE] with acute pancreatitis. Review of pain assessments documented by nursing revealed on 1/8/13 at 6:10 a.m. the patient reported pain as a 6 on the 0-10 scale. Further review of nursing documentation revealed no reassessment of the pain level within an hour as required by facility policy.

The Clinical Nurse Coordinator, who was present during the record reviews on 1/9/13 and 1/10/13, confirmed the above findings for patients #1, #3 and #10.

Review of the facility's policy Propofol Infusion for Adult Patients #2.712.008 revised 1/12 requires the nurse assess the level of sedation every 4 hours while the propofol is infusing.

1. Patient #1 was intubated and placed on a ventilator on 9/15/12. An order for propofol for sedation was written by the physician. According to documentation the Propofol was infusing from 9/19-9/25/12 at 3:53 p.m. Review of nursing documentation revealed no documentation of monitoring of the level of sedation on 9/19, 9/20, 9/21, 9/22, 9/23 and 9/24/12 between the hours of 4:00 a.m. and 8:00 p.m.

The Critical Care nursing director and nursing manager were asked to review the above findings on 1/10/13 at approximately 9:00 a.m. They indicated that most likely at least some of that time the propofol had been discontinued as the patient was being weaned from the ventilator but could not locate documentation to substantiate that. The documentation revealed the assessment for the level of sedation as required by the facility's policy was not performed by nursing.

Review of the facility's policy Patient Restraint and Seclusion #2.600.049 revised 8/12 requires that physician's order include the duration of restraint and date and time of the order.

1. Review of the restraint orders for patient #1 revealed the initial order was written on 9/16/12 at 10:50 a.m. The duration of restraint was 24 hours. The next order was not written until 9/17/12 at 8:00 p.m., which was approximately nine hours after the first order had expired.

Orders were written on 9/18/12 and 9/19/12 but the time of the order was not included. The last order was written on 9/24/12 at 7:00 a.m. Review of documentation of restraint monitoring revealed the restraint was maintained from 9/16/12 until 9/25/12 at noon. The restraint order had expired at 7:00 a.m. on 9/25/12. The restraint was continued for 5 hours after the order had expired.

The Clinical Nurse Coordinator, who was present during the record review on 1/9/13, confirmed the nursing staff did not follow the facility's policy.

Show Text of Violation

Based on record review, document review, staff interview and policy review, it was determined the facility failed to comply with the requirement to accept appropriate transfer of a patient requiring services that are available at the facility for 1 (#21) of 21 sampled patients. This practice results in delay in the provision of required care of the patient.

Findings include:

Review of the facility ' s policy EMTALA- Duty to Accept , # 1.780.007, last reviewed 2/12, requires that a hospital with specialized capabilities shall accept, from a transferring hospital, an appropriate transfer of an individual with an emergency medical condition. It further indicated that only the facility ' s Chief Executive Officer or designee and the emergency physician in consultation with the appropriate hospital representative have the right to accept or refuse to accept a patient transfer. Interview with a Behavioral Health intake person on 8/9/12 at approximately 2:30 p.m. revealed that one of the facility ' s psychiatrists is to make the final decision regarding acceptance or refusal of a transfer to Behavioral Health. The intake form indicated that referral to the psychiatrist was not required.

Review of the facility ' s policy Baker Act (Involuntary and Voluntary Treatment/Transfer), # 2.917.003, last revised 2/12, revealed that a Baker Act Receiving facility is designated by the Department of Health and Human Services to receive and hold involuntary patients under emergency conditions or for psychiatric evaluation and to provide short-term treatment. Review of documentation from the Department of Children and Families (DCF) revealed the facility is a Baker Act Receiving Facility. The policy also indicated that the Baker Act is initiated if it is believed that there is substantial likelihood that without care or treatment the person will cause serious bodily harm to himself/herself or others in the near future, as evidenced by recent behavior.

Review of the medical record of patient number 21 revealed the patient was taken facility #1's (transferring facility) ED on 7/30/12 at approximately 11:29 a.m. A medical Screening examination was initiated by the ED physician at approximately 12:49 p.m. The patient was evaluated in the ED by a psychiatrist at 1:15 p.m. for bizarre behavior . The psychiatrist documented the diagnosis of Bipolar with psychotic features verses schizoaffective disorder. She determined the patient required psychiatric hospitalization and initiated the Baker Act for involuntary admission for psychiatric evaluation. The ED physician documented the patient was medically clear for psychiatric admission at 4:20 p.m. She also noted the patient would be transferred to an outside facility. Review of the Social Worker notes revealed a note entered at 9:16 p.m. indicating that the patient ' s information had been faxed to 4 facilities that are designated baker act receiving facilities. The note also indicated that facility #2 (Brandon Regional Hospital) was contacted via phone call. The note further indicated that the Social Worker had phoned the Behavioral Health intake person at facility #2, requesting the facility accept the transfer of the Baker Acted patient for admission. The note indicated the intake person asked for the patient ' s funding source and then told the Social Worker that she had been instructed by her supervisor to decline transfer of unfunded patients. Review of the call log for Behavioral Health intake revealed an entry on 7/30/12 at 8:53 p.m. indicating the name of the person at the transferring hospital and the funding source of charity pending. The disposition time was also 8:53 p.m. The Behavioral Health Center Inquiry Form related to that entry listed the name of the caller from the transferring facility, the fact that the patient was in the facility ' s ED, was a Baker Act patient and was unfunded. It further indicated that referral to a psychiatrist for review was not required. Review of the medical record from facility #1 revealed another Social Work note on 7/31/12 that indicated a second call and fax of patient information to the facility #2 was placed. The outcome of that contact was not documented. Review of the Behavioral Health call log revealed no entries for that date for the facility #1. Further review of the medical record of patient #21 revealed that she was finally transferred to a local crisis stabilization unit on 8/1/12 at 1:36 p.m. This was approximately 50 hours from the time she presented to the ED.

Review of the Behavioral Health Unit census at facility #2 revealed there were 16 patients on 7/30/12 and 19 patients on 7/31/12. The Behavioral Health unit is a 24 bed unit. There were beds available at the time of the requests for transfer. The facility failed to accept an appropriate transfer of an individual who required the facility's specialized psychiatric capability and capacity to treat patient #21 on 7/30/12 and 7/31/12.

The Behavioral Health intake person at facility #2, who was on duty on 7/30/12, was interviewed on 8/9/12 at approximately 4:00 p.m. She stated that the Social Worker at the transferring facility volunteered the information concerning the patient ' s funding source. She denied refusing the transfer and asked that the Social Worker at the transferring facility fax the patient ' s information. This information was not indicated on the Behavioral Health Center Inquiry Form completed by the intake person, however. She indicated no further actions were required on the form. There were no copies of the patient ' s records from the transferring facility available at facility #2. The intake person indicated they were never faxed by facility #1.

The Risk Manager at facility #1 was asked to verify the documentation by the social workers regarding the accuracy of the information related to contact with the facility being investigated. She provided email documentation that both social workers stated the documentation was accurate.

The Behavioral Health Director at facility #2 was interviewed on 8/9/12 at approximately 2:00 p.m. He indicated that the intake workers do not request funding information from the facilities seeking to transfer patients to the Behavioral Health unit. Review of the intake log revealed that the funding source for most of the patients seeking admission to the unit was listed. The director indicated that most of the transferring facilities send the face sheet, which has the funding source listed.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview and review of the facility's policy and procedures it was determined the facility failed to provide the standardized notice An Important Message from Medicare (IM) within 2 days of admission and/or within 2 days of discharge for four (#7, #11, #22, #23) of thirty eight patient's sampled. This does not ensure patients and/or their representatives have the information necessary to exercise their rights.

Findings include:

1. Review of the medical record for patient #7 revealed the patient was admitted on [DATE] and was a medicare beneficiary. Review of the record revealed no indication the IM was provided to the patient within 2 days of admission.

An interview with the case manager on 3/20/2012 at 11:45 a.m. confirmed there was no evidence an IM was provided to the patient within 2 days of admission.

2. Review of the medical record for patient #11 revealed the Case Manager's initial note dated 03/13/12 documenting the patient's Mental Status/Cognition as alert/oriented and the Discharge Plan Discussed with Patient. The Case Manager's note dated 03/20/12 indicated Patient refusing everything per nurse. Asked secretary to mail IM (Important Message) to patient's son who is POA (Power of Attorney). Further review of the notes did not reveal a discussion of the content of the POA document or why the Case Manager was having the IM letter sent to the son rather than discussing it with the patient, who had been identified as alert and oriented and having had signed the choice letter.

Interview with the Director of Case Management on 03/22/12 beginning at 9:15 a.m. revealed when IM letters are mailed to responsible parties a green postal card was attached requiring signature on receipt that the hospital received back. She confirmed the hospital did not ask the responsible party to return a signed copy of the IM letter to the hospital.

3. Review of the medical record for patient #22 revealed the patient was admitted on [DATE] and was a medicare beneficiary. Review of the record revealed upon admission the patient was incapacitated and the patient's representative was identified. Review of the record revealed an IM was signed by the patient's representative but there was no date or time on the form. Review of the case management documentation on 3/06/2012 at 11:55 a.m. stated the IM letter left at bedside for the patient's representative to sign. Review of the record revealed the patient was discharged on [DATE]. There was one IM signed by the patient's representative with no date or time. It could not be determined if the IM was signed within 2 days of admission or discharge.

Interview with the Director of Case Management on 3/21/2012 at 4:00 p.m. confirmed there was only one IM form signed by the patient's representative that had no date or time on it.

4. Review of the medical record for patient #23 revealed the patient was admitted to the facility on [DATE] and was a medicare beneficiary. Nursing documentation revealed the patient was alert and oriented. Review of the record revealed no evidence of an IM form that was presented and signed by the patient within 2 days of admission. Review of the record revealed the patient was discharged on [DATE]. There was no evidence the IM was presented or signed by the patient.

Interview with the Director of Case Management on 3/21/2012 at 4:00 p.m. confirmed the findings.

Review of the facility's policy Important Message last revised 01/2012 stated all Medicare beneficiaries will be provided the Important Message no more than two (2) days prior to discharge to assist with CMS compliance guidelines.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, staff interview and review of policy and procedures it was determined the Registered Nurse (RN) failed to reassess the effectiveness of pain medication according to the facility's policy for one (#37) of thirty eight patients sampled. The RN failed to

ensure nursing documented a patient event for one (#31) of thirty eight patients sampled. This practice does not ensure needed information to develop or change the plan of care is available.

Findings include:

1. Patient #37 was admitted on [DATE]. Review of the nursing assessments revealed the patient complained of pain to both knees. Documentation revealed the pain was chronic. Review of physician orders revealed on 3/21/2012 at 11:00 a.m. an order for Morphine 30 mg (milligrams) by mouth every 4 hours as needed for pain.

Review of the MAR (Medication Administration) revealed the patient received Morphine on 3/21/2012 at 8:22 p.m. for a pain score of 8 on a scale from 1 to 10 with 10 being the worst pain. Review of the nursing documentation did not reveal evidence the nurse reassessed the patient's pain to determine if the medication was effective.

Review of the facility's policy, Pain Management, last revised 10/2011, stated a reassessment of the patient's pain will be completed within one hour after intervention to determine the effectiveness of the intervention.

Review of the record revealed the patient received Morphine on 3/22/2012 at 12:30 a.m. and 10:03 a.m. Review of the nursing documentation revealed no evidence the patient's pain was reassessed for effectiveness.

On 3/23/2012 at 11:00 a.m. an interview with the patient's RN and the Nurse Manager confirmed the above findings.

2. Patient #31 was found on the floor in the patient's room on 11/26/2011 at 4:30 p.m. Review of the record revealed no documentation by the nursing staff that the patient was found on the floor. There was no documented evidence of an injury assessment or any treatment or intervention. There was no indication the patient's representative was notified. Documentation revealed the patient was confused upon admission and prior to the fall.

Review of the facility's policy, Occurrence Reporting, last revised 6/2011, stated patient events will be documented in the medical record and will include the type of event or injury, injury assessment, any treatment intervention, notification of the physician, follow up plan of care and follow up assessments and interventions.

Interview with the Director of Quality on 3/22/2012 at 3:15 p.m. confirmed there was no documentation in the patient's record to indicate the patient was found on the floor, injury assessment, intervention, or family notification.

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Based on observation in the main kitchen and interview with dietary staff it was determined the facility failed to ensure that the main kitchen and procedures related to maintaining holding temperatures of a potentially hazardous food, was maintained in sanitary order to prevent transmission of food borne illness, and physical contamination.

Findings include:

During the comprehensive tour of the main kitchen on 03/21/12 beginning at 9:30 a.m. the following concerns related to food borne illness were noted:

1. In the dish machine room, on the ceiling in the two corners across from the entrance to the room, the ceiling was noted to be spotted with a black substance.

2. In the walk in freezer four boxes, and the inside plastic bags, of frozen foods were noted to be open to the air.

3. In the walk in refrigerator, a box of health shakes, containing approximately half of the shakes was noted to have expired in January 2012.

4. During the lunch tray line, on 03/21/12 beginning at 11:50 a.m., a slice of meat loaf was plated for service to a patient. The meatloaf had been taken from a container (later identified as containing beef broth) on the steam table. The temperature of the meat loaf was taken by the Production Manager (with the facility's digital thermometer) and read 104 degrees Fahrenheit (F). The temperature of the beef broth that the meat loaf had been taken from was 143 degrees F.

(Foods that are held for hot service must be maintained above 140 degrees F. The steam table was not to be used to bring foods to appropriate temperatures, only to hold the food at the appropriate temperature once that temperature was reached. )

The Production Manager was questioned, at that time, about the low temperature and he reported that the meat loaf slices had been taken from the production chiller and placed into the beef broth to come to temperature.

The Patient Services Manager reported, at that time, that the procedure was to remove cold meat items from the chiller and place them on the 'flat top' (grill surface) until they came to the appropriate temperature and then to place them in the beef broth to maintain the temperature until service. The Production Manager confirmed that the process of using the flat top to bring foods to temperature had been used in the past. The flat top was small and not able to accommodate all protein foods needing to be cooked or warmed, he had been omitting the step of warming on the flat top and was placing the items directly into the steam table pans to hold for service, assuming the foods would come to the appropriate temperature.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined that the facility failed to initiate tracking of indicators following identification of an adverse incident. This resulted in failure to identify missed telemetry order. This practice places patients at risk of death if a lethal arrhythmia were to occur.

Findings include:

Review of the medical record of Patient # 1 revealed that she was admitted to the facility on [DATE] at approximately 11:15 p.m.. with the diagnosis of gastrointestinal bleeding. The physician ordered that the patient be placed on telemetry at the time of admission. Review of nursing documentation revealed no evidence that the patient was placed on telemetry. A nurses' note written at 8:02 a.m. on 5/5/11 documented that around 0555 when we went to change the patient, found her not responding to our wake up call. Found her not breathing. Called Code Blue right away and started CPR.. Passed away at 0619.

The Risk Manager was interviewed on 12/30/11 at approximately 11:30 a.m. She explained that following the event, the facility implemented an action plan to ensure all patients with telemetry orders are placed on telemetry. The plan called for a report listing all patients with telemetry orders to be pulled by the telemetry technician (tech) every shift to ensure that all patient with telemetry orders are on telemetry. In addition, the electronic physician order system was changed so that the order for telemetry would be displayed on the nurses' status board, providing the nursing staff with an easy way to identify all patients with telemetry orders.

The facility's policy Telemetry # 2.600.124, revised 11/1/11 (after the date of the adverse event), did not include the requirement that the telemetry tech was to run the electronic report of all patients with telemetry orders, which should have been done to ensure staff was aware of the requirement.

1. Interview with the three telemetry techs who were on duty on 12/30/11 revealed that none of them were aware of the report listing all telemetry orders that they were to be print each shift.

2. The Risk Manager was interviewed on 12/30/11 at approximately 11:30 p.m. She stated that no monitoring of the above action plan had been implemented.

3. Patient #10 was admitted to the facility on [DATE] at approximately 3:00 p.m. The medical records revealed that the telemetry order was not implemented until approximately 6:00 p.m. on 12/29/11 over forty eight hours later.

4. Patient #4 was admitted to the facility on [DATE]. She was sent to 4 South at approximately 11:00 p.m. with the diagnosis of mental status change. Telemetry was ordered at the time of admission. Review of the medical record revealed that there was a nursing assessment at 11:40 p.m., but no nursing assessment of the telemetry rhythm. The first nursing assessment of the telemetry rhythm was at 2:13 a.m., which was 3 hours after the patient was admitted .

5. Patient #6 had a delay of 4 hours in the implementation of the telemetry order from the physician.

The fact that the corrective action plan was not included in the policy, effectively communicated to the monitor techs and was not being monitored for effectiveness by nursing management resulted in the patients remaining at risk if telemetry was not initiated when ordered and a lethal cardiac arrhythmia should occur and go undetected and untreated.