40295 Based on record review and interview, the facility failed to administer drugs in accordance with standards of nursing practice for 1 (SP#1) of 3 sample patients (SP). Findings include: Review of SP#1 Physician Order documented Chlorhexidine Gluconate, 15 milliliters, Oral Rinse, Three Times a Day for 42 doses to Start: 01/25/2022 and Stop: 02/08/2022. Review of SP#1 Medication Administration Record for Chlorhexidine Gluconate dated 01/30/2022 through 02/10/2022 documented nine (9) doses not given between 02/03/2022 through 02/06/2022. Interview with the Risk Manager (RM) on 02/11/2022 at 3:55 PM acknowledged Chlorhexidine Gluconate was not administered for nine (9) doses. The RM stated no comment was documented for the missed doses. Review of the Administration of Medication General Policy, Effective: 12/2021, documented medications shall be administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice.

40295 Based on interview, record review and policy the facility failed to follow the infection control standards of practice for 1 (SP#1) of 3 sample patients (SP) who tested positive for the Coronavirus (Covid-19) virus with symptoms. Findings include: Review of sample patient (SP) #1 Emergency Provider Report dated 12/16/2020 at 11:39 PM documented Chief Complaint: Shortness of Breath. Cat Scan to Chest impression documented patchy opacities compatible with multi focal pneumonia typical findings of COVID-19 pneumonia are present. Patient admitted . Review of SP#1 Serology for Coronavirus dated 12/16/2020 at 11:30 PM documented a POSITIVE result. Review of SP#1 Serology for COVID19 dated 12/17/2020 at 3:10 AM documented a NEGATIVE result. Review of SP#1 Hospitalist History and Physical dated 12/17/2020 at 4:16 AM documented Assessment: Multifocal pneumonia likely secondary to viral infection with COVID-19. Plan: Admit to Immediate Care on Isolation Droplet Precautions. Review of SP#1 Nephrology Progress Note dated 12/18/2020 at 10:31 AM documented Interval History: Subjective: Newly diagnosis with COVID-19 by PCR (polymerase chain reaction test). Positive COVID-19, new diagnosis, Respiratory Isolation. Review of SP#1 Serology for COVID19 dated 12/23/2020 at 11:15 AM documented a NEGATIVE result. Interview with Infection Control Preventionist on 01/27/2021 at 11:25 AM revealed a COVID-positive patient should have two-negative COVID-19 results greater than 24 hours apart before being moved out of the COVID-19 unit or discharged home. Interview with Interim [NAME] President Quality on 01/27/2021 at 12:41 PM revealed SP#1 transmission-based isolation precautions were discontinued to standard precautions on 12/24/2020. Stated patient was treated on a designated COVID-19 unit from 12/19/2020 to 12/23/2020. Stated patient had 1-negative COVID-19 result dated 12/23/2020. Acknowledged that SP#1 did not meet the criteria for discontinuation of transmission-based isolation precautions. Review of Facility COVID-19 Bundle, Version 13 - Updated 07/21/2020, pg.14, Florida Hospital Association (FHA) Testing and Disposition Guidance documented Clarification of COVID-19 Guidance pertaining to Testing and Disposition of hospitalized Patients, Dated 03/22/2019, 2. Consideration of discontinuation of isolation should include: Negative COVID-19 test results from at least two consecutive sets of paired nasopharyngeal and throat swabs specimens collected at least 24 hours apart [total of four negative specimens including two nasopharyngeal and two throat]. The facility failed to collect two negative COVID-19 test results at least 24 hours for 1 (SP#1) out of 3 sample patients (SP) prior to discontinuation of transmission-based isolation precautions.

40295 Based on interview, record and policy review, the facility failed to reassess and evaluate on an ongoing basis and in accordance with accepted standards of nursing practice for changes in the vascular condition of the toes on right foot in 1 (SP#1) out of 3 sample patients (SP). Findings include: Review of sample patient (SP) #1 Emergency Provider Report dated 04/04/2020 at 7:34 PM documented patient physical exam of the lower extremities noted as atraumatic, Skin assessment noted as atraumatic, color normal limit, no rash, warm. Patient stabilized and admitted for continuation of care. Review of SP#1 Photographic Mounting Tool dated 04/11/2020 (no time) documented wound location as right lower extremity comment as blisters. Review of (sample patient) SP#1 Photographic Mounting Tool dated 04/11/2020 (no time) documented wound location as left lower extremity comment as blister. Review of SP #1 Hospitalist Progress Notes dated 04/11/2020 documented vascular dorsalis pedal pulses +(plus) 2, no cyanosis noted on extremities. Interview with Wound Care Coordinator via telephone on 05/05/2020 at 2:26 PM revealed Photographic Mounting Tool is completed when a staff discovers a skin alteration. Stated a blister is an intact wound. Stated the blister identified in the picture dated 04/11/2020 for SP#1 is a skin alteration that would not require a wound care consult because it appears to be vascular. Stated pictures are taken for any skin alteration found on admission, at assessment after admission, every Wednesday and at discharge. Stated an incident report is to be completed for any skin alteration found after admission. The facility did not provide evidence of nursing reassessments of changes in vascular condition to the right foot from 04/11/2020 to discharge on 04/23/2020 for SP#1. Review of SP#1 (Readmission) Emergency Provider Report dated 04/23/2020 at 5:11 PM documented the patient presented with chief complaint of right foot swelling and right foot deformity. Patient was discharged earlier in the day and returned for necrotic toes on right foot noted on intake from transferring facility. Patient with necrotic appearing 3rd, 4th and 5th toes with skin loss between toes and serous drainage consistent with wet gangrene. Primary Impression: Gangrene of right foot. Review of SP#1 Podiatry Consultation Report dated 04/23/2020 documented painful upon palpitation at digits 3, 4, 5 of right foot, mild malodor noted. Necrotic lesion extends to the base of the 3rd, 4th and 5th digits. Localized soft tissue swelling noted at digits 3, 4, and 5 and surrounding tissues at the dorsal aspect of the right foot. Plan: Podiatry recommends emergent amputation of digits 3, 4, and 5 of right digits. Review of SP#1 Bilateral Legs Arterial Ultrasound dated 04/24/2020 at 4:15 PM documented impression of asymmetric low pulsatility, monophasic waveforms in the right common femoral artery and distally, characteristic for atherosclerotic narrowing. No occlusion is evident. Interview with Director of Patient Safety on 05/05/2020 at 1:25 PM revealed that there was no evidence of nursing reassessment documentation for changes in the vascular condition to the right foot of SP#1 and the only documentation of SP#1 Photographic Mounting Tool form was dated 04/11/2020. Review of Hospital Plan for the Provision of Care 2018 documented Telemetry Medical/Surgical (Unit 5) patients are assessed within 8 hours of admission and are reassessed every shift or whenever there is a change in condition, diagnosis, or in response to treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40295 Based on record and policy review the facility failed to administer drugs in accordance to the orders of the practitioner and accepted standards of practice for 1 (SP#4) out of 4 sample patients (SP). Findings include: Review of sample patient (SP) #4 medical records showed he was admitted on [DATE] with right foot Osteomyelitis (infection). Medication administration observation of SP#4 and Registered Nurse-Staff C on 02/12/2019 at 1:30 PM revealed Staff C entered a note that pharmacy was contacted. Staff C explained that there is a time conflict with another IV antibiotic and inquired with pharmacy to readjust time. The IV Vancomycin 1750 mg in 500mg was given at 13:36 PM. The medication was scheduled to be given at 10:00AM. Staff C opened a new piggyback tubing, primed the tubing with medication and administered the medication via piggyback. Staff C entered a rate of 150cc/hr (per hour). into the infusion pump. The medication rate ordered was for 125cc/hr. The IV tubing was not labeled with date and time. SP #4 [NAME] orders showed that on 02/12/2019, Vancomycin (1,750 mg) in 500 ML IV, 10:00 AM dose was given at 13:36 PM. The orders revealed that Vancomycin IV (intravenous) 1,000mg Vial (1,750 mg) in 500 ML (milliliters) rate of 125 MLs/HR was ordered every 12 Hours at 10:00 AM and 22:00 PM. The [NAME] orders also showed that IV Zosyn 3.375 GM/ Vial in 100 ML was ordered every 8 hours at 02:00 AM, 10:00 AM, and 18:00 PM. The 10:00 AM dose was ordered at the same time as the Vancomycin. Interview with the Pharmacist and Pharmacy Manager on 02/14/2019 at 12:30 PM, stated that this patient was on two antibiotics that requires 4 hours infusion on 02/12/2019 in the afternoon. The Nurse called pharmacy for the difficulty for the past two days giving the medications on time because of the Vancomycin BID (twice a day) over 4 hours each, and Zosyn in every 8 hours over 4 hours each, and both medications were scheduled at 10:00 AM. Then Zosyn was rescheduled to 4:00 AM, 12:00 and 8:00 PM and Vancomycin was maintained at 10:00 AM and 10:00 PM. Review of the policy Standard Hours For Administration of Medication, Department: Pharmacy/Nursing; Effective Date: 03/18; revealed Procedure: Medications with Special Consideration 1. B. Timed Doses: Doses of vancomycin (pharmacokinetic dosing) must be given and charted precisely and timed from the initial dose of the medication. These medications should be administered within 1 hour before or after the scheduled dosing time for a total window of 2 hours unless otherwise prescribed. Do not use standardized times. Notify the pharmacist immediately of any missed or incorrectly timed doses so levels can be retimed. E. Missed or Late Administration of Medications 1. At times, medications eligible for scheduled dosing times are not administered within their permitted window of time. This includes doses which may have been missed due to the patient being temporarily away from the nursing unit, for example, for tests or procedures, patient refusal; patient inability to take the medication; problems related to medication availability, such as shortage; or other reasons that result in missed or late dose administration. 2. The physician or other practitioner responsible for the care of the patient must been consulted regarding missed or omitted doses for time-critical medications and medications not eligible for schedule dosing. The policy IV Therapy Protocol (revised 11/17) , states J. All tubings shall be labeled with the date, time and initials of the person who initiated tubing. All The facility failed to follow its policies.

27503 Based on record review and interview, the facility failed to have an on-call physician available within 30 minutes through a medical staff call roster for initial consultation for further medical examination and treatment within it capabilities for 1 (SP#1) out of 20 sampled patients. (Refer to 2404)

27503 Based on reviews of medical records, Medical Staff Rules and Regulations, policies and procedures, on-call schedules, and interviews, the facility failed to follow its policies and Medical Staff Rules and Regulations to have an on-call physician respond via telephone and in person for an initial consultation for further medical examination and treatment within it capabilities for one (SP#1) out of 20 sampled patients, who had an identified ophthalmology emergency medical condition (EMC). The Findings: Review of the Medical Staff Rules and Regulations under Emergency Services, page 15, D. show that telephone communication with ED must be established within 30 minutes of notification, ED personnel will contact the physician/practitioner twice during the 30-minute period. If unable to communicate with the physician/practitioner within the allotted period of time, the next physician on the call schedule in that specialty shall be contacted. The facility failed to adhere to their Medical Staff Rules and Regulations. The facility's policy and procedure titled, EMTALA-Florida Provision of On- Call Coverage Policy, Original Date: 2/09, reviewed/revised date 02/16 was reviewed. The policy specified in part, Purpose: To establish guidelines for the hospital, including a specialty hospital, and its personnel to be prospectively aware of which physicians, including specialists and sub-specialists are available to provide additional medical evaluation and treatment to individuals .Policy: The hospital must maintain a list of physician on its medical staff who have privileges at the hospital .Physicians on the list must be available after the initial examination to provide treatment to relieve or eliminate EMCs (emergency medical conditions) to individuals who are receiving services in accordance with the resources available to the hospital .Physician Responsibility: The hospital has a process to ensure that when a physician is identified as being on-call to the ED for a given specialty, it shall be that physician's responsibility to assure the following: .1. Immediate availability, at least by phone, to the DED physician for his or her scheduled on-call period .3 Arrival or response time to the DED within 30 minutes .4. The on-call physician has a responsibility to provide specialty care services as needed to any individual with an EMC who requests emergency services and case either as an initial presentation or upon transfer .Physician Appearance Requirements: .If a physician is listed as on-call and requested to make an in-person appearance to evaluate and treat an individual, that physician must respond in person within 30 minutes. The hospital's On-Call Ophthalmology May 2016 on -call schedule was reviewed. The on-call schedule validated that MD-D was the ophthalmologist on call on 5/12/2016 when SP#1 presented to the ED with complaints of blurry vision to the right eye. On 05/12/16 at 11:23 AM Sample Patient (SP) #1 presented to ED (Emergency Department) with chief complaints of sore throat for 2 days and blurry vision to the right eye the morning of coming to the ED. Review of SP#1 the Emergency Provider Report: Consultation date 5/12/16 revealed: At 11:58 AM -a requested call time for consultation with the ophthalmologist MD-D was made At 1:24 PM (one hour and 22 minutes later) the call was returned by Ophthalmology MD-D regarding the consult and recommended that pt. should go to Facility #2 for a retinal specialist as he is not able to do anything related with the retina. At 2:16 PM and again at 2:29 PM a requested call for Ophthalmologist MD-D was made for consultation At 2:39 PM call was returned by the tech (technician) from the ophthalmologist MD-D to inform that the doctor will call in 10 minutes. After speaking with the Ophthalmologist MD-D , he again stated that the pt. needs to be transferred to another facility as he is not able to do surgery related to the retina. At 7:31 PM called in [named ophthalmologist MD-D] who is coming into seeing the pt prior to transfer to receiving facility. I discussed the case with the incoming MD who is aware of the plan for the ophtho (ophthalmologist) consult and possible transfer if higher level of care is necessary. At 7:59 PM other requested call time was made and was responded to at 7:59 PM by the ophthalmologist MD-D who stated that he will see the patient, the receiving facility will not want the transfer without our ophathos (ophthalmologist ) evaluation. Dr. [named] MD-D is coming in now to evaluate. Review of the Consultation Report of Ophthalmologist MD-D dated 05/12/16 and dictated at 9:02 PM revealed that SP#1 came to ED due to painless right eye loss of vision that occurred the morning pt. presented to ED. Physical Examination revealed that SP#1 with counting fingers was found to have a visual acuity of 20/30 to the right eye. Pupils were dilated and evaluation of the retina demonstrated areas of bleeding in the peripheral retina of the right eye. The left eye had areas of bleeding but did not affect the patient's center vision. Recommendations and plan include transferring the pt. to another facility for evaluation of a retinal specialist that could determine whether surgery or observation is needed. The facility failed to ensure that their policy and procedure were followed as evidenced by failing to ensure that the on-call ophthalmologist responded telephonically within 30 minutes as stated in the policy and the Medical Staff Rules and Regulations. Review of the Emergency Patient Records: Patient Notes dated 5/12/16 authored by nurse, showed that SP #1 was transported at 11:37 PM via ambulance in a stable condition to the receiving facility. Phone interview on 7/8/16 at 8:48 AM with [NAME] President of Quality and the Ophthalmologist MD-D was conducted and the Ophthalmologist stated as an on-call physician, I try to call back as quickly as I can. If I am with a patient, I call back as quickly as I can. I don't have a time frame to get there, but I respond as quickly as I can and possibly and when traffic permits. The hospital also failed to ensure that the on call ophthalmologist came to the hospital in person within 30 minutes, as per the hospital's policy and procedure after a request was made by the ED physician to come and evaluate SP#1 on 5/12/2016 prior to transfer. The delay in examining SP #1 on 5/12/2016 was inappropriate, the patient waited up to 9 + hours for an examination by the on-call ophthalmologist. Interview with the Medical Director of ED on 07/7/16 at 11:00 am revealed Consultation is done at the ED by an ED physician if he/she cannot handle this type of the pt. condition. The on-call physician is called, and both the ED physician discuss the case and plans together and the care of the patient. Depending on the discussion between the ED physician and the on-call, it may or may not require the on-call physician to come in and evaluate the pt. The two plan collaboratively and come to a decision together. The on-call can give direction on the phone. If it is a life and limb or eye threatening emergency, time is of essence. It is based on the decision together by the 2 practitioners and depending on the case, may demand for the on-call to come in and evaluate the pt. and provide appropriate management; or it can be done over the phone. For a case that requires stabilization, the ED care could start the correction so the likelihood of deterioration of transfer may not occur. It is a case by case basis, based on the clinical decision and judgment of the physician, and of the patient presentation. On-call physicians are expected to call back within 30 minutes, otherwise, the nursing supervisor is called and the administrator to intervene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33385 Based upon record review and interview, the nursing personnel failed to provide one to one (1:1) sitters per physician's order for one sampled patients (SP) #2, to respond to call bells in 2 sampled patients # 2 and #3. The findings include: 1. On 11/22/14 at 11:45 AM during observation of the 5th floor, the surveyor was approached by sampled patient (SP#2) family member. The patient family member stated the patient was supposed to have a (one to one)1:1 sitter but many times when I came to the facility, the patient was left by herself. The family member also stated that when I visit the patient, no one came in the room to take care of the patient. The family member then stated that when the family comes, the sitter leaves the patient's room. Review of sampled patient (SP)# 2 Adult Shift Assessment record, dated 12/19/2014 showed the patient had a history of a fall in the last three months, with the month and year of the last fall: [DATE]. The patient was also noted to be a high risk for falls. The record further report that on 12/14/14 at 8:57 AM, the Physician's ordered a 1:1 sitter. The Sitter Record noted that 1:1 sitters was not started until 12/14/14 at 7:00 PM. There was no documentation that a sitter or a family member was at the bedside on 12/16/14 from 8:00 PM to 7:00 AM. On 12/22/14 at 12:12 PM, Staff F- RN (registered nurse) stated that SP#2 always had a sitter at the bedside. He stated that the nursing assistants rotate turns sitting with patients every hour. On 12/22/14 at 12:15 PM, Staff E-RN stated that if there are blank spaces on the Sitter record, it could be that the patient went for a test. The duties on the Sitter's Record for 1:1 sitters include: the patient is never to be left unattended. 2. On 11/22/14 at 11:45 AM SP #2 family member stated that while she was assisting SP#2 to the bathroom, SP#2 felt weak and she was able to lower the patient to the floor. However, when she pulled the emergency light in the bathroom, no one answered or came to assist and that she had to leave the patient alone on the floor and go in the hallway and yell for help. On 12/22/14 at 11:20 AM, SP#3 stated that last night (12/21/14) when she called for assistance with the call light, no one answered. She stated that she had to go up to the nursing station three times in order to get assistance with her meal.

33385 Based upon record review and interview, the facility failed to ensure the patient is reassessed per the facility's policy in one sampled patient (SP#2) of thirteen sampled patients. The findings include: Review of the facility's policy titled: Reassessment, (review/revised 12/11) showed that all patients shall be reassessed by nursing staff at regular specified intervals related to the patients level of care. The policy state that medical/surgical patient shall be reassessed every shift, and as needed. Review of sampled patient (SP) #2 nursing assessments showed that there were no nursing assessments completed between 8:30 PM on 12/17/14 and 8:00 PM on 12/18/14. On 12/22/14 at 11:31 AM, Staff B-RN ( registered nurse) stated that for medical surgical patients, nursing assessments are completed every shift and more frequently, depending on the patient's condition. On 12/22/14 at 12:15 PM, Staff E- RN stated that nursing assessments are completed once per shift and if something happens. On 12/23/14 at 10:36 AM, Staff- RN stated that nursing assessments are completed once per shift for medical surgical patients.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33385 Based upon observation, interviews and record reviews, the facility failed to ensure that Registered Nurses are available on the Behavioral Health Unit to provide care to all patients which include: i). Fifteen minutes round are performed, per policy and that vital signs are documented per Physician Order, in 2 (Patients #1 and 2) of 14 sampled patients. ii) Nursing Assessments are documented each shift, per policy, in 7 Patients # 3, 4, 5, 6, 7, 8 and 9) of 14 sampled patients. iii) And the immediate availability of a registered nurse for bedside care of the 23 patients on 07/28/2014. The findings include: i). Review of SP #1 closed medical record revealed that the patient was admitted to the facility on [DATE] and with complaints of suicidal attempt associated with alcohol use. Sampled patient #1 was transported from the Emergency Department (ED) to Behavioral Health Unit (BHU) on 06/22/14 at 4:35 pm. Review of Admission Orders on 06/22/14 at 4:45pm showed orders for vital signs every 8 hours. Review of the vital sign records did not show that the patient ' s vital signs were taken every 8 hours as ordered by the physician. There were no documented vital signs for the patient after 4:45pm on 06/22/14. Review of SP#2 closed medical record revealed that on 06/20/14, the patient visited the ED for bizarre behavior. Physician orders on 06/21/14 at 3:05 am showed an order for vital signs every shift. Review of vital signs assessments showed that the patient ' s vital signs were taken daily, and not every 8 hours as ordered. The patient's vital signs were only assessed on 06/21/14 at 2:30am, and at 5:30am. On 06/22/14 the vital signs were only taken at 7:30am. On 06/23/14 the vital signs were taken at 8:01am and on 06/24/14 at 6am. In an interview with the Unit Leader of Behavioral Health Unit (BHU) on 07/29/14 at 11:20am, the Registered Nurse states, the vital signs are done daily, most likely at 6am. If the doctor orders vital signs, we follow the order. ii.) Review of SP#3 open medical record reveal that on 07/24/14, the patient visited the ED with complaints of depression. The ED Physician History and Physical reported on 07/24/14 that the patient is tearful in ED and admits to suicidal ideation. Review of the BHU Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:59am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 11:32pm. Review of SP#4 open medical record showed that the patient was admitted to Behavioral Health Unit on 07/19/14 for schizoaffective disorder. Review of the patient ' s plan of care showed that the patient is a potential for self- injury and that the RN will continually assess the patient ' s self- harm urges, impulses and feelings. Review of the BHU Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:31am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 10:57pm. Review of SP#5 open medical record showed that the patient was arrived at the facility ED on 07/23/14 at 7:35pm with complaints of suicidal ideation and chest pain. Review of the patient ' s medical record showed that the patient was transferred from the medical floor to BHU on 07/25/14 at 7:19pm. Review of Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/28/14 at 1:11am. Review of SP#6 open medical record showed that the patient was admitted to the facility on [DATE] for major depressive disorder. Review of the ED Physician History and Physical dated 07/20/14, showed that the patient visited the ED for complaints of depression with an onset of 1 (one) month ago. Review of the Nursing Reassessments showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am), only one Nursing Reassessment was documented on 07/27/14 at 11:15pm. Review of SP#7 open medical record showed that the patient was admitted to the facility on [DATE] for major depressive disorder. Review of the patient ' s Baker Act Order on 07/24/14 also showed that the patient was depressed, delusional and had self- inflicted wounds to arms. Review of Nursing Reassessment showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:46am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 10:59pm. Review of SP#8 open medical record showed that the patient was admitted to the facility on [DATE] for major depressive disorder with psychotic features. Review of ED Physician History and Physical on 07/20/14 shows that the patient visited the ED on 07/20/14 for complaints of suicidal ideation and depression. Review of Nursing Reassessment showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 11:24pm. Review of the SP#8 Plan of Care shows that the patient is a potential for self- injury and that the RN will continually assess the patient ' s self- harm urges, impulses and feelings. Review of SP#9 open medical record show that the patient was admitted to the facility on [DATE] for major depressive disorder with psychotic features. According to the ED Physician History and Physical, the patient has history of seizures. Review of Nursing Reassessment showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/28/14 at 12:01am. In an interview with the Charge Nurse on 07/28/14 at 2:25pm, the nurse stated that on each shift, the RN does an assessment. There are three shifts. In an interview with the Interim Program Director of HCA on 07/29/14 at 10:20 am, he stated that the standard is every shift for assessments. There are three shifts during the week and two shifts on weekends. In an interview with the Unit Leader of BHU on 07/29/14 at 11:20 am, the nurse stated, that assessments are done every shift. Mondays thru Fridays, there are three shifts: 7am to 3pm, 3pm to 11pm and 11pm to 7am. On Saturdays and Sundays, there are two shifts: 7am to 7am and 7pm to 7am. The Unit Leader of BHU also stated that the patient's nurse documents assessments/reassessments, but if the nurse is busy the Unit Leader take over and make sure the assessments are documented. Review of the facility ' s policy titled, Safety Rounds/ Patient Care Rounds, revised on 02/13, stated that on admission, when patient ' s enter the unit (Behavioral Health Unit), the Admitting Nurse will ask the Mental Health Technician to initiate a safety round shift for the patient; where the special precautions are recorded. Mental Health Technicians or Registered Nurse assigned to conduct safety rounds at Patient ' s Admission and they are conducted every 15 minutes, thereafter. When conducting safety rounds the staff members will enter patient ' s rooms to confirm patient ' s location and safety. If the door is closed staff will knock at the door and announce his/her presence in the room by saying staff and inform the patient that staff will enter the room. The facility ' s Behavioral Health Policy : Admission Procedure Guidelines( effective date: 06/20/2013) note that on every shift BH R.N. (Behavioral Health Registered Nurse) will reassess the patient and will reassess more frequently as warranted by the patient's condition. iii). Observation was made on the Behavioral Health Unit (BHU) on 07/28/14 at 10:55am, in the presence of the Director of Risk Management and the Charge Nurse of BHU. Review of the staffing assignment for 07/28/14 showed that there were two Registered Nurses (RN) and 23 patients. One RN was assigned patients who were in rooms 3101A to 3109B, and one RN was assigned patients who were in rooms 3110A to 3115B. At 11:56 am on 07/28/14, the Charge Nurse of BHU stated that there were now two RNs on the unit [the RN who had stayed till 11am, left]. The Charge Nurse stated that there were 23 patients at this time. The Charge Nurse stated that she had call staff to come in to help but no one came. We have this situation for a long time, the Charge Nurse stated, we've been short staff for a long time. The Charge Nurse also stated, according to the Supervisor, interviewing is in process for hiring staff, we need staff. In an interview with RN#A on 07/18/14 at 11:43am, she stated, sometimes staffing is low, sometimes there are 2 RNs and 1 tech (technician). We cover each other. It can be difficult when you have to give breakfast, lunch, snack and dinner. If one tech is a sitter, there is only one other tech on the unit. Sometimes, we call the supervisor. Sometimes, staffing is a problem. In an interview with the Interim Program Director of HCA (Hospital Corporation of America) on 07/29/14 at 10:20am (on the BHU), he stated, It is a challenge with staffing. We terminated three staff from one shift, and one staff from another. Sometimes, we had to stop from admitting patients. At times, patients are held in the ED (Emergency Department) until patients on the units are discharged to avoid giving the RNs too much. Our staffing is based on one RN with 6 to 7 patients.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33385 Based upon interview and record review, the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan that include: i.) the patient ' s vital signs for 2 Sampled patients (SP) # 1 and #2) of 14 sampled patients; ii.) And reassessments are completed in 7 out of 14 sampled patients (SP)# 3 thru #9. The findings include: i.) Review of SP #1 closed medical record revealed that the patient was admitted to the facility on [DATE] and with complaints of suicidal attempt associated with alcohol use. Sampled patient #1 was transported from the Emergency Department (ED) to Behavioral Health Unit (BHU) on 06/22/14 at 4:35 pm. Review of Admission Orders on 06/22/14 at 4:45pm showed orders for vital signs every 8 hours. Review of the vital sign records did not show that the patient ' s vital signs were taken every 8 hours as ordered by the physician. There were no documented vital signs for the patient after 4:45pm on 06/22/14. Review of SP#2 closed medical record revealed that on 06/20/14, the patient visited the ED for bizarre behavior. Physician orders on 06/21/14 at 3:05 am showed an order for vital signs every shift. Review of vital signs assessments showed that the patient ' s vital signs were taken daily, and not every 8 hours as ordered. The patient's vital signs were only assessed on 06/21/14 at 2:30am, and at 5:30am. On 06/22/14 the vital signs were only taken at 7:30am. On 06/23/14 the vital signs were taken at 8:01am and on 06/24/14 at 6am. In an interview with the Unit Leader of Behavioral Health Unit (BHU) on 07/29/14 at 11:20am, the Registered Nurse states, the vital signs are done daily, most likely at 6am. If the doctor orders vital signs, we follow the order. ii.) Review of SP#3 open medical record revealed that on 07/24/14, the patient visited the ED with complaints of depression. The ED Physician History and Physical reported on 07/24/14 that the patient is tearful in ED and admits to suicidal ideation. Review of the BHU Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:59am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 11:32pm. Review of SP#4 open medical record showed that the patient was admitted to Behavioral Health Unit on 07/19/14 for schizoaffective disorder. Review of the patient ' s plan of care showed that the patient is a potential for self- injury and that the RN will continually assess the patient ' s self- harm urges, impulses and feelings. Review of the BHU Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:31am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 10:57pm. Review of SP#5 open medical record showed that the patient was arrived at the facility ED on 07/23/14 at 7:35pm with complaints of suicidal ideation and chest pain. Review of the patient ' s medical record showed that the patient was transferred from the medical floor to BHU on 07/25/14 at 7:19pm. Review of Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/28/14 at 1:11am. Review of SP#6 open medical record showed that the patient was admitted to the facility on [DATE] for major depressive disorder. Review of the ED Physician History and Physical dated 07/20/14, showed that the patient visited the ED for complaints of depression onset 1 (one) month ago. Review of the Nursing Reassessments showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am), only one Nursing Reassessment was documented on 07/27/14 at 11:15pm. Review of SP#7 open medical record showed that the patient was admitted to the facility on [DATE] for major depressive disorder. Review of the patient ' s Baker Act Order on 07/24/14 also showed that the patient was depressed, delusional and had self- inflicted wounds to arms. Review of Nursing Reassessment showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:46am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 10:59pm. Review of SP#8 open medical record showed that the patient was admitted to the facility on [DATE] for major depressive disorder with psychotic features. Review of ED Physician History and Physical on 07/20/14 shows that the patient visited the ED on 07/20/14 for complaints of suicidal ideation and depression. Review of Nursing Reassessment showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 11:24pm. Review of the SP#8 Plan of Care shows that the patient is a potential for self- injury and that the RN will continually assess the patient ' s self- harm urges, impulses and feelings. Review of SP#9 open medical record show that the patient was admitted to the facility on [DATE] for major depressive disorder with psychotic features. According to the ED Physician History and Physical, the patient has history of seizures. Review of Nursing Reassessment showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/28/14 at 12:01am. The facility ' s Behavioral Health Policy : Admission Procerdure Guidelines( effective date: 06/20/2013) note that on every shift BH R.N. (Behavioral Health Registered Nurse) will reassess the patient and will reassess more frequently as warranted by the patient's condition. In an interview with the Charge Nurse on 07/28/14 at 2:25pm, the nurse stated that on each shift, the RN does an assessment. There are three shifts. In an interview with the Interim Program Director of HCA on 07/29/14 at 10:20 am, he stated that the standard is every shift for assessments. There are three shifts during the week and two shifts on weekends. In an interview with the Unit Leader of BHU on 07/29/14 at 11:20 am, the nurse stated, that assessments are done every shift. Mondays thru Fridays, there are three shifts: 7am to 3pm, 3pm to 11pm and 11pm to 7am. On Saturdays and Sundays, there are two shifts: 7am to 7am and 7pm to 7am. The Unit Leader of BHU also stated that the patient's nurse documents assessments/reassessments, but if the nurse is busy the Unit Leader take over and make sure the assessments are documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29933 Based on record review and interview the facility failed to ensure that the assessment of the pressure ulcer and care for each patient was conducted in 2 out 3 sampled patients(SP) (SP#10 and SP #12) with pressure ulcers of 13 Sampled Patients. Findings include: (1). Clinical record review of SP#10 conducted on 3/25/2014 revealed an admitted [DATE] due to end-stage lung cancer. Review of the Wound Assessment/Reassessment Form on 3/4/2014 showed that the buttocks/sacrum areas were reddened but no broken skin. On 3/7/2014, the Wound Assessment/Reassessment Form showed that there was a pressure ulcer that was a Stage II and Unstageable. There was no wound measurements documented, or location on this date. On 3/12/2014, the Wound Assessment/Reassessment Form showed that the pressure ulcer to the gluteal as a Stage II with slough/fibrin noted but there were no wound measurements documented on this date. On 3/19/2014, the Wound Assessment/Reassessment Form showed that the pressure ulcer remained a Stage II to the gluteal with slough/fibrin noted, with maceration and erythema but there were no wound measurements documented on this date. On 3/21/2014, the Wound assessment/Reassessment Form showed that the pressure ulcer to the sacrum as a Stage II with epithelialization and pink in appearance but there were no wound measurements documented on this date. On 3/24/2014, the Wound Assessment/Reassessment Form showed that the Stage II pressure ulcer to the sacrum is resolving and no measurements. The Wound Care Response to Referral has the pressure ulcer as 3x4 cm (three by four centimeters) in measurements. There was lack of documentation of the pressure ulcer measurements on the shift assessments record and on the Wound Assessment/Reassessment Form. The Wound Care Nurse (WCN) stated on 3/25/2014 at 4:05 p.m. in the presence of the Director of Risk Management (Dir. of RM) the wound measurements must be charted, the tools are always available for the nurses to use to be able to measure the wounds. The Wound Care Nurse checked to see if there were any documentation of the wound measurements in the shift assessments and the Wound Care Nurse stated at 4:25 p.m. I didn't see in the shift assessments that the measurements were done either. These findings were confirmed by the Wound Care Nurse and the Director of Risk Management at 4:25 p.m. that there is no documentation of the wound measurements. (2). Clinical record review of SP#12 conducted on 3/25/2014 revealed an admitted [DATE] due to Chronic Obstructive Pulmonary Disease (COPD) Exacerbation and bronchitis. The Adult Admission Assessment on 1/10/2014 showed that the patient's skin was intact. On 2/5/2014, it was documented in the Wound Care Center Response that the patient developed a Stage II pressure ulcer at the coccyx area. The Wound Assessment/Reassessment Form dated 2/5/2014 showed that wound measurements were done which has documented a stage II sacrum pressure ulcer at 3cm in length x 1cm in width. The above findings were confirmed with the Wound Care Nurse and the Director of Risk Management on 3/25/2014 at 4:05 p.m. that the facility failed to ensure that the skin integrity of the patients was maintained intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29933 Based on observation, record review, and interview, the facility failed to ensure that the nursing staff implement the nursing care plan by enforcing the policy on Fall Prevention in 2 of 3 Sampled Patients (SP) (#23, and #24); and and that the nursing assessments were completed in 2 out of 10 sampled patients (SP)#3 and #4. The findings include: 1). Clinical record review of SP#23 conducted on 12-11-2013 revealed an admitted on 12-09-2013 . Review of the Assessment Form showed that the patient is on Fall Precautions and that the patient must have a (yellow) Fall Risk armband on, and non-slip (yellow socks) footwear. An observation of SP#23 was conducted on 12-11-2013 at 9:45 a.m. with the Charge Nurse (CN) of 4 West and it was observed that SP#23 did not have a (yellow) Fall Risk armband on nor the yellow socks in use. The above findings were confirmed from the Charge Nurse on 12-11-2013 at 9:45 a.m. that there was failure to follow the Fall Precautions for this patient. Clinical record review of SP#24 conducted on 12-11-2013 revealed an admitted on 11-11-2013. Review of the Assessment Form showed that the patient is on Fall Precautions and that the patient must have a (yellow) Fall Risk armband on and (yellow socks) non-slip footwear. An observation of SP#24 was conducted on 12-11-2013 at 9:50 a.m. with the Charge Nurse of 4 West and it was observed that SP#24 did not have a (yellow) Fall Risk armband on. The above finding was confirmed from the Charge Nurse on 12-11-2013 at 9:50 a.m. that there was failure to follow the Fall Precautions for this patient. The Charge Nurse stated on 12-11-2013 at 9:55 a.m. the patients should have the yellow socks and yellow armbands on. I don't know why they were not on the patients. Review of the policy: Fall Prevention Program showed that the purpose is to establish minimal safety interventions to be implemented for the at-risk patients. The procedure include an identification system that include the following: a yellow arm band. The fall prevention activities are implemented for all patients: patients are provided with non-slip footwear and instructed to wear them. 2) Review of SP#3 face sheet revealed that the patient was admitted to the facility on [DATE]. Review of the Nursing Assessments from 12/06/2013 to 12/09/2013 revealed that there was no nursing assessment documented for SP#3 on 12/07/2013 on the 7am to 7pm shift. On 12/09/2013 at 2:05pm, in an interview with sampled employee (SE) #G, who was SP#3 Nurse on 12/07/2013 on the 7am to 7pm shift, the Nurse stated, that I assessed the patient but I did not document, I thought I did. Review of SP#4 medical records on 12/09/2013 to 12/11/2013 revealed that the patient was admitted to the facility on [DATE]. Review of Nursing Assessments from 12/05/2013 to 12/09/2013 revealed that there is no nursing assessments documented for SP#4 on 12/07/2013 on the 7am to 7pm shift. On 12/09/2013 at 2:05pm in an interview with SE#F who was SP#4 nurse on 12/07/2013 on the 7am to 7pm shift, the RN stated that I came in at 11am, I did the assessment, I did not document. I had a critically ill patient at the same time. In an interview with the Director of 4 West on 12/09/2013 at 2pm, the Director stated that the nursing assessments are done every shift and prn (as needed). These findings were also confirmed with the Director of 5 East and the Director of 4 West on 12/09/2013 and on 12/11/2013 Review of the facility ' s Unit Specific Assessment/Reassessment policy criteria showed that for Medical/Surgical areas which includes 5 East, assessments must be initiated within 4 hours and completed within 8 hours and reassessments should be completed every shift and as needed.

29933 Based on record review and interview, the facility failed to ensure that medications given are based upon the orders of the medical staff and in accordance with the facility's policy, in 1 out of 10 sampled patients (SP) #1. The findings include: Review of SP#1 Physician Orders revealed an order that started on 09/04/2013 at 08:00 am for Regular Insulin AC (before meals) and HS (at sleep) on the medium Insulin sliding scale, and an order for Insulin Detemir(Levemir) 25 units that also began on 09/04/2013 at 08:30 am. According to the Medication Administration Record (eMAR), the patient was scheduled for Regular insulin daily (before meals and at hours of sleep) at 08:00 am, 12:30 pm, 17:30 pm, and 22:00 pm and Insulin Levemir was scheduled daily at 08:30 am. Review of the orders for the Regular Insulin Medium sliding scale showed for: Blood sugars(BS) of 151-200 = 2 units Blood sugars(BS) of 201-250 = 6 units Blood sugars(BS) of 251-300 =8 units Blood sugars(BS) of 301-350 = 10 units Blood sugars (BS) > greater than 350, the physician was to be called. Review of SP#1 record revealed that the point of care (POC) Blood Glucose (BG) results on 09/04/2013 at 09:21 am was 85. The Insulin (Levemir) scheduled for 08:30 am was not given, and the reason for non -administration was charted as hypoglycemia. On 09/05/2013; at 16:44 pm, the patient ' s BG/BS result was 397 and 10 units of Regular Insulin was given at 18:04 pm. At 21:23pm, the patient ' s BG/BS was 422 and 10 units of Regular insulin was also given. On 09/06/2013 at 05:45pm the patient ' s BG/BS was 379 and 10 units of Regular insulin was given . A On 09/06/2013 at 16:18 pm, the patients BG/BS was 369 and 10 units of Regular insulin was given. On 09/07/2013, Insulin Levemir scheduled for 08:30 am was given at 09:56 am (the patient ' s BG/BS was 323. At 12:04pm the patient ' s BG/BS was 361 and 10 units of Regular insulin was given. At 16:18pm the patient ' s BG/BS results was 475. Review of the patient medical records revealed that there was no documentation that the physician was called and there was no dosage of regular insulin ordered when the above Blood Glucose's (BG/BS) were above 350. In a telephone interview with SE #A on 12/10/2013 at 3:37pm, the RN stated I work days. I don ' t remember the patient. But if the blood sugar is high I usually call the doctor, even if insulin is given. The findings were confirmed with the Director of 5 East on 12/10/2013 at 1:00pm that there was failure of the staff to follow the policy regarding medication administration. Review of the policy Preparation and Administration of Medication stated that medications will be administered only upon the order of physicians, who are members of the medical staff, and that before administering a medication, the licensed independent practitioner or qualified individual administering the medication should verify that the medication is administered at the proper time, in the prescribed dose. The policy also stated that if the medication is given outside the scheduled time frame, the nurse will document on the Meditech eMAR system, the reason for the variance.

27503 Based on interview and record review the facility failed to ensure that the nursing care that required the judgment and specialized skill was immediately available to evaluate the dialysis care of 1 of 3 sampled dialysis patients (#3) of 13 sampled patients . Findings include: Review of sampled patient #3 nurse ' s notes dated 03/08/2013 stated that a Trialysis catheter (a Short-Term Triple Lumen Dialysis Catheter) was placed in the patient. On 3/11/2013 at 08:45 am, another note has noted -started on CRRT (continuous renal replacement therapy) at this time as per [name of doctor] orders. On 03/11/2013 at 20:40 pm, received patient with CRRT in progress, patient sedated with propofol, family at bedside. Tubing changed on machine and treatment resumed eventful at this time. On 03/11/2013 at 22:56 pm, has noted that the pt ' s treatment interrupted because the machine developed a problem. Unit leader informed and the HD(dialysis) nurse was called. Patient (pt) remained stable at this time awaiting the HD nurse to restart pt ' s therapy. On 03/11/2013 at 23:34 pm (38 minutes later), has that HD nurse came in and changed offending machine and pt ' s treatment recommenced. The nurses notes also stated that on 03/12/2013 at 08:00 am , CRRT will continue till 7pm as per [name of doctor]. On 03/12/2013 at 20:00 pm, the nursing notes stated- received off CRRT, this will be restarted tomorrow at 8am. Then on 03/13/2013 at 15:14 pm, another note has that the dialysis machine sudden stopped (high venous). RN dialysis in the room unable to flush dialysis spoke with doctor regarding this matter. Doctor OK cath. flow. Procedure to be restarted in one hr (hour). Review of Medication Discharge Summary revealed that Cathflo Activase 2mg was administered on 03/13/2013 at 15:18 pm and 16:19 pm. On 03/13/2013 at 15:57 pm, the nursing notes also has noted that the CRRT stopped at 14:40 pm line clotted. Pending cath. flow. To be restarted after 2 hours. On 03/13/2013 at 19:05 pm has that the dialysis RN in the room setting up for CRRT. Then another noted on 03/13/2013 at 19:30 pm, that the pt. with BP- 90/28 with order to start HD (hemodialysis) tx (treatment). Notified doctor of pt. condition. Order to stop HD TX. Family oriented of pt. condition. In an interview with the Dialysis Coordinator, on 11/13/2013 at 3:45 pm; I had started the CRRT; one to two hours later, I received a call from the ICU nurse that venous pressure was elevating; a cartridge in dialysis machine gave an alarm that a line is clogged; I responded to the hospital to flush the line with normal saline to clear the filter. The filter was checked for fiber or blood and the line is replaced if there are many fibers. In this case we did change the filter. This process takes about 10 minutes. We call MD for an Activase order (medication to break clots) and then we must wait one to two hours before we can continue using the machine. This patient was getting CRRT because they were very unstable and unable to tolerate regular three hour dialysis. CRRT is continuous replacement renal therapy. In a telephone interview with the Associate Director of Patient Care Service on November 21, 2013 at 10:00 am, the director states that the ICU nurses who monitors the dialysis has completed dialysis competencies. The director also states that the ICU nurse to patient ratio is 1:1 or 1:2 depending on the acuity of the patient. An ICU nurse who has a patient on CRRT can have 2 patients. Also, there is contract Dialysis nurse on duty, on every shift. They are primarily on the first floor where there is an inpatient Dialysis unit. Review of the policy titled: Continuous Renal Replacement Therapy (CRRT) Protocol revealed that under II. Policy (5) Patients requiring CRRT will be taken care of in a critical care setting. The R.N. (registered nurse) who has had CRRT training and has demonstrated competencies can manage and stop therapy with the help of an easily accessible and immediately available Dialysis Nurse by phone. There was failure to have available a Dialysis Nurse who is immediately accessible and available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27503 Based on interview and record review the facility failed to keep current a nursing care plan and ongoing assessments with the appropriate nursing interventions in response to the identified nursing care needs of 1 of 10 sampled patients (SP) #1. Findings include : Review of records of SP#1 revealed that SP#1 had a procedure for implantation of a permanent pacemaker on 09-23-13 in the cardio-vascular laboratory (CVL) unit of the facility. The patient was transferred to the unit (5 East - room [ROOM NUMBER] D) at 11:12 am. Further review of SP#1 medial record revealed that she was admitted to the 5th floor (Med/Surg Telemetry) at approximately 11:12 am. Review of the post procedure physician orders include but not limited to vital signs every shift, and cardiac monitor: telemetry - continuous. Review of the nursing clinical documentation record revealed that the post procedure physician orders were followed except the continuous telemetry monitoring order. On 09/23/2013 at 4:00 pm, it was documented that the monitor rhythm was sinus rhythm with irregular heart rhythm, telemetry: yes, and monitor rhythm : atrial fibrilation on the nurses notes. The nurse notes dated 09/23/2013 at 23:30 pm also revealed that the nurse spoke to the cardiologist of the patient, and according to the medication administration record, Diltiazem 60mg tablet was given one time at 22:55 pm. On 09-24-13 at 12:00 am, the nursing documentation then showed, Received patient from sampled employee (SE) #2 with no telemetry box and no blood sugar coverage. Patient is S/P (status/post) AICD (Automatic Implantable Cardioverter-Defibrillator) placement 9/23. At this time patient heart rate (HR) slowly stabilizing. Sampled Patient #1 Rhythm Strip Recording showed a reading on 09/23/2013 at 07:57 am and another at 09:44 am pre/post procedure. The next rhythm strip record is noted on 09/23/2013 at 22:40pm(13 hours later) while patient was stationed on the 5th floor. Further review of the rhythm strip recorded at 22:40 pm has noted that the heart rate is 120 bpm and that the patient type of rhythm as Atrial Flutter. Interview with sampled employee (SE) #1 via phone conducted on 11-13-13 at 10:30 am she stated that she received SP#1 on 9-23-13 at 7 PM and she applied the telemetry monitor to SP#1. She further stated that the family found SP#1 without monitor but she already knew about it and was ready to apply it. She stated that she called the physician due to increase heart rate and to verify orders for medication reconciliation. That after she gave the medication that there was no problem all throughout the night and the heart rate went down from 120 to 80. That she checked the patient all night and patient was ok and not in any distress. Interview with SE#2 conducted on 11-13-13 at 11:10 am confirmed above findings that SP#1 would have rhythm strips recorded if the patient was put a telemetry monitor. She further stated, I admit that I possibly made mistake that I thought the monitor was placed but not. That the sinus rhythm she documented was taken from the transport monitor when the patient was transferred to the 5 East unit. Review of the facility's policy and procedure title: Communication of Remotely Monitored Patients conducted on 11-15-13 revealed under II. policy - The initial connection of the telemetry pack must be done by a nurse. The nurse must call the monitor room after initial connection to confirm the patient's name, telemetry monitor number and the initial patient's rhythm. The monitor Tech runs patient strips and records interval measurements on the strip every 4 hours.

27503 Based on record review and interview the facility failed to ensure accurate and complete the medication reconciliation, and to administer the medications as ordered by the physician in 1 of 10 sampled patients (SP) (#1). The findings include: Review of the medication discharge summary of SP#1 conducted from 11-12-13 to 11-13-13 revealed that SP#1 did not receive any home medications: Amaryl 1 mg tablet ( an antidiabetic drug) and Lisinopril 10mg tablet ( used for treating blood pressure) after the procedure on 9-23-13. Review of records revealed that medications prior to admission were reconciled before the patient ' s procedure was done at the facility on 9-23-13 at 7:21 am. Further review of records revealed that the medication reconciliation was not communicated when the patient was transferred to another setting within the facility per policy and procedure. Review of the HPF LAB discharge summary report in the medical record also revealed that the point of care (POC) Glucose (blood sugar); on 09/23/2013 at 12:00 pm the results was 139 mg/dl (H) (normal range: 70-110 mg/dl); and at 18:44 pm the results was 240 mg/dl (H). Further review of the nursing notes dated 09/23/2013 at 16:00 pm has noted an accucheck (blood sugar) result of 231 mg/dl. There is no documentation of any nursing intervention. Review of the nursing clinical documentation conducted on 11-13-13 revealed that on 09-24-13 at 12:00 am, documentation also showed, Received patient from sample employee (SE) #2 with no telemetry box and no blood sugar coverage. Patient is S/P (status/post) AICD (Automatic Implantable Cardioverter-Defibrillator) placement 9/23. Medication reconciliation not completed. Called attending physician 3 times earlier at 9/23 - 8:00pm, 9:00pm, 10:00pm. Physician didn ' t call back. Thus I informed Charge Nurse of situation. Spoke to covering physician who completed medication reconciliation and ordered appropriate medication based on patient condition. Review of the facility policy and procedure regarding medication reconciliation conducted on 11-13-13 revealed that the purpose of the medication reconciliation guidelines is to outline the processes that ensure accurate and complete medication reconciliation for all patients at the time of admission, transfer, and discharge . Further review of the Procedure B. 1. Post -procedure / transfer Medication Reconciliation revealed that medication reconciliation must occur anytime orders are rewritten, post procedure and when the patient changes setting, provider or level of care and new medications are written. Interview with sample employee #2 conducted on 11-13-13 at 11:10am confirmed above findings that she did not call the physician to verify the home medication reconciliation. She further stated that if the medications were ordered that the medications would have been given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29368 Based on interview and record review, the facility failed to ensure 1 (Sample Patient #1) out of 2 patients selected for psychiatric services received care in a safe setting, by 1) not ensuring the evaluation of the consulted psychiatrist prior to discharge; 2) not ensuring sitter documentation was completed for a suicidal patient (Sample Patient #1) who had a physician order for a one to one sitter throughout her length of stay. The findings include: Record review reflects that Patient #1 was admitted to the facility on [DATE] and subsequently discharged on [DATE]. She was admitted and Baker Act via the facility ' s emergency department with a chief complaint including suicidal ideation. Her diagnosis includes (but is not limited to): depression. She was admitted on the medical floor in the facility and assigned a one to one sitter for safety, due to the suicidal ideation. Review of the physician orders reveal the following: 8/2/2012: consultation with psychiatrist for suicide attempt; 8/3/2012: discharge if ok with attending physician; after psychiatry evaluation; 8/3/2012 (telephone order): ok to discharge patient home from psychiatric standpoint as per psychiatrist; read back, verified. There is no evidence on the medical record that the patient had been evaluated by the psychiatrist. Review of a physician progress note, from psychiatry, dated 8/31/2012 reveals: late entry, On 8/2/2012 a consult was placed to the system for psychiatry to evaluate this patient (Sample Patient #1); consult was called on 8/3/2012 in the AM; I will see the patient today late or early in am ; came to see the patient on 8/4/2012 early in AM; patient was discharged already; patient was also off my list; apparently the patient was discharged late on 8/3/2012; I did not see the patient nor did I evaluate her. Interview (telephone) with psychiatrist on 9/17/2012 at 3:35pm; he confirmed that he was the consulted psychiatrist for Sample Patient #1; and by the time he went to see her, she had already been discharged from the facility. He reports that he does not know why the patient was discharged without seeing him. He reports he normally see patients he is consulted on, in this case he is guessing the attending physician allowed the patient to be discharged prior to seeing the psychiatrist. He confirms that he does not have a recollection of this patient, nor does he have any recollection of giving a telephone order to the staff directing them to discharge a patient he had not yet physically evaluated. He conforms that the telephone order to discharge Patient #1, without out psychiatric evaluation was an inappropriate order as well as odd. Review of facility Rules and Regulations regarding Consultations reveal: Except in emergency, consultation is required in the following instances: d) in unusually complicated situations where specific skills of other practitioners may be needed. Consultation reports should contain a written opinion by the consultant based on an examination of the patient and his record. This must be dated and signed by the consulting physician. 2)Sample Patient #1 was admitted under the Baker Act and was to have a one to one sitter for suicidal ideation, by physician order. Review of the medical record reflects that there is no documentation that the one to one sitter was assigned, nor does documentation exist of the one to one sitter documentation of the hourly assessment of this patient, per the facility order. Interview via telephone with sample patient #1 care technician on 9/18/2012 at 3:38pm revealed; she was assigned to provide one to one sitter duties for Patient #1 on 8/3/2012. She confirms that she worked with another patient care technician the night of 8/3/2012; however, she does not recall Patient #1. She reports that when she is assigned one to one sitter duties, she typically does document on the facility one to one form, hourly, of the patient activities and that their safety is maintained. Interview with the Interim CNO on 9/18/2012 at 1:38pm revealed that it is the facility ' s policy for one to one sitters to complete documentation of patient activities when they are assigned this duty. She confirms that there is no one to one sitter documentation on the medical record for Patient #1. Review of facility policy and procedure titled Sitter reveals: The need for a sitter may be determined based on the following criteria: 1) Suicide watch outside the critical care unit. Attached to the policy is an example of the form titled, Sitter Record. The form reveals a section for date, time, staff name, signature, comments, all in hourly increments from 12:00AM to 11:00PM.

27308 Based on record review and interview, the facility failed to ensure that the patient's next of kin is clearly informed of the patient's discharge in a timely manner in one (#1) of 14 sample patients. The findings include: Clinical record review of Sample Patient (SP)#1 conducted from 9-10-12 to 9-12-12 revealed that she was admitted into the facility's Behavioral Unit on 7-20-12 and discharged to an Assisted Living Facility [ALF] on 7-30-12 at 1447. Documentation of the Social Worker dated 7-30-12 at 1630 included but not limited to: called the patient's daughter [named] .informed her that patient was discharged to [ALF]. Review of the Behavioral Unit Social Worker's notes conducted from 9-10-12 to 9-12-12 showed in part: 7-30-12 at 1427: Patient is scheduled to be discharged today by [Psychiatrist]. Patient is going to be discharged to [ALF]. Patient is going to be transported via ambulance. Patient and caregiver conveyed to writer for her safety and compliance with medication and follow-up appointments. Interview with the Behavioral Unit Social Worker conducted on 9-10-12 at 330pm revealed that she spoke with SP#1's daughter at the time [7-30-12 at 1427] and got her agreement for the ALF placement. She stated that SP#1's daughter even agreed to the follow-up appointments with the Psychiatrist and Medical Physician who does rounds in the said ALF. Interview with the [NAME] President of Quality Management conducted on 9-11-12 at 1150am confirmed that the Social Worker's documentation on 7-30-12 at 1427 showed communication with SP#1 and her daughter. He stated that the notes did not clearly state that SP#1's daughter was informed of the discharge to the ALF at the time (1427) compared to the clearer documentation at 1630 - called the patient's daughter - informed her that patient was discharged to [ALF].

29933 Based on interview, and record review, it was determined the facility is not in compliance with the medical screening examination requirement to determine if an emergent medical condition exist, the facility failed to provide the necessary stabilizing treatment and failed to ensure an appropriate transfer for 2 out of 22 Sample Patients (SP), (SP#21, SP#22). The facility failed to be in compliance with the Emergency Medical Treatment and Labor Act requirements at 489.24. 1. Refer to A-2406. 2. Refer to A-2407. 3. Refer to A-2409.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29933 Based on medical record review, policy and procedure review and interview, the facility failed to document and maintain medical and other records related to the individuals transferred to and from the hospital for a period of 5 years from the date of the transfer in 2 out of 22 Sampled Patients (SP) (SP#21, and SP#22). The findings include: Information contained in an electronic mail (e-mail) from the local fire and rescue revealed that on May 12, 2012 at approximately 2020 (8:20 PM), Rescue was called out to a motor vehicular accident (MVA). Two (2) pediatric Basic Life Support (BLS) patients were sent to the hospital. A four (4) year old (SP#21) and a six (6) year old (SP#22), both siblings and their mother were transported. The Emergency Department Director (ED Dir.) was asked by the surveyor about her knowledge of the incident on May 12, 2012 and the ED Dir. stated on July 9, 2012 from 10:43 A.M. to 12:15 P.M., the patients were brought together in one (1) rescue truck by the Paramedic, Firefighter F#1 and Firefighter F#2. The ED Dir. stated, Fire Rescue brought the patients in a stretcher, entered the ED, met by the ED Pediatrician and Pediatric Nurse (PN)#1. The patients were not transferred to the beds, only stayed within the hallway. The ED Pediatrician told the Fire Rescue personnel, the patient (6 year old) (SP #22) is a Trauma patient and should be transferred to Hosp.#2. The ED Pediatrician did a quick assessment while the patient was on the stretcher but did not document. The ED Pediatrician stated to the Ped. ED Med. Dir. the patient had a rigid abdomen and PN#1 told me this is what the ED Pediatrician said on that night. The ED Dir. further added, she spoke to PN#1 who told her the patients were brought by Fire Rescue, met by the ED Pediatrician who looked at the first baby and then the second (2nd) baby (6 year old). The 2nd baby had a rigid abdomen and the ED Pediatrician told Fire Rescue the patient needs to be brought to Hosp.#2. PN#1 told the ED Dir. Fire Rescue turned around and took the patients to Hosp.#2. Interview of the Ped. ED Med. Dir. conducted on July 10, 2012 from 11:26 A.M. to 11:50 A.M. revealed, according to the ED Pediatrician 2 patients came together in 1 Fire Rescue truck, 1 in each stretcher. 1 patient had blood on the face and 1 patient did not look right. The ED Pediatrician checked the patient and noted the lap-band sign or mark on the abdomen, the abdomen was tender to touch and told Fire Rescue to go straight to Hosp.#2 because of the presence of an abdominal injury, the patient needed a surgical evaluation which is not available in Hosp. #1. The patients were examined in the hallway by the ED Pediatrician. The ED Pediatrician stated to the Ped. ED Med. Dir. I do not know what happened, why I did not document. I wanted the patients transferred right away because of the injuries. The Ped. ED Med. Dir. confirmed on July 10, 2012 at 11:45 A.M. that there was no documentation done by the ED Pediatrician on the 2 patients. Pediatric Nurse (PN)#1 stated during an interview conducted on July 11, 2012 from 7:35 A.M. to 7:58 A.M. in the presence of the ED Unit Leader (ED U.L.) revealed, Fire Rescue came with the kids. They were met by the ED Pediatrician in front of room [ROOM NUMBER]. He examined them, looked them over, palpated, it was relatively quick; time-wise, I can't tell. One of the children had bruising on the face, injuries and the other child had seat belt marks. The ED Pediatrician said, they were trauma patients and they need to go to a trauma center, it's a belly that needed a surgeon. PN#1 was asked if vital signs were taken and the answer was, No vital signs were taken. The ED Dir. confirmed on July 9, 2012 at 12:00 P.M. by stating, The Pediatrician and the Pediatric Nurse did not document anything at all. No medical records for these patients. The facility failed to ensure that medical records and other records related to sampled Patients #21 and #22 were maintained on May 12, 2012 when these patients presented on the hospital's grounds.

29933 Based on the review of emergency room Logs, policy and procedures, record review and interview(s), the facility failed to maintain a central log on each individual who comes to the Emergency Department in 2 out of 22 Sampled Patients (SP) (SP#21, and SP#22). The findings include: The hospital's policy titled, EMTALA(Emergency Medical Treatment and Labor Act) -Florida Central Log Policy Review/Revised Date 6/2012 was reviewed. The policy documented in part, Policy: The hospital will maintain Central Log information on each individual who comes to the hospital campus, requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination (MSE) could be performed, whether he or she was refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged . The emergency room Register Log used by the Flow Charge Nurse showed documentation that on May 12, 2012 at 2050(8:50PM) information was received from R-58 about a 4 year old with right cheek pain and on May 12, 2012 at 2051 (8:51 PM), information was received about a 6 year old with nosebleed and abdominal pain. The Emergency Department Director (ED Dir.) stated on an interview conducted on July 9, 2012 at 10:43 A.M. to 12:15 P.M., whenever a patient is brought to the ED, a piece of paper is stamped by either the Fire Rescue or Ambulance personnel and then given to the Unit Secretary (U.S.). A telephone interview of the Unit Secretary who worked on the 7 P.M. to 7 A.M. shift on May 12, 2012 was conducted on July 9, 2012 at 4:51 P.M. in the presence of the Emergency Department Director and the Director of Risk Management. She stated, I do not remember these patients that night. The Nurse Director talked about the incident that there were 2 patients who were not accepted or placed in the computer and then were transferred to another hospital. The Electronic Central Log for Both Emergency Services and Labor & Delivery Departments for May 12, 2012 failed to show documentation of the names of SP#21 and SP#22. The above findings were confirmed with the ED Dir. on July 9, 2012 at 12:15 P.M., there was failure by the facility to document and maintain a central log for each individual who comes to the ED.

29933 Based on a review of policy and procedures and interview, the facility failed to ensure that an appropriate transfer was provided for 2 out of 22 Sampled Patients (SP) (SP#21, and SP#22). The findings include: The hospital's policy and procedure titled, Transfer of Patients to Other Facilities or Agencies documents any transfer of an individual with an Emergency Medical Condition (EMC) must be initiated by the written request from the patient or the legally responsible person acting on the patient's behalf for such transfer or by a physician order with the appropriate physician certification. It is further documented (a) the transferring hospital must, within its capability, provide treatment to minimize the risks to the health of the individual, (b) the receiving hospital must have available space and qualified personnel for the treatment of the individual and must have agreed to accept the transfer and (c) the transferring hospital must send copies of available medical records related to the individual's EMC. The ED Dir. confirmed on July 9, 2012 at 12:00 P.M. by stating, The Pediatrician and the Pediatric Nurse did not document anything at all. No medical records for these patients. There is no evidence of any documentation for SP#21 and SP#22 on May 12, 2012 that an appropriate transfer was undertaken by Hosp. #1 as stated in the facility's policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29933 Based on review of the hospital's Emergency Department (ED) Reportable Issue form, policy and procedures and interview(s), the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability and capacity of the hospital's emergency department to determine if an emergency medical condition existed for 2 out of 22 Sampled Patients (SP) (SP#21, and SP#22) when these Individuals presented to the hospital on May 12, 2012. The findings include: A review of the hospital's policy titled, EMTALA-Florida Medical Screening Examination and Stabilizing Policy Review and revised date 6/2012 was reviewed. The policy specified in part, Procedure: . 2. When an MSE (medical screening examination) is required: A hospital must provide an appropriate MSE with the capability of the hospital's emergency department, including ancillary services routinely available to the DED (Dedicated Emergency Department), to determine whether or not an EMC (Emergency Medical Condition) exists: .(ii) an individual who has such a request made on his or her behalf; (iii) an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC A. ii. The MSE of the individual must be documented. SP #21's medical record from the receiving hospital was reviewed. Review of the ED/Triage Assessment-Text, indicated the patient arrived via ambulance on May 12, 2012, and the patient was triaged and assessed by the ED nurse at 9:35 P.M. The ED Note-Physician .Final Report dated May 12, 2012 indicated in part, Motor vehicle crash-major. History of present illness: 4 year old with a history of renal surgery secondary to uretheral reflux (abnormal movement of urine from the bladder into the ureters or kidneys) c/o (complain/of) abdominal pain and right cheek pain after being involved in a MVA (motor vehicle accident). Skin symptoms: Bruising, abrasions, right cheek ecchymosis and edema with pain .Gastrointestinal symptoms: Abdominal pain, moderate, right lower quadrant, left lower quadrant, constant .Physical examination: Skin: Wound(s): lower abdomen and abrasion .Head .right cheek, ecchymosis (passage of blood from a ruptured blood vessel into subcutaneous tissue- purple discoloration) and edema .Gastrointestinal: abdominal distension (swelling). Tenderness: moderate, right lower quadrant, and left lower quadrant . Trauma: right lower quadrant, left lower quadrant abrasions and ecchymosis. Signs: positive Seatbelt sign .medical decision making: differential diagnosis: Head injury, contusion, neck injury, internal hemorrhage, abrasion . Impression and plan: Diagnosis: Trunk abrasion . Contusion (bruise) to the face. Admit for further evaluation and treatment. Ped SurgH&P (History and Physical): Basic information: Admit information: Admit to surgery; S/P (status/post) trauma . review of systems: Eye: right eye swollen shut with bruising .gastrointestinal: Abdominal pain: lower quadrant, pt (patient) with moderate to severe abdominal pain and bruising overlying her suprapubic areas (Urinary and Uterus) where her seat belt was. SP' s #22 medical record from the receiving hospital was reviewed. A review of the ED/Triage Assessment -Text, revealed that the patient arrived via ambulance on May 12, 2012. The patient was triaged and assessed by the ED nurse at 9:39 P.M. The ED Note Physician .Final Report dated May 12, 2012 .History of Present illness: 6 y/o . with a h/o (history /of) Choanal atresia (congenital disorder where the back of the nasal passageway is blocked), c/o abdominal pain and epistaxis (after being involved in a MVA). ENMT (Ear, nose, mouth, throat) Nose: Bleeding, swelling.gastrointestinal symptoms: Abdominal pain severe, right lower quadrant, left lower quadrant, constant.Physical examination: Ears nose, and throat:.Nose/nares: Bleeding, tenderness and swelling. . Gastrointestinal: Abdominal distension, tenderness: severe, right lower quadrant and left lower quadrant. Guarding: moderate and involuntary. Medical Decision Making: Differential Diagnosis: head injury, fracture, closed contusion, laceration, abrasion Plan: Admit to inpatient unit. The Discharge summary revealed in part, CT (Computerized Tomography scan- specialized x-ray) of the head, which showed.nasal bone fracture .CT of abdomen showed small bowel injury and edema, and ischemia (decrease in blood supply to a bodily organ or tissue). Transferred to PICU (pediatric intensive care unit-unit within the hospital where specializing in care critically ill children) . surgery on May 13, 2012 for closed reduction of decompressed fracture . surgery on May 13, 2012 for an ischemic small intestine and perforation of the sigmoid colon (medical condition an injury of large intestine result from inadequate blood supply in which) . exploratory laparotomy (surgical procedure that explores the abdomen) . .small bowel resection . sigmoid colon resection with And distal colostomy (surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body). The Emergency Department Director (ED Dir.) was asked by the surveyor about her knowledge of the incident on May 12, 2012 and the ED Dir. stated on July 9, 2012 from 10:43 A.M. to 12:15 P.M. that the patients were brought together in one (1) rescue truck by the Paramedic, Firefighter #1 and Firefighter F#2. The patients were not transferred to the beds, only stayed within the hallway. The ED Pediatrician told the Fire Rescue personnel that the patient (6 year old) is a Trauma patient and should be transferred to Hosp.#2. The ED Pediatrician did a quick assessment while the patient was on the stretcher but did not document the assessment. The hospital's ED Reportable Issue (RI) form dated May 18, 2012 revealed a Summary of the RI as follows: On 5/12/12, Fire Rescue transported 2 pediatric patients Status/Post MVA to Hospital (Hosp.) #1 as a non-trauma alert. Upon arrival, the Pediatric ER physician noted that Patient A had facial trauma (later determined to be a fractured nose) and seat belt marks with a distended abdomen. The physician told Fire Rescue that Patient A needed to be transported to Hosp.#2 as a trauma alert. Hosp.#1 is not a pediatric trauma facility. The 2 patients were not accepted in the system or evaluated by the nurse and did not receive a complete screening by the Pediatric ER physician. Interview of the Ped. ED Med. Dir. conducted on July 10, 2012 from 11:26 A.M. to 11:50 A.M. revealed that according to the ED Pediatrician 2 patients came together in 1 Fire Rescue truck, 1 in each stretcher. One patient had blood on the face and 1 patient did not look right. The ED Pediatrician checked the patient and noted the lap-band sign or mark on the abdomen, the abdomen was tender to touch and told Fire Rescue to go straight to Hosp.#2 because of the presence of an abdominal injury, the patient needed a surgical evaluation which is not available in Hosp. #1. The patients were examined in the hallway by the ED Pediatrician. The ED Pediatrician stated to the Ped. ED Med. Dir. I do not know what happened, why I did not document. I wanted the patients transferred right away because of the injuries. The Ped. ED Med. Dir. confirmed on July 10, 2012 at 11:45 A.M. there was no documentation done by the ED Pediatrician on the 2 patients. There is no evidence of any documentation for SP#21 and SP#22 that an appropriate MSE was performed to determine whether or not an Emergency Medical Condition (EMC) existed, when the patients presented to the ED on May 12, 2012. Pediatric Nurse (PN) #1 stated during an interview conducted on July 11, 2012 from 7:35 A.M. to 7:58 A.M. in the presence of the ED Unit Leader (ED U.L.) revealed, Fire Rescue came with the kids. They were met by the ED Pediatrician in front of room [ROOM NUMBER]. He examined them, looked them over, palpated, it was relatively quick; time-wise, I can't tell. One of the children had bruising on the face, injuries and the other child had seat belt marks. The ED Pediatrician said that they were trauma patients and they need to go to a trauma center, it's a belly that needed a surgeon. Pediatric Nurse (PN#1) was asked if vital signs were taken and the answer was No vital signs were taken. There was also no evidence of triage assessments provided for SP# 21 and SP #22 on May 12, 2012. The above findings were confirmed from the Ped. ED Med. Dir. on July 10, 2012 at 11:50 A.M. there was failure by the ED Pediatrician to provide an appropriate MSE of SP#21 and SP #22 on May 12, 2012 for both patients with EMC's and failure to maintain documentation of the MSE's findings, as stated in their policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29933 Based on interview, review of policy and procedure, Emergency Department's Reportable issue and medical record review, the facility failed to provide the necessary stabilizing treatment that was within the capability and capacity of the hospitals Dedicated Emergency Department (DED) for 2 out of 22 Sample Patients (SP) (SP#21, and SP#22). See tag 2406 for additional information on SP #21 and SP #22. The findings are: The hospital's policy titled, EMTALA (Emergency Medical Treatment and and Labor Act) - Florida Medical Screening Examination and Stabilization Policy documents the hospital must provide an appropriate Medical Screening Examination (MSE) to determine whether or not an an Emergency Medical Condition (EMC) exists. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment or an appropriate transfer. The hospital's Emergency Department's Reportable Issue (RI) form dated May 18, 2012 revealed a Summary of the RI as follows: On 5/12/12, Fire Rescue transported 2 pediatric patients Status/Post MVA to Hospital (Hosp.)#1 as a non-trauma alert. The 2 patients were not recepted in the system or evaluated by the nurse and did not receive a complete screening by the Pediatric ER physician. There was no patient information entered into the Central Log. The ED Dir. confirmed on July 9, 2012 at 12:00 P.M. by stating, The Pediatrician and the Pediatric Nurse did not document anything at all. No medical records for these patients. There is no evidence of any documentation for SP#21 and SP#22 that any stabilizing treatment were done before the patients were taken by Fire Rescue to Hosp.#2 as of May 12, 2012. Interview of the Pediatrics Emergency Department Medical Director. conducted on July 10, 2012 from 11:26 A.M. to 11:50 A.M. The Ped. ED Med. Dir. confirmed on July 10, 2012 at 11:45 A.M. that there was no documentation done by the ED Pediatrician on the 2 patients. Pediatric Nurse (PN)#1 stated during an interview conducted on July 11, 2012 from 7:35 A.M. to 7:58 A.M. in the presence of the ED Unit Leader revealed that Fire Rescue came with the kids. They were met by the ED Pediatrician in front of room [ROOM NUMBER]. He examined them, looked them over, palpated, it was relatively quick; time-wise, I can't tell. One of the children had bruising on the face, injuries and the other child had seat belt marks. The ED Pediatrician said, they were trauma patients and they need to go to a trauma center, it's a belly that needed a surgeon. Pediatric Nurse PN#1 was asked if vital signs were taken and the answer was, No vital signs were taken.

27572 Based on record review and interview the facility failed to ensure the administration of medication in a timely manner to 1 of 15 sampled patients (#4.) The findings include: Record review of sample patient #4 revealed she presented in the emergency department on 11/29/11 with abdominal pain. The record revealed the physician diagnosed the patient with colitis and an infection. Review of the documentation revealed the physician ordered Zosyn(antibiotic) 3.375 grams intravenously on 11/29/11 at 9:50 a.m. The patient was administered the Zosyn( antibiotic) on 11/29/11 at 7:39 p.m. (9 hours and 40 minutes after ordered.) Interview with the Director of the Pharmacy on 2/9/12 at 10:30 am revealed she is aware of the incident with sample patient #4 ' s medication. The Director of the Pharmacy stated that the emergency room physician ordered Zosyn for the patient and that the medication is in stocked in the AccuDose machine in the pharmacy. The Director of the Pharmacy stated that the nurse in the emergency room should have given the medication in the emergency room or notified the pharmacy to send the medication to the patient ' s room once a room was assigned. The Director stated that the envelope that would have alerted the pharmacy to question whether the dose was given in the emergency department was not in the bin so she thinks the envelope must have been returned to the emergency department by mistake. The Director of the Pharmacy stated that this is the first incident of this type she has been made aware of. The Director of the Pharmacy stated that the pharmacy has added a second courier to avoid wait time and that there have been no complaints to the pharmacy regarding services or wait time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29368 Based on observations , and interviews, the hospital failed to conduct ongoing maintenance inspections to identify patient care areas and equipment that are in need of repair for 1 sampled patient #2 and the random patients who occupied the following affected rooms: # 301, #308, #309, #312, # 313, #319, #321 , # 322, # 323, # 326, #229, #330, # 334, #336, and #340 on the 3rd floor Unit, as well as the Lactation Room on the Neonatal Intensive Care Unit (N.I.C.U) on the second floor. The findings include: On 7/12/2011 at 11:10am, during the tour of the 3rd floor telemetry unit the following observations made of: room [ROOM NUMBER]: brown colored stain on a ceiling tile in the bathroom; room [ROOM NUMBER]: brown colored stain on a ceiling tile in the bathroom; room [ROOM NUMBER]: bathroom had a hole in the wall, above the toilet, with some evidence of paint chipping visible; room [ROOM NUMBER]: ceiling tile in bathroom with 4 fairly large sized black colored areas on ceiling and 2 fairly large sized brown colored areas; room [ROOM NUMBER]: ceiling tile in bathroom had 1 brown colored area; room [ROOM NUMBER]: ceiling tile in bathroom had 2 brown colored areas; room [ROOM NUMBER]: upon entry into patient room, there was 3 fairly large brown colored spots on the ceiling tile; in the bathroom there was a fairly large brown-yellow colored area on the ceiling tile; room [ROOM NUMBER] (subject of this complaint investigation) had 3 fairly large black colored areas and 2 smaller black colored area on the ceiling tiles in the bathroom, the patient room had a black colored area on the ceiling tile upon entry into the patient room; room [ROOM NUMBER]: yellow colored and black colored areas noted on the ceiling tile in the bathroom, yellow colored areas noted on the ceiling upon entry into the room; room [ROOM NUMBER]: brown colored area noted on ceiling tile in bathroom; room [ROOM NUMBER]: brown colored area noted on ceiling tile, around a panel, in the bathroom; room [ROOM NUMBER]: brown colored areas noted on ceiling tile near panels in the bathroom; room [ROOM NUMBER]: small hole in bathroom ceiling tile; room [ROOM NUMBER]: bathroom ceiling with hole/missing tile around vent; Room: 340: strong odor in bathroom noted; 2nd floor NICU (directly below room [ROOM NUMBER], the subject of this complaint investigation): room labeled lactation room had a brown colored brown-pink colored area in ceiling tile. On 7/12/2011 at 11:20am, interview with Sampled Patient (SP) #2 revealed that she informed the facility of the above findings upon entry to the unit days prior. On 7/12/2011 at 11:20am, Sampled Employee (SE)# 3 reports that she was aware of the conditions in room [ROOM NUMBER] and immediately reported it to her charge nurse. On 7/12/2011 at 11:30 am , the charge nurse of the unit confirmed she was aware of the conditions in room [ROOM NUMBER] and reported them to the maintenance department. She confirms that the maintenance department had not addressed the environmental issues on the unit to date. She reports that she does not have any documentation of her communication with the maintenance department. On 7/12/2011 at 11:56am, interview with the Supervisor of Plant Operations was done, on the 3rd floor telemetry unit. He reports that he has not been made aware of the environmental issues on this unit. He confirms that patients should not be in this area, specifically in room [ROOM NUMBER]. He was then observed to report this to the charge nurse on the unit. At 3:54pm, SP#2 was no longer occupying room [ROOM NUMBER] and moved to another room on the unit. Maintenance crews were observed going into room [ROOM NUMBER] to work, a notice was placed on the door that the room was closed for repairs. At 3:57pm observation of the maintenance department working in room [ROOM NUMBER]. A total of 2 panels were removed from the ceiling at the entrance to the room and replaced with additional panels, which did not have any discolored areas. A total of 5 panels were removed in the bathroom. On 7/12/2011 at 3:57pm, the Supervisor for plant operations reports that the discoloration on the ceiling tiles came from condensation from the pipes above them. He reports that the crews will work to replace the panels, and re-insulate the pipes. He confirms that a sign will remain on the door to this room until the repairs are completed. On 7/13/2011 at 10:15am, interview with the Director of Plant Operations reveals that he has been made aware of the 3rd floor telemetry unit physical environmental issues. He confirms that the cause for the discoloration on the ceiling tiles on the 3rd floor is due to condensation and damp insulation. He reports that the facility had previously refurbished the 4th and 5th floors. He reports that the facility has planned to start this process on the 3rd floor in September 2011.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29368 Based on observations and interviews the facility failed to develop a system for reporting , identifying, and implementing measures to maintain a clean, safe, and orderly environment for 1 sampled patient #2 and the other patients who occupied the affected rooms # 301, #308, #309, #312, # 313, #319, #321 , # 322, # 323, # 326, #229, #330, # 334, #336, and #340 on the 3rd floor Unit, as well as the Lactation Room on the Neonatal Intensive Care Unit (N.I.C.U) on the second floor. The findings include: On 7/12/2011 at 11:10am, during the tour of the 3rd floor telemetry unit the following observations made of: room [ROOM NUMBER]: brown colored stain on a ceiling tile in the bathroom; room [ROOM NUMBER]: brown colored stain on a ceiling tile in the bathroom; room [ROOM NUMBER]: bathroom had a hole in the wall, above the toilet, with some evidence of paint chipping visible; room [ROOM NUMBER]: ceiling tile in bathroom with 4 fairly large sized black colored areas on ceiling and 2 fairly large sized brown colored areas; room [ROOM NUMBER]: ceiling tile in bathroom had 1 brown colored area; room [ROOM NUMBER]: ceiling tile in bathroom had 2 brown colored areas; room [ROOM NUMBER]: upon entry into patient room, there was 3 fairly large brown colored spots on the ceiling tile; in the bathroom there was a fairly large brown-yellow colored area on the ceiling tile; room [ROOM NUMBER] (subject of this complaint investigation) had 3 fairly large black colored areas and 2 smaller black colored area on the ceiling tiles in the bathroom, the patient room had a black colored area on the ceiling tile upon entry into the patient room; room [ROOM NUMBER]: yellow colored and black colored areas noted on the ceiling tile in the bathroom, yellow colored areas noted on the ceiling upon entry into the room; room [ROOM NUMBER]: brown colored area noted on ceiling tile in bathroom; room [ROOM NUMBER]: brown colored area noted on ceiling tile, around a panel, in the bathroom; room [ROOM NUMBER]: brown colored areas noted on ceiling tile near panels in the bathroom; room [ROOM NUMBER]: small hole in bathroom ceiling tile; room [ROOM NUMBER]: bathroom ceiling with hole/missing tile around vent; Room: 340: strong odor in bathroom noted; 2nd floor NICU (directly below room [ROOM NUMBER], the subject of this complaint investigation): room labeled lactation room had a brown colored brown-pink colored area in ceiling tile. On 7/12/2011 at 11:20am, interview with Sampled Patient (SP) #2 revealed that she informed the facility of the above findings upon entry to the room days prior. On 7/12/2011 at 11:20am, Sampled Employee (SE)# 3 reports that she was aware of the conditions in room [ROOM NUMBER] and immediately reported it to her charge nurse. On 7/12/2011 at 11:30, the charge nurse of the unit confirmed she was aware of the conditions in room [ROOM NUMBER] and reported them to the maintenance department. She confirms that the maintenance department had not addressed the environmental issues on the unit to date. She reports that she does not have any documentation of her communication with the maintenance department. On 7/12/2011 at 11:56am, interview with the Supervisor of Plant Operations was done, on the 3rd floor telemetry unit. He reports that he has not been made aware of the environmental issues on this unit. He confirms that patients should not be in this area, specifically in room [ROOM NUMBER]. He was then observed to report this to the charge nurse on the unit. At 3:54pm, SP#2 was no longer occupying room [ROOM NUMBER] and moved to another room on the unit. Maintenance crews were observed going into room [ROOM NUMBER] to work, a notice was placed on the door that the room was closed for repairs. At 3:57pm observation of the maintenance department working in room [ROOM NUMBER]. A total of 2 panels were removed from the ceiling at the entrance to the room and replaced with additional panels, which did not have any discolored areas. A total of 5 panels were removed in the bathroom. On 7/12/2011 at 3:57pm, the Supervisor for plant operations reports that the discoloration on the ceiling tiles came from condensation from the pipes above them. He reports that the crews will work to replace the panels, and re-insulate the pipes. He confirms that a sign will remain on the door to this room until the repairs are completed. On 7/13/2011 at 10:15am, interview with the Director of Plant Operations reveals that he has been made aware of the 3rd floor telemetry unit physical environmental issues. He confirms that the cause for the discoloration on the ceiling tiles on the 3rd floor is due to condensation and damp insulation. He reports that the facility had previously refurbished the 4th and 5th floors. He reports that the facility has planned to start this process on the 3rd floor in September 2011. On 7/14/2011 at 1:55pm during an interview with the Infection Control Director, she stated that she make daily rounds throughout the facility and encourage infection control practices. She also states that her role is to develop a multi- disciplinary program. She also states that her role is to prevent spread, monitor, report exposures, and educate staff. She also stated that she was not aware of the black colored stains on the 3rd floor. She also reported that there were no increases in infections in patients who were admitted /housed in this area of the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29368 Based on observations, interviews and policy review the hospital failed to establish a process for prompt resolution of the grievances of 1 sample patient #2 out of 11 Sampled Patients . The findings include: On 7/12/2011 at 11:10am, observation of room [ROOM NUMBER], subject of this complaint investigation, revealed a black colored stain on the ceiling tile upon entering the room. Additionally, the bathroom in room [ROOM NUMBER] had 3 large, and 2 small black colored stains on the ceiling tile. On 7/12/2011 at 11:20am, interview with Sampled Patient (SP) #2 revealed that she informed the facility on 7/5/2011 of the above findings upon entry to the room days prior. On 7/12/2011 at 11:20am, Sampled Employee (SE)# 3 reports that she was aware of the conditions in room [ROOM NUMBER] and immediately reported it to her charge nurse. On 7/12/2011 at 11:30, the charge nurse of the unit confirmed she was aware of the conditions in room [ROOM NUMBER] and reported them to the maintenance department. She confirms that the maintenance department had not addressed the environmental issues on the unit to date. She reports that she does not have any documentation of her communication with the maintenance department. On 7/12/2011 at 11:56am, interview with the Supervisor of Plant Operations was done, on the 3rd floor telemetry unit. He reports that he has not been made aware of the environmental issues on this unit. He confirms that patients should not be in this area, specifically in room [ROOM NUMBER]. He was then observed to report this to the charge nurse on the unit. On 7/12/2011 at 3:54pm, SP#2 was no longer occupying room [ROOM NUMBER] and was moved to another room on the unit. On 7/13/2011 at 10:15am, interview with the Director of Plant Operations reveals that he has been made aware of the 3rd floor telemetry unit physical environmental issues. He confirms that the cause for the discoloration on the ceiling tiles on the 3rd floor is due to condensation and damp insulation. He reports that the facility had previously refurbished the 4th and 5th floors. He reports that the facility has planned to start this process on the 3rd floor in September 2011. Record review of the facility policy and procedure titled: Patient's Rights reveals that if a grievance was voiced to an employee that cannot be resolved to the patient's satisfaction will be documented in the Risk Management Module under the Patient Notification section. This will be done within 24 hours from receipt of the grievance. There was no documentation that this patient complaint/grievance was documented and handle per hospital policy.