Based on medical record review and staff interview the facility failed to properly assess /reassess and initiate appropriate interventions to evaluate patient outcome in one (#1) of nine sampled patients. Findings include: Review of Patient #1's medical record reveals that the patient arrived to the progressive care unit (PCU) on 01/09/2021 at 10:54 PM, status post Open approach Inspection of Lower Vein for possible Kidney transplant (surgery). Further review of Patient #1's Medical record reveals that the Blood pressure (BP) on arrival was 156/99 with a heart rate (HR) of 117. An extensive review of the Patient's clinical record failed to show that the doctor was notified of the elevated BP and HR. No interventions were found in Patient #1's medical record in an attempt to reduce the BP and HR or find the cause of elevation. No reassessment was found in the record that the BP and HR came down. Patient #1's medical record reveals the nurse went to get a second set of vital signs at 5:15 AM and found the patient without a pulse. Interview with the Director of Critical Care on 02/11/2021 at 9:00 AM confirmed the above findings.
Based on policy review, document review, record review, and staff interviews it was determined the facility failed to ensure the nursing staff documented nursing care and services in compliance with facility policies for two (#3, #10) of 10 sampled patients. Findings included: The review of the policy titled Assessment and Reassessment, reference number WFD.PC.002, revised 12/2016, indicated the nursing staff was required to document reassessments of intensive care patients' conditions at a minimum of every four hours. The review of the staffing assignment sheet revealed RN A was assigned to care for Patient #3 and Patient #10 for the 7 am-7 pm shift in the intensive care unit on December 19, 2017. The review of the Shift Assessment for Patient #3 revealed RN A documented a comprehensive nursing assessment at 8:00 a.m. on 12/19/17. The detailed review of the record revealed no documentation of the reassessment of the patient until 4:15 p.m. The review of the Shift Assessment for Patient #10 revealed RN A documented a comprehensive nursing assessment at 8:00 a.m. on 12/19/17. The detailed review of the record revealed no documentation of the reassessment of the patient until 5:00 p.m. An interview was conducted with the Interim Director of Critical Care on 2/27/2018 at 11:00 a.m. The Director indicated the standard practice in the intensive care unit was for nursing staff to document patient reassessments every two hours and document either the patient's condition was unchanged from the initial Shift Assessment, or document details of the change in condition. An interview was conducted with the Chief Nursing Officer (CNO) on 2/28/18 at 12:30 p.m. The CNO confirmed the nursing documentation for Patient #3 and Patient #10 on 12/19/17 was not in compliance with facility policy and standard nursing practice in the intensive care unit.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of the medical record and staff interview it was determined the facility failed to ensure the discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services. The facility failed to ensure the discharge planning evaluation included the patient's capacity for self-care or the ability of family to provide the required care needed upon discharge for one (#2) of eleven patients sampled. Findings included: Review of the medical record for patient #2 revealed the patient was admitted on [DATE]. Review of the physician documentation on 9/23/2016 revealed the patient was incompetent to make decisions regarding care. On 9/23/2016 telephone contact with the patient's spouse revealed the spouse agreed to act as the patient's proxy. Review of the Case Management documentation on 9/24/2016 revealed the patient was assessed for discharge planning. Documentation by the case manager revealed the patient was unable to participate in the assessment. Review of nursing technician's documentation revealed the patient required assistance for ADLs (Activities of Daily Living) during the admission. Assistance was required for transfers, toileting and eating. Review of Case Management documentation on 9/26/2016 revealed the case manager spoke with the patient's spouse. Documentation revealed the conversation was to finalize discharge. The case manager documented the patient would return home via facility provided transportation. Review of the record revealed no evidence the discharge planning included an evaluation of the patient's post-hospital needs or the availability of the services. There was no evidence an evaluation of the patient's capacity for self-care or the possibility of the patient being cared for at home by the spouse. Documentation revealed the patient was discharged home on 9/26/2016. Review of the medical record for patient #2 revealed the patient was readmitted to the facility on [DATE]. Documentation revealed the patient was confused, was refusing to bathe, had an inability to walk or do anything independently and had multiple falls at home. Documentation revealed the patient's spouse was unable to assist the patient following the falls. The spouse was unable to assist with ADLs. Interview with the Manager of the BH (Behavioral Health) Unit at the time of the record review on 11/02/2016 at approximately 2:30 p.m. confirmed the findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review and staff interview it was determined the facility failed to ensure referral for services was made for one (#1) of nine discharged patients reviewed. Findings included: Review of patient #1's record revealed the patient was admitted on [DATE] as an involuntary admission. Documentation by the psychiatrist on 8/31/2016 at 5:05 p.m. determined the patient was incompetent to make decisions. Review of Case Management (CM) documentation revealed the facility was unable to contact a family members. Review of the record revealed a court appointed guardian advocate was placed on 9/13/2016. On 9/17/2016 documentation by nursing revealed the patient's spouse contacted the facility. On 9/18/2016 nursing documentation revealed the patient's spouse agreed to assume the role of the patient's proxy. On 9/25/2016 case management documentation revealed a family session was conducted with the patient and spouse. It was agreed the patient could return home with home health services to assist with continued care of the patient. Review of the record revealed no documentation a referral for home health services was implemented. Interview with the nurse manager on 11/02/2016 at approximately 11:30 a.m. confirmed the findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure staff obtained and documented in the medical record the intent of the patient's advance directives according to policy and procedure for two (#3, #5) of ten sampled records. Findings include: Review of the facility policy Advance Directive policy #B.03, last revised 8/2013, indicated the facility will determine if the patient has an advance directive or health care surrogate; (II) Procedure (B) Patient Access Department shall ask the patient (or patient's representative, if patient is not capable) whether the patient has executed an advance directive. If an advance directive has been executed, admissions personnel shall request a copy be provided for the patient's medical record; the admitting nurse will document in the patient's medical record whether or not the patient has executed an advance directive; (D) if a copy of the advance directive is not provided, the patient's nurse will record the substance of its contents on the Admission Data Form. 1. Patient #3 was admitted on [DATE]. Review of the Conditions of Admissions form dated 4/27/2015 at 12:00 p.m. revealed the patient indicated with their initials she had advance directives and the patient was requested to supply a copy to the facility. Review of the medical record revealed the patient was transferred from a SNF (Skilled Nursing Facility) to the hospital. The SNF supplied a copy of the patient's facesheet from the SNF indicating the patient was a full code. Review of the nursing admission history dated 4/27/2015 at 6:21 p.m. revealed no indication the nurse gathered the information of the patient's intent as stated in the advance directive. 2. Patient #5 was admitted on [DATE]. Review of the Conditions of Admissions form revealed the patient indicated she had advance directives and a copy was requested to be placed on the medical record. Review of the nursing admission history dated 4/27/2015 at 1:10 p.m. revealed the patient confirmed she had advance directives. Review of the documentation revealed no evidence the nurse documented the patient's intent that was indicated in the advance directives. Interview with the Director of PCU (Progressive Care Unit) on 6/2/2015 at approximately 1:30 p.m. confirmed the above findings at the time of the medical record review.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, staff interview and review of policies and procedures it was determined the facility failed to involve the patient and family in care decisions and failed to educate the patient or family on a change in treatment for one (#1)of ten sampled records. Findings include: Patient #1 was admitted on [DATE] after a transfer from the acute care hospital. Review of the History and Physical dated 6/13/13 revealed the patient was alert and oriented to self with difficulty following one step commands, disoriented and confused and unable to understand or answer questions appropriately. The patient's spouse signed the conditions of admission and was making the patient's decisions. Speech Therapy evaluation dated 6/14/13 revealed an evaluation for Clinical Dysphagia Evaluation. The documentation indicated the patient had overt signs and symptoms of oral and pharyngeal decompensation and a video swallow study was recommended. The report stated Video swallow study warranted to rule out aspiration. NPO (Nothing By Mouth) recommended except meds with video swallow study on Monday. However, if family or patient refuses, patient appears to handle thin liquids and mechanical soft solids. Patient should be strictly monitored due to poor endurance and fatigue. Suspect Pharyngeal Dysphagia. Under the section for Teaching and Education it stated the patient was the learner and that barriers to learning were fatigue and cognition. Physician's order dated 6/14/13 indicated NPO except for meds, until video swallow evaluation performed. Start IVF ( Intravenous Fluids) to maintain hydration while NPO. Interview with the Director of the Rehabilitation Unit and the RN Manager on 9/26/13 at 1: 00 p.m. revealed there would be signage that indicated the patient was NPO and the patient would have an orange armband. All water pitchers and anything that would present risk would be removed from the room and there would be education to the patient and the family. The RN Manager stated they would be told due to safety with swallowing that we are not going to give them food or drink until the test is done and they are determined safe. Review of nursing notes revealed the NPO status and intravenous fluids were initiated on 6/14/13. Review of physician's note for 6/15/13 at 1:18 p.m. revealed the spouse was upset over the NPO status and IVF. The status was discussed at length with patient and spouse. The documentation noted the patient remains significantly confused and does not demonstrate the ability to make his own medical decisions at this time. Review of the hospital's policies and procedures revealed Policy No: B.36 Patient's Rights and Responsibilities with a review date of 1/13. Review of the policy revealed Purpose: LMC must protect and promote each patient's rights. Policy: Each patient/representative must be informed of the patient's rights and responsibilities, whenever possible, in advance of providing or discontinuing patient care. Patients and/or the responsible representative have the right to 6. A patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks , and prognosis. 7. A patient has the right to refuse any treatment, except as otherwise provided by law. Review of the patient's record revealed no documentation the decision to place the patient on NPO status and intravenous fluids was discussed with or explained to the patient's family prior to this being instituted.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, staff interview and review of policy and procedure it was determined the registered nurse failed to supervise and evaluate nursing care related to falls blood glucose monitoring and implementing physician orders for two (#1, #5) of ten patients sampled. This practice does not ensure patient goals are met and may lead to a prolonged hospitalization . Findings include: 1. Patient #1 was admitted to the facility on [DATE]. Documentation revealed the patient had orthopedic surgery of the right ankle. Review of the admitting orders, dated 8/23/2012, stated to have the patient up as tolerated with crutches. Review of the nursing documentation revealed the patient was not assisted out of bed until 8/26/2012. Review of documentation from another acute care facility revealed the patient was admitted to the facility on [DATE] with a diagnosis of [DIAGNOSES REDACTED]provoked PE due to a right lower extremity fracture and post-op inactivity. 2. Review of the medical record for patient #1 revealed on 8/24/2012 at 4:25 p.m. a urinary catheter was inserted. Review of the nursing documentation revealed no indication for the insertion of the catheter. Review of the physician orders revealed no evidence of an order to insert the urinary catheter. 3. Review of the medical record for patient #1 revealed a physician's order on 8/25/2012 at 12:30 p.m. to resume NS (Normal Saline) IVF (Intravenous fluids) at 100 ml/h (milliliters/per hour). Review of the MAR (Medication Administration Record) revealed the NS was resumed by nursing on 8/26/2012 at 2:10 a.m. There was no documentation for the delay in resuming the IV fluids. Interview with the director of PCU (Progressive Care Unit) confirmed the above findings on 3/21/2013 at approximately 1:15 p.m. 4. Patient #5 was admitted to the facility on [DATE]. Review of the record revealed the patient was an Insulin Dependent Diabetic. The physician orders dated 3/21/13 ordered to monitor the patient's blood glucose prior to meals and at the hour of sleep. Review of the blood glucose monitoring revealed on 4/2/2012 at 8:51 a.m. the patient's blood glucose was 44 (70-110). Documentation revealed at 8:54 a.m. the blood glucose was 53. There was no documentation if the patient exhibited any signs or symptoms of [DIAGNOSES REDACTED]. Review of the facility's policy, Reporting Critical Test Results/Findings, policy #K.17, states the results will be reported to the Licensed Independent practitioner within 30 minutes. The critical value for blood glucose, as defined by the facility policy, states glucose of <50 mg/dl will be reported. 5. Review of the medical record for patient #5 revealed on 4/3/2012 at 2:50 a.m. the patient was found in his room on the floor. Nursing documentation revealed an assessment was performed by the RN (Registered Nurse). Documentation revealed the patient complained of back/hip pain, no laterality documented. Nursing documented the patient's right shoulder blade had excoriation. Review of the record revealed no evidence the physician was notified of the patient's fall until 9:20 a.m. Review of the record revealed no evidence the patient's family or significant other was notified. Review of the facility's policy, Fall Risk Assessment and Prevention, #600-79-085, states the post fall protocol will be implemented after a fall occurs. Nursing intervention is to assess the patient for injuries, vital signs, cardiac rhythm (if applicable), and level of consciousness, orientation and neurological status. The physician will be notified, orders implemented, and family/significant other notified. Interview with the Director of PCU on 3/21/2013 at approximately 3:00 p.m. confirmed the above findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure the availability of appropriate services of home health agencies was presented to the patient for one (#1) of ten patients sampled. This practice does not ensure a safe and effective discharge. Findings include: Patient #1 was admitted on [DATE]. The patient was discharged on [DATE]. Review of the physician's orders, dated 8/27/2012, stated to discharge home with home health care. Review of the facility policy, Patient Choice, last reviewed 8/2012, states (III) (A) if post- discharge services are anticipated, or after a physician order is written for post discharge services, the discharge planner will inform the patient that he has the right to select any healthcare provider/supplier; (1) this choice may be limited to the network utilization of their insurance carrier. If this occurs, the discharge planner will inform the patient and or patient representative of their options; (2) the patient/patient representative will be given a Patient Choice Letter and, upon request, a Health Care Providers/Suppliers List to review; (C) the choice letter is placed in the patient chart with consents and becomes a permanent part of the medical record. Review of the record revealed no evidence the patient was informed of his right to select a home healthcare provider. Review of the record revealed no evidence of a patient choice letter. Interview with the case manager on 3/21/2013 at 1:30 p.m. confirmed the findings.
Based on clinical record review, policy review and staff interview it was determined the facility failed to comply with the requirement to provide an appropriate medical screening examination for 1 ( #1) of 20 sampled patients. See A 2406; 489.24(i) Medical Screening Examination.
Based on reviews of clinical records, policy and procedure and interview it was determined the facility's emergency department (ED) physician failed to complete an appropriate medical screening examination (MSE) to include ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition existed for 1 (#1) of 20 sampled patients. Findings include: A review of Patient #1's clinical record dated 1/20/13 revealed the patient presented to the emergency department at 5:05 am, via ambulance, with a stated complaint of headache, A review of the emergency department (ED) nursing notes revealed the patient arrived by ambulance. The nurse documents according to the ED clerk and the ED physician involved, the physician advised the patient we weren't going to do anything further for her and she should just leave. The patient intravenous line was removed by the paramedics and the patient left without being visualized by the hospital nursing staff. Further review of the clinical record revealed the patient never received a MSE on 1/20/13 by a physician. A review of the facility's policy, EMTALA: Florida Medical Screening Examination and Stabilization, policy # B. 17, reviewed 7/12, page 3 of 15, paragraph 2,when a Medical Screening Examination (MSE) is required, revealed the following: A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the dedicated emergency department (DED), to determine whether or not an emergency medical condition (EMC) exists; (i) to any individual who has such a request an examination. A review of the Medical Staff Rules and Regulations approved 11/24/12, page #29, Part D, paragraph 1, states members of the medical staff shall accept responsibility for care in accordance with Emergency Department policies and procedures. An interview was conducted with the Director of Risk Management on 1/29/13 at approximately 3:00 pm. Upon review of the credential file of the physician involved revealed the physician was relieved of her privileges with the hospital by the Governing Body on 1/28/13 and is no longer employed with the emergency department partnership group. The removal of the physician was based on Peer review of the incident conducted on 1/22/13. The Emergency Department Physician's completed a refresher course on EMTALA on 1/30/13. The Emergency Department staff is scheduled for a refresher course following the Physicians course. The Director of Risk Management confirmed the above.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview, it was determined the facility failed to ensure consistent assessment and implementation of appropriate interventions for 4 (#1, #3, #5, #10) of 10 sampled patients. This practice does not ensure patients will achieve goals of the plan of care. Findings include: 1. Patient #1 was admitted to the facility on [DATE] and discharged to a skilled nursing facility on 12/10/10. Review of the initial skin assessment documented on 11/9/11 revealed The following deficiencies in wound assessments were identified: 11/15/10 - 7 am - 7 p.m. shift - no documentation of repositioning every 2 hours and floating heels off mattress 11/16/10 - 7 am - 7 p.m. shift - no documentation of repositioning every 2 hours and floating heels off mattress 11/17/10 - 7 pm - 7 am shift - no assessment of heel wounds that had been identified by wound care nurse on 11/17/10 at noon. 11/19/10 - 7 am - 7 pm shift - no wound assessment 11/19/10 - 7 pm - 7 am shift - no assessment of heel wounds 11/20/10- 7 am - 7 pm shift - no assessment of heel wounds 11/20/10 - 7 pm - 7 am shift - no wound assessment, no documentation of interventions to relieve pressure, except the specialty mattress 11/21/10 - 7 am - 7 pm - no assessment of heel wounds 11/21/10 - 7 pm - 7 am - no wound assessment 11/22/10 - 7 pm - 7 am - no documentation of interventions to relieve pressure 11/23/10 - 7 pm - 7 am - wounds listed, but not assessed 11/24/10 - 7 pm - 7 am - wounds listed, but not assessed 11/26/10 - 7 am - 7 pm - wound listed, but not assessed 11/27/10 - 7 am - 7 pm - wounds listed, but not assessed 11/28/10 - 7 am - 7 pm - wounds listed, but not assessed 11/28/10 - 7 pm - 7 am - no wound assessment 11/29/10 - 7 am - 7 pm - wounds listed, but not assessed 11/29/10 - 7 am - 7 pm - wounds listed, but not assessed 11/30/10 - 7 am - 7 pm, - no assessment of right heel 11/30/10 - 7 pm - 7 pm - no assessment of either heel 12/1/10 - 7 am - 7 pm - no assessment of either heel 12/2/10 - 7 am - 7 pm - wounds listed not assessed 12/6/10 - 7 am - 7 pm - wounds listed, not assessed 12/8/10 - 7 am - 7 pm - nurse documented both heel wounds were open, but did not document appearance of wound 12/8/10 - 7 pm - 7 am - wounds listed , not assessed 12/9/10 - 7 am - 7 pm - wounds listed, not assessed 12/9/10 - 7 pm - 7 am- wounds listed, not assessed 12/10/10 - 7 am - 7 pm - no wound assessment 12/10 10 - 11:56 am - wound care nurse assessment did not include assessment of pressure ulcers of coccyx and bilateral heels. The patient was discharged on [DATE]. The condition of the wounds had not been documented since 12/7/10 and were not documented at the time of discharge. 2. Patient # 3 was admitted to the facility on [DATE] and discharge on 7/6/11. Wounds of the sacrum and left heel were identified during the initial assessment. The following deficiencies related to skin assessments were noted: 7/2/11 - 7 am - 7 pm - no wound assessment, no documentation of intervention to relieve pressure 7/2/11 - 7 pm- 7 pm - no wound assessment 7/3/11 - 7 pm - 7 am - no wound assessment 7/4/11 - 7 am - 7 pm - no skin assessment, no documentation of intervention to relieve pressure 7/6/11 - Patient discharged at 10:30 a.m. - No assessment of wounds prior to discharge. 3. Patient #5 was admitted to the facility on [DATE] with a fractured femur as the result of a ground level fall. He was a patient on the MICU at the time of the investigation. He had been identified as having a hospital acquired pressure ulcer by the Director of Quality Improvement. The initial skin assessment documented on 7/8/11 at 12:38 a.m. indicated hematomas on both arms and both shins. It also indicated the coccyx was reddened. The following deficiencies related to skin assessments were noted: 7/9/11 - 7 am - 7 pm - no assessment of arms, legs and coccyx wounds. There was also no documentation of a Braden score and no documentation on interventions to prevent pressure ulcer development. 4. Patient #10 was admitted to the facility on [DATE] with the diagnosis of acute gastrointestinal bleeding. She was also identified as having a hospital acquired pressure ulcer. The initial skin assessment documented on 6/24/11 at 10:50 a.m. noted the patient had a incision on the right foot and no other wounds. The following deficiencies regarding skin and wound assessments were noted: 6/24/11 - 7 pm - 7 am - no wounds or incisions noted 6/25/11 - 7 am-7 pm - no wounds or incisions noted 6/25/11 - 7 pm - 7 am - no wounds or incisions noted 6/26/11 - 7 am - 7 pm - no documentation of Braden score or interventions to relieve pressure 6/26/11 - 7 pm - 7 am - no skin assessment 6/27/11 - 7 am - 7 pm - no wound or incision noted 6/27/11 - 7 pm - 7 am - no documentation regarding incision on right foot. First documentation of a blister on the coccyx 6/28/11 - 7 pm - 7 am - no documentation of incision on right foot. The blister on the coccyx was listed, but not assessed 6/29/11 - 7 am - 7 pm - no wound or incision assessment 6/29/11 - 7 pm - 7 am - coccyx blister now open, the right foot incision again documented 6/30/11 - 7 am - 7 pm - open blister on right heel, new wound 7/2/11 - 7 pm - 7 am - coccyx wound not documented or assessed 7/5/11 - 7 am - 7 pm - coccyx wound not documented or assessed. 7/7/11 - 7 pm - 7 am - wounds listed but not assessed 7/9/11 - 7 am - 7 pm - wounds listed but not assessed 7/10/11 - 7 am - 7 pm - wounds listed but not assessed 7/12/11 - 7 am - 7 pm - no documentation of coccyx wound Review of the physician orders dated 6//24/11 revealed an order to transfuse 2 units of packed red blood cells. Review of the medical records revealed no evidence that the blood was administered. There was also no documentation that the blood administration had been canceled by the physician.
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