01932 Based on interview, patient record review and a review of the Emergency Department Log, Florida EMTALA Medical Screening Examination and Stabilization and Triage Process hospital policies, and video, the hospital failed to triage on arrival and provide a medical screening exam for 1 of 20 sampled patients (Patient #3). Findings: Refer to A2406.

01932 Based on patient and staff interviews, review of hospital video, patients' Emergency Department's medical records, Emergency Department (ED) log, and hospital policies on Emergency Department Triage and Patient Flow, the hospital failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department to determine whether an emergency medical condition existed for 1 of 20 sampled patients (Patient #3). Findings: 1. EMERGENCY DEPARTMENT (ED) LOG The emergency department (ED) Log revealed that patient #3 arrived at 11:57 PM on 5/07/2022. The Disposition Category was listed as Refused Treatment. The Disposition Type was listed as Left Prior to Triage. 2. INTERVIEWS On 05/11/2022 at 8:52 AM, Patient #3 said he walked into the ED on 05/07/2022 at 11:57 PM with chief complaints of shortness of breath and a loss of consciousness after a bicycle accident near the hospital. The patient said he signed into the kiosk and waited to be triaged and get medically screened. Upon Nurse B's arrival to the desk, he went to the desk to let the staff know he had difficulty breathing. The patient said a verbal altercation occurred between Nurse B and the patient. Patient #3 said Nurse B asked security to take me [Patient #3] out of the waiting room. Patient #3 said the Security Guard then removed him from the ED waiting area. On 05/11/2022 at 2:05 PM, the Security Guard who escorted Patient #3 out of the ED stated, The nurse [Nurse B] asked me to escort him [Patient #3's name] out because she didn't want to deal with him anymore. He [Patient #3] made some remark about her [Nurse B] and that was it. On 5/11/2022 at approximately 3 PM, chart review and interviews with the Patient Safety Director and Nurse B confirmed patient #3 was removed from the ED by Security personnel and was not provided a medical screening examination within the capability of hospital's ED to determine whether an emergency medical condition existed. On 05/12/2022 at 9:30 AM, Nurse B stated Patient #3 had approached her at the desk and kept saying he had a triageable complaint. When she tried to explain the process of taking him out of the kiosk and putting him into the system so she could get him assessed, the patient began yelling at her. Nurse B said she didn't think he had a major concern because she continued to be verbally assaulted by the patient. 3. ED RECORDS Patient #3's ED chart contained documentation from Nurse B about the event. It read, Patient [Patient #3] signed into ER [ED]. As soon as I arrived to move patient information from Kiosk, patient began harassing me with his complaint of being in an accident. I replied, 'No problem, let me move you to triage and place you in a bed.' Patient sat down and then stood up again within seconds and started yelling that he had a 'triageable complaint'. I informed patient I was moving his information over, and it would take a second, but he refused and started yelling at me again stating that it is people like me that drive up the cost of medical care and he works at [named of hospital]. I called security and had the patient removed from lobby. Patient #3's medical record was requested and received on 05/18/2022 from another hospital where Patient #3 stated he went after he was denied services and removed from the ED. Diagnoses from that hospital's evaluation and treatment on 5/8/2022 at 12:27 AM included Mild left sided parietal scalp edema and Acute non-displaced fractures of the left lateral 7th and 8th ribs. On 05/12/2022 at 2 PM, Patient #3's ED chart was reviewed with the Patient Safety Director and Nurse B. Both confirmed the patient was removed from the ED by Security and was not provided a medical screening examination within the capability of hospital's ED to determine whether an emergency medical condition existed. 4. VIDEO The incident was also captured on hospital video and reviewed on 05/11/2022 at 1:24 PM and 05/13/2022 at 3:20 PM, confirming security escorted Patient #3 out of the ED with neither a medical screening examination nor provided treatment. 5. Hospital Policies A review of hospital's policy & procedure Emergency Department Triage and Patient Flow, last reviewed on 04/14/2021, read that the hospital is to provide a standard screening process that will be applied uniformly to all individuals in similar medical circumstances with the objective of the triage system to promptly identify individuals requiring immediate definitive care using the 5 level Emergency Severity Index (ESI) a triage system. This requirement is also stated in two other hospital policies Florida EMTALA Medical Screening Examination and Stabilization Policy, last approved on 04/01/2018, and Assessment & Reassessment in the ED, last approved on 08/01/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32131 Based on interview and record review, the facility failed to provide care and services to prevent the development of pressure ulcer, by failing to turn and reposition per skin and wound protocol for 1 of 10 sampled patients (#1). Findings: Patient #1 presented to the Emergency Department (ED) on 3/07/18 with a chief complaint of fever, shaking, chills, and decreased responsiveness. The Emergency Provider Report dated 3/07/18 read, Patient was seen for a checkup 2 days ago at [another medical center] .requires total care by his son, d/t [due to] diminished ambulation along with dementia. This AM the son found him lying in bed in a contorted position, acutely febrile, with diminished alertness and shallow irregular breathing. Pt (patient) was brought to ER [ED] by EMS (Emergency Medical service) as a SEPSIS alert. He is usually incontinent of urine and stool. The Focused PE (physical exam) showed the patient's skin was clammy. The Emergency Patient Record showed that patient #1's skin was warm, dry and intact. No complaints of lesions, rash, wounds, bruises, petechiae or abrasion. On 5/30/18 at 8:32 AM in a telephone interview, patient #1's relative said, when patient #1 was admitted to the hospital on 3/07/18, he did not have a pressure ulcer. On 3/14/15 he reported patient #1 was discharged home, from the hospital, at about 4 PM. Two hours later when he and the home health aide was changing the patient, he observed two open areas on the patient's buttocks. Patient #1's relative said he reported this to the risk manager at the hospital. He said the hospital did not turn and reposition patient #1 as they should, to help prevent the bed sores. The Admission/Shift assessment dated [DATE] and 3/14/18 showed that patient #1 had a generalized bruise to both his arms, and had intact skin no open areas. The Discharge Summary dated 3/14/18 did not show any documentation regarding the condition of patient #1's skin. Patient #1 was readmitted to the hospital on 3/15/18 at 10:57 AM. The Emergency Provider Report dated 3/15/18 read, Patient was discharged yesterday from this facility with a week long stay for altered mental status and sepsis, and presents today sent from home by the son for new bed sores on his buttocks patient states that was not there before his admission On the right buttock is a stage II decubitus with a brawning of the left posterior buttocks. Review of documentation for positioning for the period 3/09/18-3/14/18 showed that patient #1 was turned and repositioned (T/R) on the following dates/times: 3/09/18 at 5:48 AM, 8:10 AM, 10 AM, and 1:41 PM; 3/10/18: none; 3/11/18 at 3:19 PM and 8:25 PM; 3/12/18 at 6:07 PM; 3/13/18 at 11:59 AM and 10:38 PM; and 3/14/18 at 10:37 AM. For the period 3/07-13/18: Positioning aids were not documented from 3/07-11/18, and on 3/13/18. On 3/12/18, Present/Exists was documented in the medical record. On 5/30/18 at 2:44 PM, the Cardio/neuro 3W/PCU (progressive care unit) manager said, patient #1 was admitted to her units on both admission 3/07/18 and 3/15/18. His first admission was to 3W, and the second admission was to the PCU. She said wounds were discussed with the interdisciplinary team daily, but wounds did not come up for pateint #1 until his readmission on 3/15/18. The manager said she could not say that patient #1's pressure ulcer happened at the hospital during his first admission, since the facility did not have documentation regarding the patient's buttocks on admission, and proper documentation was not done throughout the patient's hospital stay. The activity form for turning and repositioning (T/R) was reviewed with the manager who verified that documentation showed that patient #1 was not turned and repositioned every two hours as per hopsital protocol. The Policy and Procedure Skin and Wound Care Policy effective 5/16/2017, read, To provide guidelines that promote continuity of care as it relates to the prevention and management of a patient at-risk for development of pressure injuries A skin assessment will be performed for each patient on admission, on every shift, on transfer to a different unit Assessment for moisture induced irritation, maceration, or denudement are included in the skin assessment and reassessment process Assessment/reassessment of the integumentary system is done daily and every shift if a wound is present The patient is turned at least every 2 hours and more frequently if necessary Patients on any type of specialty mattress must be turned every 2 hours unless documented as medically contraindicated Heels are suspended off the bed surface The skin is inspected and any devices removed every shift and as needed for pressure areas and findings are documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32131 Based on interview and clinical record review, the facility failed to monitor and accurately document turning and repositioning to prevent the development of pressure ulcers for 1 of 10 sampled patients (#1). Findings: Patient #1 presented to the Emergency Department (ED) on 3/07/18 with a chief complaint of fever, shaking, chills, and decreased responsiveness. The Emergency Provider Report dated 3/07/18 read, Patient was seen for a checkup 2 days ago at the [another medical center]. He requires total care by his son, d/t (due to) diminished ambulation along with dementia. This AM the son found him lying in bed in a contorted position, acutely febrile, with diminished alertness and shallow irregular breathing. Pt (patient) was brought to ER(emergency room ) by EMS (Emergency Medical Services) as a SEPSIS alert. He is usually incontinent of urine and stool. The Focused PE (physical exam) showed the patient's skin was clammy. The Emergency patient record showed that patient #1's skin was warm, dry and intact. No complaints of lesions, rash, wounds, bruises, petechiae or abrasion. The Admission/Shift assessment dated [DATE] and 3/14/18 documented generalized bruise to bilateral arm and intact skin no open areas. The Activity form for turning and repositioning (T/R) from 3/09/18-3/14/18 showed the following: Patient #1 was T/R on 3/09/18 x 4 at 5:48 AM, 8:10 AM, 10 AM, and 1:41 PM, 3/10/18 x 0, 3/11/18 x 2 at 3:19 PM, and 8:25 PM, 3/12/18 x 1 at 6:07 PM, 3/13/18 x 2 at 11:59 AM, and 10:38 PM and on 3/14/18 x 1 at 10:37 AM . On 5/30/18 at 2:44 PM the Cardio/neuro 3W/PCU (Progressive Care Unit) manager said, patient #1 was admitted to her units on both admission 3/07/18 and 3/15/18. His first admission was to 3W, and the second admission was to the PCU. The manager said daily shift assessments done by the nurses,covered skin assessment, and T/R was shared between the nurse and the nurse tech, and documented in the patient's electronic chart. The activity form for T/R was reviewed with the manager who verified that documentation was not done every two hours per protocol. The manager said she would hope for better documentation on a bedridden patient. The manager said the facility's expectation was that documentation for T/R should be completed every two hours, and in review there were some missed documentation, and a lot of missed opportunity for proper documentation and proper implementation of a T/R schedule for patient # 1. She said nothing was documented on the patient's first admission, and very little was documented during his first hospital stay. The Cardio/neuro 3W/PCU manager said she could not say that patient #1's pressure ulcer happened at the hospital during his first admission,since the facility did not have documentation regarding the patient's buttocks on admission and no proper documentation throughout the patient's hospital stay. She verbalized that both nurses and nurse techs did not document per protocol. On 5/30/18 at 3:05 PM, the chief nursing officer (CNO) said the facility recognized there was needed improvement on documentation, and assessment. She said the nurses and nurse techs did not document per protocol, so the facility did not know what patient #1's skin was like on his first hospital admission. The CNO said there was no documentation to support intact skin, or the presence of any skin breakdown. The Policy and Procedure Skin and Wound Care Policy effective 5/16/17, read, To provide guidelines that promote continuity of care as it relates to the prevention and management of a patient at-risk for development of pressure injuries A skin assessment will be performed for each patient on admission, on every shift, on transfer to a different unit Assessment for moisture induced irritation, maceration, or denudement are included in the skin assessment and reassessment process Assessment/reassessment of the integumentary system is done daily and every shift if a wound is present Findings are documented in the patient's medical record per documentation guidelines

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13640 Based on interview and record review, the facility failed to ensure a nursing care plan in compliance with hospital policy for a patient with documented skin tears and pressure sores for 1 of 10 sampled patients (#1). Findings: Patient #1's medical record revealed the patient was seen in the emergency roiagnom on [DATE] and admitted to the 3 East unit on 2/22/17 at 3:01 AM. The Wound/Ulcer Evaluation, dated 2/22/17 at 2:30 AM, read, Tear-left buttocks. Non-open Open to air. This site and type of wound (tear) was mentioned in other shift notes on subsequent days during the patient's stay, until there was classification of this site as a stage II pressure sore on 2/27/17. On 2/24/17 at 3:35 PM, the Wound/Ulcer Evaluation read, Location: RU (right upper) posterior back. Wound eval: open transparent dressing. This was the first mention of a wound at this location. Regarding the steps to take upon discovery of a skin tear, a review of facility policy Skin and Wound Care Policy read, Within 24 hours of discovery and identification of skin tears . the registered nurse will obtain the 'Skin Tear, Abrasion and Perineal Dermatitis Treatment Order' form . and notify the physician. The nurse will (2) review the treatment outlined in the form that corresponds to the appropriate type of skin alteration with the physician, (3) mark any changes indicated by the physician, and (4) either obtains signature or telephone/read back signature. It is the intent that the physician review and indicate treatment within 24 hours. A review of the medical record did not reveal any evidence that these steps were followed with respect to the two skin tear entries, and with any of the other subsequent record entries which continued to indicate the presence of a skin tear either on the buttocks or on the upper back. Although the above entry regarding the left buttocks skin tear site revealed an initial approach to keep the site open, and later entries concerning the site indicated the use of a dressing, there was no evidence in the record at any other point in the patient's stay that either of these approaches were instituted as a result of physician contact which lead to an order, as specified in policy. Also, although the above entry and later entries regarding the upper back skin tear revealed an approach to apply a dressing, there was no evidence in the record at any point in the patient's stay that this approach was instituted as a result of physician contact which lead to an order, as specified in policy. A nurse's note on 2/27/17 at 6:15 AM read, (The patient) has stage 2 center buttocks This was the first and only entry in the record which classified the buttocks wound site as a stage II pressure sore. The next wound entry in the medical record, on 2/27/17 at 8 AM, again classified it as a skin tear. Until 2/27/16 at 6:15 AM, there was no explanation in the medical record regarding this classification from pressure sore on the back to a skin tear. There was no statement which indicated that the preceding 2/27/17 at 6:15 AM entry was in error. The hospital's Skin and Wound Care Policy read, The physician is notified immediately upon suspicion of a developing pressure ulcer/or confirmation of the presence of a pressure ulcer The Wound Care Nurse is also notified for recommendations for further interventions and changes to be made to patient treatment plan Assessment and Documentation of Pressure Ulcers and Wounds Measurements are to include length X (by) width X depth in centimeters The condition of the surrounding skin and wound edges is noted. The color of the wound bed is noted and the percentage described using colors The presence of exudate is noted. The findings are documented on the nursing assessment and the physician notified of the findings. There was no evidence in the record that any of these steps were taken upon the documentation of the presence of a pressure sore. The hospital's Skin and Wound Care Policy also read, Orders need to be obtained for post-hospital care for the treatment of any ulceration that remains open. These orders are to be indicated on discharge instructions for the patient. There were no such instructions in the medical record for the patient's two wound sites. The policy was not followed. During an interview of the Risk Manager at approximately 5:45 PM on 5/03/17, she confirmed the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13640 Based on interview, record review, video review and a review of facility documentation, the facility failed to ensure that personnel who complied with facility policy for outpatient admission were available to presenting patients where outpatient services are offered for 1 of 21 sample patients (#21). Findings: An interview was performed with the Patient Liaison of the Outpatient Registration department at 10:33 AM on 3/13/17. During the interview, she stated that when a patient arrives in her area and presents a prescription, she checks to see if it is valid. She stated that when she checks a prescription, she looks for the following: the presence of a full name; an order date that is not more than six months old; the name of the procedure or test; the diagnosis; the presence of wording such as rule out or history of (which they cannot accept); and the presence of a practitioner signature (no stamp pad signatures). She stated that she may also ask what type of insurance would be used. She stated that if everything is in order, she would place the patient on the computer tracker and indicate whether or not the patient was a walk-in or an appointment. After this, the patient would be asked to have a seat and await a call by the patient Registrar. During the interview, the Patient Liaison was asked if she recalled any recent presentations by a pregnant woman in which there was some confusion or discrepancy regarding orders they might have put forth. She indicated that a patient of Dr. A, patient #21, had presented with an order for lab work on 3/08/17. She stated that after learning the name of the patient's insurance provider, she told the woman that they could not accept her insurance. She then told her that she could go to the nearby [NAME] or LabCorp to get the labs drawn. She stated that since the patient could not be accepted for lab work, she was not entered into the computer. She stated that the patient then left the facility. The facility produced a copy of an e-mail which was sent by the Patient Liaison to the Director of Patient Access and the Manager of Patient Access on 3/10/17. It read: I had three expectant mothers come to my desk on the same day (3/08/17) I do not remember names, it was very busy, however I do remember it was a (Dr. A) patient with . insurance the patient told me she was here for labs, and to my knowledge, the paperwork given to me was for labs. I also asked (patient registration staff member) or (patient registration staff member) could we accept orders for labs, not NSTs (non-stress test). I did so because I wanted confirmation with someone who handles insurance more than me because of the daily charges that occur with insurances. Regarding the statement in the e-mail of the paperwork not having an order for a NST, an interview with the Manager of Patient Access was performed on 3/13/17 at 12:01 PM. At this time, the name of the patient to which they were referring was patient #21. She stated that the office manager of this patient's physician had called her in the afternoon of 3/08/17 and inquired about what happened when the patient presented to the hospital. The Manager of Patient Access stated that the office manager told her that the patient had been given two prescriptions, one for labs and one for a NST. The Manager for Patient Access stated in the Patient Liaison's e-mail that only a prescription for labs was presented by the patient. The text of the above mentioned e-mail continued with further clarification of the previously quoted e-mail text which mentioned NST. It read, I did not see NST on the order. I also am aware that NSTs can go to L&D (Labor & Delivery). I am not sure how I could have missed that, as I see them often I gave her a printout with LabCorp, and [NAME] on it so she could be seen that day An observation of security camera footage which covered the Outpatient Registration desk was performed on 3/13/17 at approximately 1:22 PM. The video revealed the presentation of the woman as described (and confirmed) by the Patient Liaison at approximately 1:55 PM on 3/13/17. The video showed the following for 3/08/17: the patient walked in at 2:38 PM, interacted with the Patient Liaison at 2:40 PM, and handed a paper to the Patient Liaison at 2:40 PM. Between this time and patient #21's departure, the Patient Liaison was seen moving various papers around and using the telephone. At 2:44 PM, the Patient Liaison gives the woman a paper. At 2:45 PM, she gives the woman another paper, and then the woman goes out the door. At 1:55 PM on 3/13/17, the Patient Liaison stated she could not recall why there was movement of papers. On 3/13/17 at 2:10 PM, the Manager of Patient Access said during the course of this survey, the physician's office had sent over copies of the prescriptions which had been sent with patient #21. One prescription read, 24 urine protein collection. Dx: swelling in extremities and the other read, CBC (complete blood count), CMP (Comprehensive Metabolic Panel), Uric Acid, BPP (Biophysical Profile), Lipase. Dx (diagnosis): Biliary colic. Swelling in extremities. On 3/13/17 at 3:14 PM, the Director of Patient Access stated it was the job of the registrar to make inquiries as to the patient's insurance status, to determine what would be covered. A review of the Registrar's job description read, Verify all insurance and obtain pre-certification/authorization. On 3/14/17 at 11:41 PM, the Director of Patient Access stated this means the Registrar checks the patient's insurance to see if orders for tests and lab work would be covered. There was no evidence that Patient Liaison had mentioned a non-lab Biophysical Profile test which was also on the prescription. As a result, the patient was not afforded a review of her prescriptions by designated employees who would have seen that more than labs were actually involved, the Biophysical Profile, and subsequently pursue at least this aspect of the physician's desired evaluation of the patient. On 3/14/17 at 11:18 AM, the Risk Manager stated when patient #21 was at the hospital, the Patient Liaison called one of the Registrars to seek clarification regarding insurance for labs. The telephone call inquiry by the Patient Liaison dealt solely with labs, not any diagnostic testing. On 3/14/17 at 2 PM, the Risk Manager stated that if the Registrar had evaluated the prescription for the Biophysical Profile, the facility would not have pursued the implementation of this test for the patient, due to the incompatible insurance. Instead, the patient would have been told of the non-coverage and tell her where the test could be performed with her insurance. The patient would also have been told of the option to self-pay in the facility. Since none of this occurred, the patient was deprived of the ability to pursue a diagnostic evaluation. During an interview of the Risk Manager at approximately 3:30 PM on 3/14/17, she confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21084 Based on interview, record review and review of facility policies, the facility failed to assure 2 of 10 sampled patients received physician care services in a timely fashion (#1 & 2). Findings: 1. Patient #1's record revealed the patient was transferred via emergency services to the hospital emergency department (ED) on 2/18/17 at 5:49 PM. Diagnosis included upper gastro-intestinal (GI) hemorrhage. The record documented ED physician ordered a consultation for a gastroenterologist (physician B) for GI bleed on 2/18/17 at 6:41 PM. Documentation read physician B's GI consultant service was notified at 6:41 PM, and a recipient name was documented. There was no documentation regarding the response time of physician B, the GI consultant. An intensive care unit (ICU) nurse's note, dated 2/19/17 at 5:10 AM read, 2/18/17 at 10 PM, call placed to (physician B) to report patient's admission and bloody emesis/stool. A nurse's note, dated 2/18/17 at 10:30 PM, indicated a call was placed to intensivist physician C, and No call returned from (physician B). Second call placed. A nurse note on 2/19/17 at 5:14 AM read, 11 PM - Call returned from Dr. (physician B). Condition update given. Orders received, entered and followed. Review of the hospital policy On-Call Responsibilities, revised 3/05/14, read, When an on-call physician is requested to respond by the Emergency Department Physician, the physician must: (a) Be immediately available by telephone, to the Emergency Department; and (b) Respond in person, if so requested, within a reasonable time period. Generally, response is expected within 30 minutes. The Emergency Department physician, in consultation with the on-call physician, will determine whether the patient's condition requires the on-call physician to see the patient as soon as possible (d) Documentation of the time the call is placed at the request of the ED physician and the time the call is returned will be documented in the medical record and the telephone contact log in order to confirm response timeliness. On 2/18/17, the ED telephone contact log for patient #1 indicated one consultation for the hospitalist. There was no documentation on the contact log for the gastroenterologist for patient #1. On 2/28/17 at 3:15 PM, the director of the Emergency Services and the Risk Manager revealed the contact log was not completed per hospital policy, and did not contain the ordered GI consultation for patient #1. A nurse's note read on 2/19/17 at 7:36 AM, STAT call placed to Dr. (intensivist) regarding Pt. (patient's) SBP (systolic blood pressure) 60s. Will await call back. At 7:45 AM, a nurse's not read, Addendum: 2/19/17 at 7:56 AM 'Will continue current regimen'. The next concurrent nurse note on 2/19/17 at 7:45 AM read, Spoke with Dr. (intensivist, physician C) regarding pt. status. She will be here to assess pt. soon. No new orders. Will continue to monitor. Review of the hospital policy ICU Physician Staffing (IPS) Standard Revision Date: 8/29/16, second page documented Protocol: To fulfill the IPS standard (hospital name) will operate our critical care units as followed: a. All patients in the ICUs with the exception of the patients being cared for by the cardiologists for the conditions or procedures defined, are managed or co-managed by one or more physicians who are critical care intensivists. b. Intensivists are present during daytime hours to provide clinical care exclusively to the ICUs. c. When not present on-site or via telemedicine, intensivist returns pages for emergent changes in patient condition, at least 95% of the time, within five minutes Attachment A included documentation of: Homodynamic - Acute change in systolic blood pressure to <90 mm Hg. heart rate to <40/min or 150/min. Documentation in the nurse notes revealed the intensivist was called at 7:36 AM, and the call returned by the intensivist at 7:45 AM. 2. Record review revealed patient #2 went to the ED with a chief complaint of profuse vomiting, was admitted to the hospital, and received diagnostic care and services. The ED record documented a gastroenterologist (physician B) consultation order for patient #1, dated 2/21/17 at 11:02 AM. The order was classified as a routine consultation. The record indicted the consultation was called to physician B's office at 11:11 AM on 2/21/17. A nurse's note on 2/21/17 at 8:30 PM read, pt HR (heart rate) elevated throughout day, only symptom of C/O (complained of) nausea reported by pt. PRN (as needed) Zofran and Lopressor IV (intravenous) given per order protocol. (Physician B) and (3 other physicians) have all been verbally informed of patient status and arrythmias There was no documentation in the patient's record that the physician B's GI consultation was completed, and documentation was not found in the patient's record form physician B. The record reflected the patient was discharged on [DATE] to an area nursing facility without any written documentation from physician B. Review of the hospital Rules and Regulations read, Any qualified practitioner with clinical privileges in this hospital can be called by the attending physician for consultation within his/her area of expertise. Consultations shall be completed within twenty-four (24) hours from the time the consultant is notified or otherwise specified. STAT (immediate) consult requests must be called physician to physician if immediate surgical evaluation is needed. #8. Response Time Definitions: 1) Routine - 24 hours 2) Urgent - 4 hours 3) STAT - 30 minutes On 2/28/17 at 10:30 AM, the Risk Manager confirmed there was no documentation found that physician B's GI consultation was completed prior to the patient's discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21084 Based on record review, interview and review of facility policy, the facility failed to reassess discharge plans for 1 of 7 sampled patient records reviewed for appropriate and safe discharge plans (#1). Findings: Review of hospital policy Patient Discharge read, To assure timely discharge of patients, the charge nurse is responsible to monitor the progress of the discharge process until the patient has been discharged from the room Patient #1 was admitted to the hospital's intensive care unit on 9/29/15. The record documented the patient was discharged to her home on 10/17/15 with a peripherally inserted central catheter (PICC) line. The patient had a history of drug abuse. A case management note dated 10/15/15 read, Spoke to (name of family member), she agrees with (name of SNF), will wait for available bed tomorrow or Saturday per (name of facility representative). A case management note dated 10/16/15 read, no d/c today A physician order dated 10/17/15 to discharged the patient from the hospital. A Discharge Instruction form dated 10/17/15 revealed a destination of Home. Page 2 of the Discharge instructions revealed a handwritten additional note which read, I will not use the PICC line to use An illegible signature was written next to the entry. Documentation in the medical record revealed the following case management notes: 10/18/15 Late entry for 10/17/15 - Received an unconditional discharge order. Pt had evidently asked to be discharged home. Pt. had been scheduled to go to (SNF). I did not receive a call or inquiry from nursing or physician. Pt was discharged home with her aunt at her request I received a call from pt's. aunt inquiring about pt's. (patient's) PICC line which pt. was discharged home with it in place. She was asking if pt. was to receive IVAB (intravenous antibiotics). Further documentation related the case manager contacted the patient's nurse to inquire of the patient's discharged medications and no intravenous medications were written for the patient. No IVAB ordered. Requested the nurse to call the patient 10/17/15 at 6 PM. 10/18/15 AT 2:55 PM, Contacted the director of the 3rd floor to assist in patient's return to the hospital from home. Patient # 1 was readmitted to the hospital on 10/19/15 and again discharged on [DATE] to an area skilled nursing facility (SNF) with the PICC line for IVAB administration. On 11/16/15 at 2:40 PM, the third floor charge nurse revealed the on-call physician came in and wrote an unconditional discharge for the patient and she went home with her PICC line. He related the patient's nurse was an agency nurse and it was her first time on the floor. He related the nurse filled out and went over the patient's discharge instructions with the patient. On 11/16/15 at 3:10 PM, the director of case management related there were 4 or 5 case mangers in the hospital over the 10/17/15 weekend. However, they respond to physician orders and do not routinely check on current patients unless they get a call. She related patient #1's discharge plan was for the patient to be transferred to a SNF for continued IVAB and not to be discharged home. At 12:05 PM on 11/16/15, the risk manager specialist revealed she had received a telephone call from the patient's mother on 10/21/15 due to her concern that the hospital sent the patient home with a PICC line and she had a history of drug abuse. The risk management specialist documented the complaint and the facility investigated the incident. On 11/16/15 at 5:05 PM, the risk manager and the vice president of quality revealed the facility had investigated the incident, had returned the patient to the hospital and then discharged the patient to a SNF.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13640 Based on interview and record review, the facility failed to ensure that nursing care in the form of a sitter was assigned in accordance with the patient's needs as defined by physician orders for a sitter for 1 of 10 sampled patients (#1). Findings: A review of the medical record of patient #1 was performed. The patient was admitted to the facility on [DATE]. A physician ordered a sitter on 2/13/14 at 3:19 PM. Regarding the basis for assigning a sitter, there was no specific mention in the medical record by the physician of a justification for it through the point of discharge. However, the Discharge Summary, dictated on 3/23/13 at 3:09 PM read, he was not stable enough on the gait; so apparently, he was at high risk for falls, so he had a sitter in the room all the time A nurse's note of 2/13/14 at 5:15 PM read, Pt (patient) sitter at the bedside A nurse's note of 2/13/14 at 8 PM read, Pt very restless and combative-hitting, kicking and spitting. Code Gray was called. A nurse's note of 2/14/14 at 10:51 PM read, Sitter at bedside. A nurse's note of 2/16/14 at 8 AM read, Pt has sitter at bedside A nurse's note of 2/17/14 at 7:04 PM read, Pt was combative and uncooperative much of the day Continued to be combative and uncooperative Per interview of the Director of Critical 3/31/14 at 3:10 PM, this was a day shift (7 AM-7 PM) nurse. The Director of Critical Care confirmed in an interview on 3/31/14 at 3:10 PM that there was no sitter available on the 7 PM-7 AM shift (2/17/14 into 2/18/14); therefore, the patient was moved at the beginning of this shift to room [ROOM NUMBER], which was very close to the nurse's station. She stated that there was no cancellation of the sitter order. Placement by the nurse's station is considered as an option to provide increased patient visibility over placement in a room which is away from the nurse's station. However, during an interview of the Risk Manager on 2/01/14 at 12:44 PM, she agreed that placement by a nurse's station (without a sitter) cannot ensure the same non-stop visibility as possible with a sitter. A fall risk assessment of 2/17/14 at 8 PM read, Is patient following fall prevention directions: N (no) Pt is confused and consistently asking or attempting to get OOB (out of bed). Presently place in soft wrist restraints to prevent self injury. High risk for falls: Y. It then listed various fall prevention approaches which excluded mention of a sitter. It also read, Plan to initiate sitter for pt. This last note indicated that the nurse perceived a need for a sitter. As indicated above, no sitter was available during this shift During the above interview of the Risk Manager on 3/31/14 at 2:55 PM, she stated that the patient had a fall in the evening of 2/17/14. A nurse's note of 2/18/14 at 12:10 AM read, Pt. fell climbing OOB (out of bed). Dr made aware of laceration to right eyebrow and that steri strips were applied. He asked was the patient complaining of any pain. I 'said no'. He then said to observe him throughout the night. No orders at this time. An interview was conducted with the Director of Critical Care on 4/01/14 at 2:40 PM concurrent with an interview of the Risk Manager. She stated that staff learned of the fall when an alarm sounded and that staff could not get there quick enough. She confirmed that there was no evidence that a nursing assessment was performed prior to removal from a sitter. She stated that the patient needed someone to be with him during the evening shift of 2/17/14 to help keep him in bed. Thus, a physician had ordered the use of a sitter on 2/13/14. A physician had associated this measure with fall prevention. This order was not canceled as of 2/17/14. The patient was deemed at a high risk of falls at the beginning of the evening shift on 2/17/14. The facility removed the patient from sitter coverage on the shift commencing at 7 PM, due to staffing concerns. A nursing assessment was not performed with respect to this sitter removal. This left the patient who had a high risk of falls and the behavior of constantly attempting to get out of bed with a room assignment which afforded reduced observation by staff. The patient subsequently experienced a fall with injury. During an interview of the Risk Manager on 4/01/14 at 5:45 PM, she confirmed the findings.

13640 Based on interview, record review and a review of facility documentation, the facility failed to ensure that policies and procedures governing medical care provided in the emergency department in the form of timely responses by on-call physicians were followed for 1 of 10 sampled patients (#1). Findings: A review of the medical record of patient #1 was performed. The patient was admitted to the emergency room (ER) on 12/27/13 at 10:43 PM. A nurse's note at this time read, Pt (patient) reports 14 weeks preg (pregnant) with vag (vaginal) bleed X 1 week. Bleed became heavy today with clots blood soaked towels. The ER physician saw the patient at 9:51 PM on 12/27/13. A nurse's note of 12/28/13 at 12:52 AM read, Spoke with (nursing supervisor) regarding 4 calls over 1.5 hours trying to reach on-call OB (Obstetrician). Dr .after hanging up with (nursing supervisor), Dr. (Obstetrician) returned call at this time and is now on the phone with Dr. (ER physician) for consult. Thus, the nurse reported to the nursing supervisor that it took 90 minutes to contact the physician. A physician note of 12/28/13 at 3:22 AM read, Consultant called: OB/GYN (Obstetrics/Gynecology). Requested call time: 11:40 PM. Requested call date: 12/27/13. Call returned time: 12:55 AM. Call returned date: 12/28/13. Thus, the physician noted a response of 75 minutes minutes later. A review of the ED Physician Call Log revealed that the first call to the OB/GYN was placed at 11:18 PM on 12/27/13 and was answered at 12:54 AM on 12/28/13, a duration of approximately 90 minutes. A review of the Emergency On Call Schedule revealed that the on-call obstetrician, as written, was the one who was on-call for OB/GYN (Obstetrics/Gynecology) on 12/27/13. A review of hospital's policy EMTALA -Florida Provision of On-Call Coverage Policy read, The hospital has a process to ensure that when a physician is identified as being 'on-call' to the DED (dedicated emergency department) for a given specialty, it shall be that physician's duty and responsibility to assure the following: Immediate availability, at least by telephone, to the DED physician for his or her scheduled 'on-call' period, or to secure a qualified alternate if appropriate. Arrival or response to the DED within a reasonable timeframe (generally, response by the physician is expected within 30 minutes.) Since the on-call physician had not responded within the thirty minute time frame, he was in violation of this policy. During an interview of the Risk Manager at 2:15 PM on 2/20/14, she confirmed the findings.

13640 Based on interview, record review and a review of facility documentation, the facility failed to ensure the enforcement of bylaws which required the entry of an Operative Note in the medical record following surgeries for 1 of 10 sampled patients (#1). Findings: A review of the medical record of patient #1 was performed. A physician note of 4/08/13 at 7:52 AM read, Going for surgery today morning. A physician's note dictated on 4/08/13 at 3:27 PM read, Patient going for surgery for thoracic outlet syndrome. A Brief Op/Inv Procedure Note, dictated on 4/08/13 at 10:12 PM, indicated that the patient underwent a 1st and cervical rib resection, neurolysis that day. Regarding this note for the 4/08/13 procedure, the medical record did not contain a corresponding more detailed Operative Report. A review of facility bylaws revealed the following: Operative reports shall be dictated or written immediately following surgery for outpatients as well as inpatients. The operative report shall include the name of the licensed, independent practitioner(s) who performed the procedure and his or her assistant(s); the name of the procedure performed; a description of the procedures; a detailed description of the findings of the procedure; any estimated blood loss; the specimens removed, the postoperative diagnosis. The completed operative report is authenticated by the surgeon and filed in medical records as soon as possible after surgery. The operative report should be dictated within twenty-four hours after a procedure is performed. During an interview of the director of nursing on 5/29/13 at approximately 2:15 PM, she confirmed the finding that the surgeon was not in compliance with the bylaws.

13640 Based on interview, the facility failed to ensure the confidentiality of patient records sent with police officers during a patient discharge for 1 of 30 sampled patients (#21). Findings: During an interview of the Risk Manager on 3/15/13 at 12:30 PM, she stated that after patient #1 left, the Chief Operating Officer (COO) spoke to the emergency room physician at South Seminole Hospital. During this conversation, it was learned that a nurse had sent information from the medical record which belonged to patient #21. During an interview with the COO at 3 PM on 3/15/13, he confirmed that incorrect paperwork had been sent with the police. During an interview of the Risk Manager on 3/15/13 at 4:15 PM, she confirmed the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13640 Based on interview and record review, the facility failed to ensure the direct transfer of patients and medical information to appropriate healthcare facilities for follow-up or ancillary care in the form of psychiatric services for 1 of 30 sampled patients (#1). Findings: A review of the medical record of patient #1 was performed. A nurse's note indicating occurrence at 9:14 AM on 2/28/13 read, Pt (patient) arrived EMS (Emergency Medical Services) The patient was Baker Acted on 2/28/13 at 10 AM (per the Certificate of Professional Initiating Involuntary Examination). An emergency room physician note indicated that hospitalist physician #A returned his call at 11:55 AM on 2/28/13. He wrote, Will see patient, agrees with eval, accepts admit. Physician #A admitted the patient at 12:10 PM on 2/28/13 for medication overdose. Physician's order at this time read, Admission .overdosage. The History and Physical, dictated on 2/28/13 at 10:55 PM by physician #A read, We will need psychiatric input. Possible discharge to an inpatient facility when medically cleared. Physician #A's note signed at 12:57 PM on 3/01/13 read, Plan: Pt. medically clear for dc (discharge) to inpatient psych facility. Non HOME candidate. Physician #A's order on 3/01/13 at 2:31 PM read, D/C (discharge) plan Elec (electronic) med (medication) rec (reconciliation) done. Physician #A's order on 3/1/13 at 2:34 PM read, Discharge pt. The Discharge Summary dictated on 3/04/13 at 7 AM by physician #B, read, After he was medically cleared I explained to the case managers and nursing staff that the patient should be discharged to a Psych Facility. Dr. (#C) from Psychiatry agreed with this as well. Case Management notes beginning on 3/01/13 at 5:59 PM, where efforts to secure a psychiatric facility transfer were documented, confirm an understanding of the physician's intention for discharge as mentioned in the Discharge Summary. Psychiatrist #C's note on 3/01/13 at 11:16 PM read, Diagnosis, Assessment & Plan . Discharge planning: to psych, inpatient. Physician orders on 3/01/13 at 11:18 PM were for Ativan (Lorazepam) 2 mg (milligrams). A nurse's note on 3/02/13 at 3 AM mentioned that the patient had become highly combative to the point that restraints were applied and the medication Geodon was ordered to be given. Up to the time of this preceding note, and throughout the patient's entire stay, there was never a cancellation of the discharge order for a psychiatric facility of 3/01/13. However, the preceding report of combative patient behavior was followed by handwritten physician orders by physician #B on 3/02/13 at 5:59 AM which altered this understanding significantly, for it added a condition to continuing transfer attempts. It read, If pt continues to be combative, D/C (discharge) to Police Dept. Physician #B's orders on 3/02/13 at 7 AM also read, If pt continues to be combative OK to discharge to police department. The nature of these 3/02/13 orders, which would be implemented if a behavior is exhibited, allowed the patient to stay in the facility if he was not combative, while efforts to secure a psychiatric facility discharge/transfer to obtain physician-mandated mental health treatment would move forward simultaneously. If, however, the patient was combative, the psychiatric facility discharge/transfer attempts under the orders of 3/01/13 would essentially be ignored per the new 3/02/13 orders. There was no assertion in the medical record at the time of this 3/02/13 order or at any later time that the patient was no longer in need of psychiatric treatment by a psychiatric facility. In fact, later text reveals that this need was still perceived by physicians. This meant that the patient still had not addressed or unresolved psychiatric treatment needs which required further treatment and they would actually not abate if a specified behavior was exhibited. The effect of these orders, when they were issued, was that on any unknown future date after their issuance, the patient could be automatically discharged to a non-medical entity without a physician being apprised. Physician #B's note on 3/02/13 at 7:18 AM read, The patient had become very violent breaking things and swinging a walker and trying to break windows I explained to the nurse supervisor that she needed to call the police if she believed that she and other nurses were in danger Plan Pt medically clear for dc (discharge) to inpatient psych facility. Non HOME candidate. Need to d/c to crisis center as soon as possible. A nurse's note indicating occurrence on 3/02/13 at 11:09 PM read, (psychiatrist #C) here, visits with pt and his father, medications increased. Pt took extra meds without difficulty. Psychiatrist #C's note on 3/02/13 at 10:47 PM read, . plan increase Seroquel to 200 mg q hs (bedtime). The record revealed that for much of 3/02/13, there were continued unsuccessful attempts to transfer the patient to a psych facility. Physician orders of 3/02/13 at 11:30 PM read, Zyprexa 5 mg IM (intramuscular) prn (as needed) q8hr (every eight hours) prn agitation. Physician orders were issued at 11:23 PM on 3/2/13 for STAT (urgent) Zyprexa at 10 mg PO (by mouth). Physician orders for Lorazepam inj (injection) 2 mg (milligrams)/1 ml (milliliter) vial (2 mg.) were issued at 1:32 AM on 3/03/13 (not given). Seroquel was given at 10:53 PM (again, an increased dose) on 3/02/13; PO Zyprexa was administered at 11:39 PM (the first time this medication was given). Lorazepam was administered at 3/02/13 at 10:17 PM (per the 3/1/12 orders) and also at 1:41 AM on 3/03/13 (per the orders of 1:32 AM on 3/03/13; the first time this medication was given at a close interval). The Lorazepam injection under the orders of 1:32 AM on 3/03/13 was given at 1:41 AM. Later text reveals that most of these medications were administered just a short time before the patient's departure (2:09 PM on 3/03/13). A nurse's note indicating occurrence on 3/03/13 at 2:41 AM (after the patient discharge at 2:09 AM, see below) read, 12:00 AM - Pt (patient) given Lorazepam, Seroquel, Zyprexa to calm him (see administration times, above). Not effective. Pt's father at bedside, safety sitter, hospital security also at bedside holding pt to keep from harming himself. Soft wrist restraints on bil (bilateral) wrists to keep pt from harming himself. Dr. had already medically cleared pt yesterday (it was actually on 3/01/13 at 12:57 PM). Pt not reacting to meds and is extremely violent. [NAME] Police called to help with violent pt who is discharged . During an interview of physician #B on 3/15/13 at 12:15 PM, he concurred that the patient was in need of treatment at a psychiatric facility throughout his entire stay. A review of a Security report revealed that the patient was violent and combative on 3/02/12 at 12:55 a.m. It read, Patient was discharged over to SPD ([NAME] Police Department). Patient was transported. The officer who wrote this report returned to his office at 2 PM. A handwritten note from [NAME] Police Department by a police officer, written at 2:06 AM on 3/03/13 read, (Patient #1) was discharged to the [NAME] Police Department, and it was our decision to take (patient #1) to South Seminole Hospital. Discharge Instructions were printed on 3/03/13 at 2:09 AM read, Discharge to police custody A nurse's note indicating occurrence on 3/03/13 at 2:46 AM read, 2:17 AM - Pt discharged to his father and [NAME] Police due to violence and him not being able to be handled by his parents at home. There was no mention in this note of any post-facility treatment needs, despite the fact that the physicians had continuously voiced a need (see prior text) for the patient to be transferred to a psychiatric facility for further treatment. Although the patient had combative behavior and had received new and increased dose medications just prior to departure, there was no evidence in the record of the physician having been notified of this automatic discharge at or before the time it took place and provided an opportunity to attest to whether medical stability still existed or issue any final orders if deemed necessary. There was no evidence in the medical record of pertinent documents from the medical record having been sent along with the patient at the time he departed the facility. There was no evidence of any consideration of the possible effect, while in police custody, of the new or increased dose medications which the patient was provided just prior to discharge. There was no evidence of any assurance being provided to the facility that the patient would have readily available medical attention (as found in health care transport), should a need arise, during the interim between his departure and any eventual acceptance into another health care facility. Since the police were not health care providers and there was no accepting facility, the standard practice of providing a report could not be effected. Through the implementation of the 3/02/13 order, the stated intent of the 3/01/13 order (discharge to a facility, not the police) was violated. This was an order which even the physician who entered the 3/02/13 order asserted on the same day as being in force. The Discharge Summary on 3/04/13 at 7 AM by physician #B read, Disposition: The patient was discharged to the care of the [NAME] Police Department. After he was medically cleared, I explained to the case managers and nursing staff that the patient should be discharged to a Psych Facility. Psychiatrist #C agreed with this as well On hospital day 3, the patient became unruly again, and police were called. They came and evaluated the patient, and took him to the South Seminole. In summary, orders of 3/01/13 for a direct transfer of a patient and their corresponding medical information to a healthcare facility, through healthcare transport, was not effected as a result of the orders of 3/02/13. These latter 3/02/13 orders made no reference to follow-up healthcare and no supplemental evidence was available to assert otherwise with respect to their intent. During an interview of the Risk Manager on 3/15/13 at 4:15 PM, she confirmed the findings.

25370 Based on review of medical records, policies and procedures, Medical Staff Bylaws, on-call lists and staff interviews the facility failed to ensure that the facility' s policy and procedure was followed when an on-call specialty physician was asked to come to the hospital to provide treatment in response to a request from the emergency room physician to provide specialty services to meet the needs of the hospital 's patients who are receiving services requested, including the availability of the on-call physicians for 1 of 23 sampled patients (#1). As this resulted in a delay in treatment by the on -call physician for patient #1. The facility also failed to list on the call schedule back up coverage on all specialty physicians, who are on call to provide treatment to respond to situations where a particular specialty, through its emergency roiagnom on -call physician, is not available to respond because of circumstances beyond his control, such as having an on-call status at more than one hospital simultaneously and being needed at both places simultaneously. Refer to findings under Tag -A2404.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13640 Based on review of medical records, policies and procedures, Medical Staff Bylaws, on-call lists and staff interviews the facility failed to ensure that the facility's policy and procedure was followed when an on-call specialty physician was asked to come to the hospital to provide treatment in response to a request from the emergency room physician to provide specialty services to meet the needs of the hospital 's patients who are receiving services requested , including the availability of the on-call physicians for 1 of 23 sampled patients (#1). As this resulted in a delay in treatment by the on -call physician for patient #1. The facility also failed to list on the call schedule back up coverage on all specialty physicians, who are on call to provide treatment to respond to situations where a particular specialty, through its emergency roiagnom on -call physician, is not available to respond because of circumstances beyond his control, such as having an on-call status at more than one hospital simultaneously and being needed at both places simultaneously. Findings: 1. The facility's policy and procedure titled, On-Call Responsibilities effective date ,d+[DATE], revised ,d+[DATE] was reviewed. The policy and procedure revealed in part, RESPONSE TO CALL . . 5. When an on call physician is requested to respond by the Emergency Department Physician the physician must: .(b) Respond in person, if so requested, within a reasonable time period. Generally, response is expected within 30 minutes. The Emergency Department physician, in consultation with the on-call physician, will determine whether the patient ' s condition requires the on-call physician to see the patient as soon as possible. (c) Physicians who are on -call and asked to come in to the Emergency Department for an STAT patient care need must comply with all EMTALA regulations .Concurrent Call/Elective Surgery: 12. Notwithstanding an on-call physician's obligation to respond when on call, the on call physician may perform elective surgery or other patient care services at the Hospital while on call, and may be at on call at another hospital. The on call physician is obligated to arrange for back- up coverage in the even he/she is not able to respond immediately to call from the Emergency Department. The on-call physician is responsible for being sure he/she or the back -up physician responds to the Emergency Department with in thirty minutes 2. The facility's Medical Staff Bylaws were reviewed. The Medical Staff By-Laws specified in part, 3.5 Basic obligations accompanying staff appointment and/or the granting of clinical privileges. The applicant shall agree to: 3.5.6. Discharge such Medical Staff Department , Division, committee, and Hospital functions, for which he/she is responsible based upon appointment , election, or otherwise, including as appropriate, providing on call coverage for emergency care services within his/her clinical specialty, as required by the Medical Staff. 3. A review of the medical record of patient #1 was performed. The patient arrived at 3:35 PM on [DATE] and was triaged at 3:38 PM. The stated complaint was stabbing. The emergency room physician first encountered the patient at 3:37 PM. The Rapid Initial Assessment, written by a nurse at 3:40 PM on [DATE], read, . arrived via FD (Fire Department) EMS (Emergency Medical Services) as a code blue (A medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest) S/P (status post) stabbing to left chest. Pt (patient) was pulseless (no heart beat) on EMS arrival. A nurse's note at 3:51 PM read, Mechanism of injury: Penetrating trauma stabbing left chest. A nurse's note at 3:41 PM read, . recd (received) to ER (emergency room ) 5 as code blue per FD EMS, S/P stabbing to the left chest. Pt was pulseless for EMS, CPR (Cardio Pulmonary Resuscitation) in progress and intubated 7.5 FR. (Dr. #A) is attending ER MD (Medical Doctor) with (Dr. #B) emergency room physician Pt has chest tube inserted per (Dr. #A) and connected to water seal at 20 cm wall sx (suction).) STAT (urgent) calls to blood bank for 4 units of blood. .CVC (Central Venous Catheter-a catheter placed in a large i.e., groin, chest to administer medications and fluids) Rt (right) groin per Dr (#B). Pt now has a pulse. A nurse's note at 3:45 PM read, (Dr. #C), cardiothoracic surgeon on-call, is on phone, 2nd unit blood hanging Pt. has lost his pulse/cpr resumed A nurse's note at 3:54 PM described the care being provided to the patient and read, (Dr. #E) vascular surgeon at bedside. (Dr. #C) has not come in. CPR continues. A nurse's note at 4:02 PM read, . (Dr. #A) went to talk to (Dr. #C)/CV surgeon on call, on phone . (Dr. #C) apparently has informed that he is not coming in for this pt. Call out to . (Dr. #F) cardiothoracic surgeon (was not on-call on [DATE]). Review of nurse's note at 4:06 p.m. read, (Dr. #D) general surgeon, here at bedside. epi (epinephrine- medication used to treat cardiac arrest) x (times) 1 given at 4:09 PM. per (Dr. #A). 36 min (minutes) into the code. Further review of the nurses note at 4:10 P.M. read, Pt has recd 4 liters of IVF (intravenous fluid), pt has a pulse now rate of 90 femoral (groin) site. 5th unit prc (packed red cells) hung now. (Dr. #F) returned call, he will be here in 10 min, call to OR (operating room) team per (Dr. #D) for surgery. b/p (blood pressure) ,d+[DATE]. A nurse ' s note at 4:14 PM read, 42 minutes into the code. ,d+[DATE] hung prc. OR team on the way pericardiocentesis (a procedure used in an emergency situation to remove excess accumulations of blood or fluid from the covering the heart (pericardial sac). being done per (Dr. #E). Pulse back into the 50's. The nurse ' s note read at 4:21 PM, no pulse, cpr continues. (Dr. #F) surgeon performing thoracotmy (a process of making a cut into the chest wall to provide access to the heart) at bedside. Call for 4 more units blood. The nurse notes reads at 4:27 PM, Thoracotomy procedures continues per (Dr. #F), with assist from anesthesiologist, (Dr. #E), (Dr. #D) . radiologist (Radiology physician). (Dr. #C), on call CVT surgeon, arrived to rm (room). The on-call physician for Thoracic surgeon delayed nearly an hour for evaluation of patient 1 on [DATE]. Now at the 1 hour mark in code 3:33 PM to 4:33 PM.The nurse's notes read at 4:33 PM, cpr resumed 4:42 PM. all surgeons still suturing thoracotmy .b/p ,d+[DATE]. The nurse's note read at 4:57 p.m. code called per (Dr. #F) in agreement with all surgeons at 4:57 PM. 1 hr 24 min code on the pt was performed. In summary, Patient #1 was pronounced dead by (Dr. #F) at 4:57 PM on [DATE]. The facility failed to ensure that their policy and procedure was followed when the on- call Cardio Thoracic surgeon was asked to come in by the ED physician STAT for the care of patient #1 on [DATE]. 4. Review of the Hospital's Emergency Call Schedule for [DATE] was reviewed. The on call schedule verified that (Dr. #C) Thoracic surgeon (CVT-cardio vascular thoracic) was on call on [DATE]. There was no documented evidence on the on-call schedule that back up coverage for the Thoracic surgeon was listed on the call schedule on [DATE]. There was no way to determine who was available to respond because the on call cardio vascular thoracic surgeon was on call at another acute care hospital simultaneously. On [DATE], the hospital where (Dr. #C) was on simultaneous call on [DATE] was visited. A review of the emergency roiagnom on -call list at this facility for the date of [DATE] revealed that (Dr. #C) who was requested to come to Central Florida Hospital on the same day, to treat patient #1 was also designated as an on-call physician. 5. (Dr. #A's) note written of 5:29 PM on [DATE] referenced, Call was placed to (Dr. #C) on pt arrival, (Dr. #B) spoke with him when he called back as I was placing chest tube. Was requested to come in STAT but he told (Dr. #B) to call General Surg . (Dr. #C) called back again He requested we get a stat ECHO (uses sound waves to build up a detailed picture of the heart) but was told there was no time for this that patient probably had tampanode (is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle and the pericardial sac) and needed emergent thoracotomy.( Dr. #E) here and performed pericardiocentesis. (Dr. #F) was called who came in and performed L (left) lateral thoratocotomy. Found stab wound to the heart and repaired. Clinical impression: Chest injury: . Penetrating heart injury. Another physician note by Dr. #A, entered at 8:54 PM on [DATE], read, (Dr. #C), thoracic surg on call, was called when pt arrived to ED (Emergency Department) at 3:34 PM. (Dr. #B) spoke with him on phone at approx.(approximately) 3:45 as I was inserting chest tube and could not leave pt side. He requested him to come immediately in but he refused, stated that since only 500 cc (cubic centimeters) of blood came out of chest tube pts injury must be abdominal, possibly spleen, and we were to call general surg (surgeon) (Dr. #D). (Dr. #B) disagreed but (Dr. #C) still refused to come in. (Dr. #D) was called . After (Dr. #C) had refused to come in and (Dr. #F) was on his way. (Dr. F) arrived at 4:20 PM . Dr. #C arrived at approx 4:30 PM. 6. A physician note by Dr. #B, entered at 6 PM on [DATE] read, Thoracic on call was paged and (Dr. #C) called back. I spoke with him at 3:45 PM. I discussed with him the situation and that this patient had a stab wound in his lower chest/upper abd (abdomen) area. He asked how much blood came out of the chest tube. I told him about 500 cc of blood. He replied, 'with that amount of blood you don't need to open the chest'. He then asked if he was on back-up for general surgery and I told him 'no. it was (Dr. #D). He responded, 'you need to call him, that's your man'. (Dr. #E) was in the department and offered his help. 7. (Dr. E 's) Operative Report dated on [DATE] at 6:02 PM, read in part, I was called emergently by both (Dr. #A) and (Dr. #B), to please come to the emergency room as they had a patient with a stab wound to the left chest. (Dr.# A)and (Dr. #B) informed me that they had contacted the thoracic surgeon on call who happened to be (Dr. # C). (Dr #C) reportedly told them that if only 500 cc of blood came out of the chest, then he was not coming in to take care of this patient. If this patient had a problem, then they were to contact the general surgeon on call. (Dr.# D) was appropriately contacted as he was on call and he was in transit. I was thus overhead paged to please come to the emergency room to assist with the management of this patient as (Dr. #C) had refused to honor his emergency room call duties. The patient was aggressively resuscitated and (Dr. #F) was now called emergently to please come as (Dr. #C) had once again refused to do so despite the fact that he was on the emergency room call duty for thoracic surgery. (Dr. #F) was in transit. 8. During an interview of (Dr. #B) on [DATE] at 12:41 PM, he stated that he had requested (Dr. #C) to come in, and that his call was not a consultation request. He stated that after explaining the case to (Dr. #C) and requesting his presence, he was told that he (Dr. #B the caller) did not need him (the call recipient, (Dr. #C). He said he was told to call another, specific physician, (Dr. #D). (Dr. #B) stated that he did not voice any agreement with (Dr. #C's) decision or voice a consensus with (Dr. #C) regarding it. During an interview of the Quality Director at Central Florida Hospital on [DATE] at 1:09 PM, she confirmed that the facility could not provide evidence of compliance with the requirement in Federal statute?489.24(j)(2)(i), which states, When the on-call physician is simultaneously on call at more than one hospital in the geographic area, all hospitals involved must be aware of the on-call schedule as each hospital independently has an EMTALA obligation.

20260 Based on record review and interview, the facility failed to ensure that the services performed under a contract are provided in a safe and effective manner, including insuring that every contracted service is evaluated as part of the QAPI plan. Findings: Review of four contracts, Anesthesia, Food Services, Pest Control, and Bariatric Service (equipment) reflected that Food Services, Pest Control, and Bariatric Service (equipment) did not document a quality review that was presented to or reviewed by the board of directors. Interview with the [NAME] President of Quality on 03/09/2012 at 9:55 a.m. confirmed that the facility did not have evidence that all contracts were review as part of the quality program by the board of directors.

30123 Based on interview and record review, the hospital failed to protect each patients' rights affecting 21 of 38 sampled residents concerning (#8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 36, 37 & 38) and 4 of 12 sampled staff (#TT, UU, VV & WW). the following: Findings: 1. Refer to A117 - Based on interview, medical record review and a review of facility documentation, the facility failed to ensure the provision of patient rights in advance of furnishing care for 20 of 38 sampled patients, and failed to ensure the provision of a process in the form of policies and procedures that described how to facilitate the expeditious and non-discriminatory resolution of disputes about whether an individual is an incapacitated patient's representative (#8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 36 & 37). 2. Refer to A154 - Based on record review and interview, the facility failed to ensure staff use appropriate restraints on 1 of 2 sampled patients (#38). 3. Refer to A168 - Based on record review and interview, the facility failed to ensure staff obtain a physician order for the use of restraints on 1 of 2 sampled patients (#38). 4. Refer to A206 - Based on personnel training file, record review and interview, the facility failed to require 1 of 12 sampled staff to have restraint training (#VV); and failed to require 4 of 12 sampled staff to have restraint related first aid training (#TT, UU, VV & WW).

13640 Based on interview, medical record review and a review of facility documentation, the facility failed to ensure the provision of patient rights in advance of furnishing care for 20 of 38 sampled patients, and failed to ensure the provision of a process in the form of policies and procedures that described how to facilitate the expeditious and non-discriminatory resolution of disputes about whether an individual is an incapacitated patient's representative (#8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 36 & 37). Findings: During a review of the medical records of patients #8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 36 and 37, no evidence was uncovered which confirmed the provision of patient rights information in advance of care. This was confirmed in during an interview with the Assistant Director of Nursing and Risk Manager at 3:15 PM on 3/08/12. A review of facility documentation did not reveal any mention of who was to inform patients of their rights in advance of care or how patient rights information was to be provided. This was confirmed during an interview with the Patient Access Director and Risk Manager during an interview on 3/8/12 at approximately 11:37 AM. A review of facility policies and procedures did not reveal any which described how to facilitate expeditious and non-discriminatory resolution of disputes about whether an individual is an incapacitated patient's representative This was confirmed during an interview with the Risk Manager on 3/08/12 at approximately 11:45 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30123 Based on record review and interview, the facility failed to ensure staff use appropriate restraints on 1 of 2 sampled patients (#38). Findings included: During an interview on 03/07/12 at 3 p.m., security officer (staff XX) said he did assist with the application of restraints, does not apply the restraints directly to the patient, but holds the patient so the other staff can put the restraints on. He said he has held patients down and has used handcuffs on patients two times when patients who were Baker Acted, were trying to escape, or hit staff. About 8 months ago, during a situation in the emergency department (ED), the nursing supervisor gave him permission to apply the handcuffs because the patient was trying to hit staff in the face. During an interview on 03/08/12 at 11:15 a.m., security officer (staff YY) said she is called to units to assist with holding patients for restraint application. She said she does not carry handcuffs, only the armed officers carry handcuffs, but she has observed other officers using handcuffs on patients, about a year ago. On one occasion, one of the other security officers grabbed a patient after the patient eloped, took him down, and put handcuffs on the patient until the police arrived. The police and security escorted the patient back to the ED to get some of the medical devices removed, but the patient became violent and was eventually taken to jail. She said she does consider handcuffs to be a restraint. Review of the medical records for patient #38 showed he arrived at the Ed on 7/12/2011 at 8:08 p.m. Review of the Security Daily Shift Summary dated 07/13/2011 for the first shift documented the following: 7:00 a.m. - Patient in handcuffs due to request by ED charge nurse, as he had escaped tough cuffs 3 times. 9:00 a.m. - Baker Acted patient in ED 15 was transported to room [ROOM NUMBER]-B. Staff XX assisted to remove cuffs for transfer to bed. 9:15 a.m. - Handcuffs were taken off Baker Acted patient in room [ROOM NUMBER] and tough cuffs were placed on patient, hospital sitter to watch patient. Review of the policy Patient Restraints dated as effective 01/10/2012, read, The use of handcuffs and other restrictive devices used by law enforcement who are not employed or contracted by the facility for custody, detention or other public safety reasons, and not for the provision of healthcare, is not governed by these standards. However, the use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. Review of the job description for the Armed and Unarmed Security Officers, dated effective 05/2010 showed the following essential function - Knows and follows hospital policies and able to put into action all codes and emergency plans as it relates to security function, and - Provide security function in ensuring a safe, secure, functional and effective environment for patients, staff members and other individuals in the hospital. During an interview on 03/08/2012 at 2:30 p.m., the director of plant operations and safety and security said handcuffs are a restraint and not appropriate for restraining a patient. He said he received a daily report from officers and was not aware of any handcuff use by his officers.

30123 Based on record review and interview, the facility failed to ensure staff obtain a physician order for the use of restraints on 1 of 2 sampled patients (#38). Findings: Medical record review for patient #38, age 22, presented to the emergency department (ED) on 7/12/2011 at 8:08 p.m. with a diagnosis of possible psychosis. Review of the restraint documentation for 7/12/11 at 10:45 p.m. showed 4 point soft restraints applied, but no physician order for the restraints. Review of the restraint documentation for 7/13/11 at 7 a.m. 10:45 p.m. showed handcuffs restraints applied, but no physician order for the restraints. During an interview on 03/09/2012 at 11:10 a.m., the [NAME] President of Quality confirmed the nurse notified the physician, but this would not be a physician's order. Review of the policy-Patient Restraints, dated as effective 01/10/2012, read, An order for restraint must be obtained from a LIP(licensed independent practitioner)/physician who is responsible for the care of the patient prior to the application of restraint . [and] The use of handcuffs and other restrictive devices used by law enforcement who are not employed or contracted by the facility for custody, detention or other public safety reasons, and not for the provision of healthcare, is not governed by these standards. However, the use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients.

30123 Based on personnel training file, record review and interview, the facility failed to require 1 of 12 sampled staff to have restraint training (#VV); and failed to require 4 of 12 sampled staff to have restraint related first aid training (#TT, UU, VV & WW). Findings included: 1. Review of the personnel training file for registered nurse (RN) #VV showed he is a contracted nurse in the dialysis unit working since 8/21/08. The file did not contain documentation of training related to restraint application or first aid related to restraint application. 2. Review of the personnel training file for RN #TT, hired 12/16/09, did not contain documentation of training related to restraint application or first aid related to restraint application. 3. Review of the personnel training file for RN #VV, hired 3/08/12, did not contain documentation of training related to restraint application or first aid related to restraint application. 4. Review of the personnel training file for RN #WW, hired 10/05/11, did not contain documentation of training related to restraint application or first aid related to restraint application. Review of the policy-Restraint Policy 900A825, dated as reviewed 01/06/2012, read: First Aid-Staff will be trained and able to demonstrate competency in first aid techniques for patients in restraint or seclusion who are in distress or injured. The patient populations will be assessed to identify potential scenarios and develop training to address those scenarios . Staff will be trained and certified in the use of cardiopulmonary resuscitation and periodically recertified. During an interview on 03/09/12 at 9:30 a.m., the [NAME] President of Quality confirmed staff receives cardiopulmonary resuscitation recertification, but the personnel files do not document the first aid training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20260 Based on observation, record review and interview, the facility failed to assure a registered nurse (RN) assessed the care for each patient upon admission and when appropriate on an ongoing basis for 5 of 37 sampled patient (#1, 9, 10, 29 & 30). Findings: 1. An observation on 03/06/12 at 11:45 a.m. found patient #10 in bed at rest with her daughter at the bed side. The daughter wore gloves but did not wear a gown to protect her clothing. A sign on the door at the entrance to the room indicated the patient was on contact precautions. The sign read, Gloves and Gown - wear gloves and gown when entering room or cubicle. Remove gown and gloves before leaving the patient's room and ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transmission of microorganisms. During an interview with the daughter on 03/06/12 at 11:50 a.m., the daughter said she did not remember staff telling her she should wear a gown when in her mother's room. She also said her mother had C-Diff (Clostridium Difficile, a bloody diarrhea) and she knew all about that because she caught the C-Diff from her mother last year. Review of the medical record showed the patient #10 as admitted on [DATE] for weakness and abdominal pain. Review of the lab work showed the urine culture dated 03/04/12 positive for pseudomonas; toxin screen dated 03/04/12 positive for C-Diff; and urine culture dated 03/04/12 for Vancomycin Resistant Enterococcus. During the record review, the nurse manager confirmed the medical record showed the patient was incontinent of stool on 03/05/12 and confirmed the nursing standard of care would include a care plan related to infection control problems and the patient did not have one. She also said the nursing staff have the option in the computerized system to select infection control as a care plan problem. 2. Review of facility policy 900A615.1 Medication Administration: Patient Controlled Analgesia Administration (PCA) read, Document administration and assessment of analgesia and sedation levels on the PCA/Epidural flow sheet q(every)15 minutes x4, q1h(hour) x4, then q4h until the PCA is discontinued . Co-signatures are required on the PCA/Epidural flow sheet. Review of facility policy 900A615, Pain Management states 5. Documentation A patient's pain is documented .When the patient is medicated for pain .and will include severity of pain, location, duration . After 30-60 minutes from the time an analgesic is given, the nurse records the effect of the medication. Review of patient #1's record reflected the patient received a Lortab-5, Vicodin tablet on 03/02/12 at 4:15 p.m. The assessment of the patient at the time of administration failed to document the intensity, location or duration of the pain. The record failed to reflect a reassessment within 60 minutes of administration. 3. Review of patient #29's record reflected the patient received a Lortab-5, Vicodin Tablet on 12/10/11 at 7:59 p.m. The assessment at the time of administration failed to document the location, or duration of the pain. Interview on 03/07/12 at 3 p.m. confirmed the records were as documented and that the policies were current. 4. Review of patient #30's record documented that Hydromorphone 10 mg.(milligrams)/50ml. (millimeter) was started on 12/08/11 at 8:52 a.m. The record failed to document assessments following the initiation of the PCA per the policy. Interview on 03/07/2012 at 3 p.m. with the Chief Nursing Officer confirmed the lack of a PCA/Epidural Flow Sheet in the documentation system, the lack of documentation on patient #30's record and that the system requires documentation on more than one screen in the current documentation system. 30123 5. Review of the medical record for patient #9, admitted on [DATE] with a diagnosis of pelvic abscess following a C-section (baby deliver by surgical incision in the abdomen) on 02/2012 showed the patient had an exploratory laparotomy, incision and drainage of the abscess, with adhesions on 03/04/2012. Wound culture dated 03/04/12 and urine culture dated 03/03/12 showed E-coli. During an interview on 03/06/12 at 12:05 p.m., the nurse manager confirmed the standard of care would include a care plan related to infection control related problems and the patient did not have one.

20260 Based on observation, record review and interview, the facility failed to assure drugs and biologicals were administered in accordance with the approved medical staff policies and procedures for 2 of 37 sampled patients (#28 & 30). Findings: 1. Review of facility policy 900A615.1 Medication Administration: Patient Controlled Analgesia Administration read, Document administration and assessment of analgesia and sedation levels on the PCA/Epidural flow sheet q (every)15 minutes x4, q1h (hour) x4, then q4h until the PCA is discontinued . Co-signatures are required on the PCA/Epidural flow sheet. Review of patient #28's record documented that Hydromorphone 10 mg. (milligrams)/50 ml. (milliliters) was started on 03/07/12 at 12:14 p.m. in the Post Anesthesia Care Unit (PACU). The documentation failed to reveal a PCA/Epidural flow sheet. The documentation required the co-signatures on the mediation administration screen and the assessments on the PCA evaluation screen. 2. Review of patient #30's record documented that Hydromorphone 10 mg./50 ml. was started on 12/08/11 at 8:52 a.m. The documentation failed to reveal a PCA/Epidural flow sheet. The documentation required the co-signatures on the mediation administration screen. The record failed to document assessments following the initiation of the PCA per the policy. Interview on 03/07/2012 at 3 p.m. with the Chief Nursing Officer confirmed the lack of a PCA/Epidural Flow Sheet in the documentation system, the lack of documentation on patient #30's record and that the system requires documentation on more than one screen in the current documentation system.

30123 Based on record review and interview, the facility failed to ensure medications on all units where keep are checked for expiration on a monthly basis. Findings included: Review of the pharmacy inventory checklist document provided by the pharmacy showed multiple areas including the Endoscopy area, ICU, 2 West, RX code cart, ER fast tract, and cardio-pulmonary rehab areas were not checked for medication expiration dates for the months of November 2011, December 2011, January 2012 and February 2012. Review of the policy Medication Area Inspections dated as revised 12/01/09 read, Unannounced inspections of all preparation and dispensing areas shall be made by the pharmacy technician assigned to the area each month. The policy requires monthly checking. The [NAME] President (VP) of Quality provided the following correspondence from the pharmacy director, Nursing Unit Inspections (undated) [read] our previous structure was to have routine unit assignments to individuals. Due to employee turnover, several areas were not reassigned and therefore went without routine inspection. During an interview on 03/09/12 at 9 a.m. the VP of Quality confirmed the blank areas of the pharmacy inventory check off list and the pharmacy director's awareness of the problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13640 Based on observation, interview and a review of facility documentation, the facility failed to ensure the implementation of policies governing infections in the form of policies addressing expired sterile items such as those in the Cardio-Vascular Intensive Care Unit supply room. Findings: During an inspection of the Supply Room for the Cardio-Vascular Intensive Care Unit on [DATE] at 11:20 AM, the following expired sterile items were discovered: 3 Twin Cath ,d+[DATE] Multiple Lumen Peripheral Catheters with the respective expiration dates of [DATE]; [DATE]; and [DATE]; 12 BBL Culture Swab(s) Plus with the respective expiration dates of February 2012; [DATE]; [DATE] (two each); February 2009 (three each); [DATE]; [DATE] (two each); [DATE]; and [DATE]. The preceding was confirmed during interviews with the Director of Cardio Vascular Services, Risk Manager and Assistant Director of Nursing at the above stated time. A review of facility policy Managing Non-Moving, Obsolete and Expired Items revealed the following: All items that have expired, are obsolete, or are non moving are to be removed from the facility in a timely manner and accounted for appropriately [and] If an expired product is identified, the following process is followed . Upon discovery of expired product, the merchandise is to be removed from stock. During an interview of the Assistant Director of Nursing on [DATE] at 10:18 AM, she confirmed that the findings in the above observation were in violation of the above stated policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30123 Based on observation, interview and record review, the facility failed to ensure staff followed facility policy related to contact isolation and visitors. Findings included: During an observation on 03/06/12 at 11:45 p.m., patient #10 was found in bed at rest with her daughter at the bed side. The daughter had on gloves but was not wearing a gown to protect her clothing. There was a sign on the door at the entrance to the room indicating the patient was on contact precautions. The sign read, Wear gloves and gown when entering room or cubicle. Remove gown and gloves before leaving the patient's room and ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transmission of microorganisms. During an interview with the daughter on 03/06/12 at 11:50 a.m., the daughter said she did not remember the staff telling her she should wear a gown when in her mother's room. She also said her mother had C-diff (Clostridium Difficile) and she knew all about that because she caught the C-diff from her mother last year. Review of the medical record showed the patient #10 was admitted on [DATE] for weakness and abdominal pain. Review of the lab work showed the urine culture dated 03/04/12 positive for pseudomonas; toxin screen dated 03/04/12 positive for Clostridium Difficile; and urine culture dated 03/04/12 positive for Vancomycin Resistant Enterococcus (VRE). During the record review on 3/06/12 at approximately 12:30 p.m., the nurse manager confirmed the medical record showed the patient was incontinent of stool on 03/05/12 and confirmed the visitor should have been wearing a gown and gloves as the sign stated. Review of the facility policy Clostridium Difficile (undated) read, Adhere to complete gowning and gloves to be worn when entering the room. Individuals with C-Difficile associated disease shed spores in the stool that can be spread from person to person. Spores can survive up to 70 days in the environment and can be transported on the hands of healthcare personnel who have direct contact with infected patients or with environmental surfaces contaminated with C-Difficile [and] Visitors are to don gown and gloves upon entering the room. Visitors are to be instructed on proper hand hygiene by healthcare workers. Only adult and adolescent visitors are permitted to visit patient.

13640 Based on interview and a review of facility documentation, the facility failed to ensure that a list of Home Health Agencies and Skilled Nursing Facilities were available in discharge documentation to patients participating in the Medicare program. Findings: A review of facility documentation revealed a list of Home Health Agencies and Skilled Nursing facilities in the facility's geographic area which were available to patients upon discharge. However, there was no indication on the list which indicated whether or not any or all these agencies and facilities participated in the Medicare program. The preceding was confirmed during an interview with the Assistant Director of Nursing on 3/09/12 at 10 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13640 Based on interview and record review, the facility failed to ensure that nursing staff followed the physician's order for the administration of Dilaudid for 1 of 9 sampled patients (#9). Findings: A review of the medical record of patient #1 indicted the patient was admitted on [DATE]. Physician orders of 2/16/11 at 7 AM read, Change Dilaudid to every 2 hours 0.5 mg. (milligrams) IV (intravenous). The physician did not specify in this order for it to be given PRN (as needed), therefore, the medication was prescribed specifically to be given every two hours. The medical record indicated that Dilaudid was administered at the prescribed dose 7:43 AM on 2/16/11. Nurse's notes at 7:59 AM read, Pt in bed sleeping quietly. Nurse's notes at 8:37 AM read, Dr. . in to see patient. Per the new physician orders of 7 AM (see above), the patient would have been due for another dose of non-PRN Dilaudid at approximately 9:43 AM. There was no evidence that it was administered at this time, or shortly thereafter, irrespective of the patient's pain status at the time. Physician orders of 2/16/11 at 11 AM read, Start Dilaudid PCA 0.2 mg/hr (1 ml/hr) continuous infusion. Nurse's notes indicated that the Dilaudid PCA pump was initiated at 11:27 AM. This was the first administration of Dilaudid in any form since the 7:43 AM administration. During an interview of the Quality Manager during a follow-up call on 4/19/11 at approximately 10 AM, she confirmed the findings.

13640 Based on interview and record review, the facility failed to ensure a uniform level of nursing care in the form of only inititiating wound care through physician orders, making accurate wound descriptions and re-evaluating ineffective wound prevention measures in one of six sampled patients. (#1) Findings: A review of the medical record of patient #1 was performed. An emergency room (ER) note of 12/29/10 at 10:55 a.m. read: Work called police after pt(patient) was a no show X 3 days. Last seen 3 days ago. Pt was found on floor in home. A nurse's note of 9:00 p.m. on 12/29/10 read: Lg pressure sore to coccyx open w/red and purple area picture taken and Mepiplex placed on coccyx and barrier creams applied. Mepiplex is a dressing made from polyurethane foam. Physician orders for this dressing (or any other dressing through 1/10/11) were not in the medical record. A History & Physical, dictated on 12/29/10 at 11:12 p.m. read: The patient has skin tears to the left side of her sacrum, left shoulder, and proximal left forearm. Regarding the use of the term sacrum, this location was used predominantly in subsequent text of the medical record (with coccyx used to a lesser degree). Later text reveals that there was no evidence of separate and distinct coccyx and sacral wounds. Skin risk interventions were set forth in nursing documentation of 12/30/10. They included: Reposition Q2hrs and PRN . Nurse's notes of 12/29/10 mentioned the application of Mepiplex to the coccyx/sacral site. Nures's notes of 1/3/11 mentioned the application of Duoderm to the coccyx/sacral site. Duoderm is a hydrocolloid (see below). Nurse's notes of 1/6/11 mentioned the application of Sacral Tegraderm to the coccyx/sacral site. Tegraderm is a transparent dressing. Nurse's notes of 1/7/11 mentioned the application of Hydrocolloid to the coccyx/sacral site. Hydrocolloids absorb wound liquid in the presence of wound exudates. A nurse's note of 1/7/11 at 8:00 p.m. mentioned a tear, non-open on the upper middle back. This description contradicts itself, as a tear constiutes a break in the skin. This site is later described as a pressure sore (see below). There was no evidence of a re-evaluation of pressure sore or skin injury prevention interventions upon the discovery of this site. This was the first mention in the medical record of the Thoracic or upper back region. A nurse's note of 1/7/11 at 7:52 p.m. read: Dressings to back and sacral region intact. This wound was addressed by the physician on the following day. There was no evidence of a physician order for this site (including a dressing) up to this point in time. Nurse's notes of 1/8/11 mentioned the application of Duoderm to the coccyx/sacral site. A nurse's note on 1/8/11 read: Checked 2 decubitus by Dr. . as one on middle back and one on sacral area. A nurse's note on 1/8/11 mentioned that the tear on the upper back was covered. A nurse's note on 1/8/11 mentioned the application of Mepiplex to the coccyx/sacral site. Nurse's notes of 1/9/11 at 8:00 a.m. mentioned that the application of Mepiplex to the tear of the upper middle back. Nurse's notes of 1/10/11 at 8:00 a.m. mentioned the application of Mepiplex to the coccyx/sacral site. Progress notes addressed the wounds on 1/10/11. A nurse's note on 1/11/11 mentioned the application of Mepiplex to the upper middle back (thoracic) site, which was described as an ulcer . A physician consultation note, dictated on 1/9/11 read: The patient has been noted to have wounds over the thoracic area of her spine, as well as a sacral wound. These have been cultured and have been growing Pseudomonas . Also: Over the patient's back she has two wounds, one in the thoracic area that appears to be a stage II ulcer. The wound in the sacral area is a stage III. There is no evidence of visible bone. There is no purulence at this time. Also: She had been found to have wounds on her back that vary in stages between a stage II in the thoracic area to a stage III in the sacral area. Pseudomonas has been cultured in heavy growth from these wounds. Physician orders of 1/11/11 read: Sacral wound orders: Aquacel . , ABD and . change daily. . Protect thoracic wound with: hydrogel, 4 X 4 secure with tape change every other day. These were the first physician orders for wound dressings of the sacral/coccyx and thoracic sites. All of the other applications of dressings as indicated in prior text were done without any physician orders. The use of various types of dressings as mentioned in the above nurses notes indicated a lack of consistency and coordination in the nursing-initiated approach. An interview with the Quality Manager on 3/28/11 at approximately 5:00 p.m.confirmed the preceding information.