**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34126 Based on record review and interview the facility failed to ensure practices were put in place to prevent facility acquired pressure ulcers and failed to prevent the worsening of facility acquired pressure ulcers for 2 of 3 sampled patients, Patients #1 and #3. Findings: A clinical record review of Patient #1's record revealed the patient was admitted to the facility on [DATE] without a pressure ulcer. The patient was bedbound. Diagnosis consisted of Chronic Obstructive Pulmonary Disease (COPD), Stroke, Mental status change, poorly controlled diabetes, legally blind, anxiety, atrial fibrillation. During an interview on 06/21/2018 with the wound care therapist Staff D RN/therapy (Registered Nurse) at 1:59 PM, it was stated Patient #1 was found to have pressure ulcers when she was evaluated by wound care on 12/12/2017. Therapy recommended the patient be on a strict every two hour turn schedule. Therapy makes the recommendation and nursing gets the physician order. During an interview on 06/21/2018 at 3:50 PM, with Staff F, RN 4 South Nurse Manager it was stated, when the nurse is documenting partial thickness that means a pressure ulcer. A skin assessment is completed once a day. A description of a full thickness wound would be a stage 3 pressure ulcer, a description of a partial thickness wound would be a stage 2 pressure ulcer. Staff F, RN confirmed the pressure wounds for Patient #1 were facility acquired. A clinical record review for Patient #1 revealed the patient was incontinent of bowel and bladder. The skin was blanchable. The patient had skin excoriation (Excoriated skin is skin that has developed a sore or ulcer from urine exposure) to the posterior coccyx. The initial nursing assessment was completed on 11/27/2017. The skin assessment revealed the patient's skin was warm and dry. A review of the nursing assessments From 11/28/2017 to 12/10/2017 revealed the following: the patient's skin remained with excoriation to the posterior coccyx. There is no documentation to reveal the patient was turned and repositioned during this time frame to help prevent the development of a facility acquired pressure wound. On 12/08/2018 a review of the nurse's notes at 2:27 PM revealed Left mid back with opened blisters covered with Mepiplex. Turned and repositioned every 2 hours for comfort and skin integrity (no documented times the patient was actually turned or which position the patient was placed). On 12/11/2017 the patient's skin remained with excoriation to the posterior coccyx. At 8 PM it was observed the patient had excoriation to lateral back middle. The Patient still had excoriation to her posterior coccyx. On 12/12/2017 at 2:13 AM the nurse documented the patient was repositioned every 2 hours (no documented times the patient was actually turned or which position the patient was placed). A review of the wound therapy note at 4:10 PM revealed moist fragile slouching skin of sacrum and buttocks. Cleansed and dressed to treatment plan. The patient was to be on a Strict 2 hour turn schedule. 0n 12/13/2017 9:56 AM the patient had excoriation to lateral back middle, and posterior coccyx. Cannot calculate area. At 11:00 PM the nurse documented the patient had superficial coccyx wound with partial thickness. 0n 12/14/2017 9:30 AM the patient had excoriation to lateral back middle, and posterior coccyx. Full thickness wound to coccyx. And at 10:36 PM unable to determine back wound area. Coccyx partial thickness dressing changed. 0n 12/15/2017 the patient had excoriation to lateral back middle, and posterior coccyx. The wound was described as Partial thickness. 0n 12/16/2017 the patient had excoriation to lateral back middle, and posterior coccyx. The coccyx wound was described as Partial thickness. 0n 12/17/2017 the patient had excoriation to lateral back middle, and posterior coccyx. The wound was described as partial thickness. 0n 12/18/2017 at 4:04 PM the patient had excoriation to lateral back middle, and posterior coccyx. The patient had a pressure injury related to posterior coccyx. Deep tissue injury. Unstageable pressure injury. 0n 12/19/2017 8:45 AM the patient had excoriation to lateral back middle, and posterior coccyx. The patient had a pressure injury related to posterior coccyx. Deep tissue injury. Stage 3 pressure ulcer. Serosagnious drainage. 0n 12/20/2017 10:26 AM the patient had excoriation to lateral back middle, and posterior coccyx. The patient had a pressure injury to posterior coccyx. Deep tissue injury. Stage 3 pressure ulcer. Small amount of bleeding. A review of the nursing documentation completed during shift assessments from 11/27/2017 to 12/20/2017 showed documentation twice that the patient was turned and repositioned (with no time parameters or position documented). The therapy recommendation was that the patient be on a strict two hour turning schedule. A review of the nurses noted dated 12/19/2017, revealed the wound was measured on 12/19/17 by the nurse. The nurse noted the coccyx wound increased in size compared to Sunday. The nurse documented the coccyx wound was around 1 inch X 1 inch. But today noted much bigger dark discoloration, and per report from previous shift. A review of the wound care consult ordered on 12/12/17. Revealed the patient had moist fragile sloughing skin of sacrum and buttocks. Strict 2 hour turn schedule. P-500 (specialty bed) placed. Presents with pressure injuries. Injury to right back and sacrum area. The patient would benefit from rehab and dressing selection. Discharge to nursing for daily wound care. Sacrum friction shear. Right back pressure stage 2. Sacrum wound stage 2 was 12 Centimeters (CM) X 8 CM and the back was 2.5 CM X 1.5 CM. A clinical record review showed there was no standard care plan documented for the prevention of pressure ulcers. The nursing care plans completed by nursing did not address the patient's pressure ulcers. A clinical record review of patient #3's record revealed the patient was admitted to the facility on [DATE] with a diagnosis of generalized weakness. A clinical record review of Patient #3's admission assessment dated [DATE] revealed the patient's skin on admission was clean and dry. There was no documentation to show the patient was admitted to the facility with pressure wounds. The clincal record for the period of 01/08/2018 to 01/11/2018 revealed the patient's skin was clean and dry. A clinical record review of the nurses assessment completed on 01/12/2018 revealed the patient's skin on her buttocks was reddened but blanchable. A clinical record review of the integrity assessment dated [DATE] revealed the patient has a pink but blanchable cup sized region on sacrum. Her sacrum and coccyx protrude. The patient is being turned every two hours to prevent skin breakdown (no documentation to show the times the patient was turned or what position the patient was turned). A clinical record review from 01/14/18 to 01/22/18 revealed as documented in the integrity assessment, the patient has pink but blanchable cup sized region on sacrum. Her sacrum and coccyx protrude. A clinical record review on 01/23/2018 of the wound consult completed by therapy revealed the patient had excoriation to the posterior buttock right. The wound care consult revealed the patient had a Stage 3 sacral decubitus ulcer. Wound #1 sacrum size 4.4 Centimeters (CM) X 4.2 CM. Wound bed pink with small areas of yellow slough in center, RN in room during wound care. Patient will benefit from rehab wound care for dressing selection. Education for pressure relief and wound healing. A clinical record review On 01/25/2018 at 2:31 PM revealed the patient had excoriation posterior buttock right. The nurse's note at 8:26 AM revealed the nurse was unable to determine document advanced wound measurements. Wound care note for the wound flowsheet revealed wound location sacrum. Serous drainage. Size 4.4 CM X 4.2 CM. A review of the interdisciplinary note revealed the sacral wound has stabilized. At risk for further breakdown related to impaired nutrition and mobility, Will discharge (d/c) to nursing, medication in meditec and supplies at bedside. Nurses assessment revealed the patient has excoriation and a stage 2 pressure ulcer. A clinical record review of the nursing assessments from 01/29/2018 and 01/30/2018 did not show documentation the patient was turned and repositioned. A clinical record review of the nursing assessments from 02/01/2018 did not show documentation the patient was turned and repositioned. A clinical record review on 02/04/2018 at 7:35 AM revealed the patient had a stage 2 pressure ulcer to posterior buttock right. A review of the Interdisciplinary notes at 9:39 AM central portion of sacral wound debrided and cleaned. Rehab note at 9:40 AM stage 3 pressure ulcer with serous drainage. 4.5 X 3.2.

30466 Based on interview(s), reviews of medical records and policy and procedures the hospital failed to provide a medical screening examination and evaluation for one (#1) of 34 patients presenting to the hospital to determine if an emergency medical condition existed. Refer to finding in Tag A-2406. Based on interview(s), reviews of medical records and policy and procedures the hospital failed to provide stabilizing treatment that was within the capability of the hospital as required for one (#1) of 34 patients presenting to the hospital to emergency department. Refer to findings in tag A-2407. Based on review of policy and procedures, and staff interview the facility failed to ensure that their policy and procedures regarding transfers was followed by failing to appropriately transfer an individual by not ensuring that medical treatment was first provided that was within the capability and capacity of the hospital to minimize risks to the individuals health; and failed to ensure the receiving hospital was contacted, and had agreed to accept the patient and had space and qualified personnel available to for treatment of 1 (#1) of 34 sampled patients. Refer to findings in Tag A-2409

30466 Based on interviews and medical record reviews the hospital failed to maintain records for one (#1) of 34 patients sampled presenting to the hospital emergency department. Findings are: Review of the patient's medical record from the transferring hospital for patient #1 revealed she was transferred via EMS to North Florida Regional Medical Center on 01/22/2014. Review of the Physicians Certification of Medical Necessity for Ambulance Transportation dated 01/22/2014 revealed: Destination: North Florida Regional Medical Center ER. Patient's physical condition and/or medical interventions that make transportation by ambulance medically necessary: Large gastric ulcer - weakness. Family wants transfer North Florida Regional. The transfer form was signed by the physician. The physician noted an accepting physician. Review of the transferring hospital nurses notes on 01/22/2014 revealed: 15:34 Report called to RN (Registered Nurse) at NFRMC ER. Transferred by EMS ground to North Florida Regional Medical Center. 15:36 ER care complete, transfer ordered by MD 16:22 Patient left the ED On 02/07/2014 at 3:45 PM a call to the Emergency Department Charge Nurse revealed she was in charge on January 22, 2014 when the patient was transferred to North Florida Regional Medical Center. She received a phone call from the nurse at the transferring hospital to give report. She determined the Emergency Department physicians had not accepted this patient. She told the transferring hospital to call the transport center and tell them which hospital they were to send the patient to. She and the ED physician went out to the ambulance when it arrived. The patient was then transported to another facility. The patient was not examined by the physician. On 02/07/2014 at 11:45 AM interview with the Emergency Department physician revealed the female patient was transferred to the facility via EMS from another hospital. She stated she called the transport center and determined the patient was to go to a different facility. The physician spoke with the ambulance driver and informed her patient was going to the other hospital. The physician stated patient never got out of the ambulance and was not examined. The hospital was unable to provide the surveyor with patient records at the facility on the date the patient#1 arrived via ambulance.

30466 Based on interview and reviews of medical record(s), Central Logs and policies and procedures, review the hospital failed to maintain records for one (#1) of 34 patients sampled presenting to the hospital emergency department. Findings are: A review of the policy and procedures 900-1.307.400 EMTALA - Florida Central Log Policy effective 04/12 revealed: The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she was refused treatment, or whether he or she was transferred or discharged . The Central log of individuals who have come to the hospital seeking medical attention or who appeared to need medical attention will be available within a reasonable amount of time for surveyor review and must be retained for a minimum of five years from the date of disposition of the individual. Review of the patient's (#1) medical record from the transferring hospital for patient #1 revealed she was transferred via EMS to North Florida Regional Medical Center (NFRMC) on 01/22/2014. On 02/07/2014 at 3:45 PM a call to the Emergency Department Charge Nurse revealed she was in charge on January 22, 2014 when the patient (#1) was transferred to North Florida Regional Medical Center. On 02/07/2014 at 11:45 AM interview with the Emergency Department physician verified the female patient (#1) was transferred to the facility via EMS from another hospital. She stated she called the transport center and determined the patient was to go to a different facility. The hospital failed to ensure that their policy and procedure on central log was followed as evidenced by failing to maintain central log information on patient #1 on 1/22/2014 when she presented to North Florida Regional Medical Center via ambulance.

30466 Based on interviews, reviews of medical records, policies and procedures the hospital failed to provide a medical screening, examination and evaluation for one (#1) of 34 patients presenting to the hospital's emergency department to determine if an emergency medical condition existed. Findings are: Review of the medical record for patient #1 revealed she was transferred via EMS to North Florida Regional Medical Center on 01/22/2014. Review of the Physicians Certification of Medical Necessity for Ambulance Transportation dated 01/22/2014 revealed: Destination: North Florida Regional Medical Center ER. Patient's physical condition and/or medical interventions that make transportation by ambulance medically necessary: Large gastric ulcer - weakness. Family wants transfer North Florida Regional. The transfer form was signed by the physician. The physician noted an accepting physician. Review of the transferring hospital nurses notes on 01/22/2014 revealed: 15:34 Report called to RN (Registered Nurse) at NFRMC ER. Transferred by EMS ground to North Florida Regional Medical Center. 15:36 ER care complete, transfer ordered by MD 16:22 Patient left the ED On 02/07/2014 at 3:45 PM a call to the Emergency Department Charge Nurse revealed she was in charge on January 22, 2014 when the patient was transferred to North Florida Regional Medical Center. She received a phone call from the nurse at the transferring hospital to give report. She determined the Emergency Department physicians had not accepted this patient. She told the transferring hospital to call the transport center and tell them which hospital they were to send the patient to. She and the ED physician went out to the ambulance when it arrived. The patient was then transported to another facility. The patient was not examined by the physician. On 02/07/2014 at 11:45 AM interview with the Emergency Department physician revealed the female patient was transferred to the facility via EMS from another hospital. She stated she called the transport center and determined the patient was to go to a different facility. The physician spoke with the ambulance driver and informed her the patient was going to the other hospital. The physician stated patient never got out of the ambulance and was not examined. She said she has since learned she had to get the patient out of ambulance and medically screen them once they arrive on the property. A review of the facility policy and procedures for the Florida Medical Screening Examination and Stabilization Policy #900-1.307 Effective 03/13 revealed: An MSE is required when: a. ii. The individual arrives as a transfer from another hospital or health care facility. Upon arrival of a transfer, a physician or qualified medical person (QMP) must perform an appropriate MSE. The Physician or QMP shall provide any additional screening and treatment required to stabilize the EMC. The MSE of the individual must be documented. This type of screening cannot be performed by the triage nurse. d. An individual is in a ground or air ambulance for purposes of examination and treatment for a medical condition at a hospital's DED, and the ambulance is either: owned and operated by the hospital, even if the ambulance is not on hospital grounds, or neither owned nor operated by the hospital, but on hospital property. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to perform a medical screening examination upon arrival of a transfer by a Physician or Qualified Medical Professional for patient#1 on 1/22/2014.

30466 Based on interviews, reviews of medical records and policy and procedures the hospital failed to provide stabilizing treatment that was within the capability of the hospital as required for one (#1) of 34 patients presenting to the hospital to emergency department. Refer to findings in tag A-2407. Findings are: A review of the facility policy and procedures for the Florida Medical Screening Examination and Stabilization Policy #900-1.307 Effective 03/13 revealed: 8. Stabilizing treatment within hospital capability and transfer. Once the hospital has provided an appropriate MSE and stabilizing treatment within its capability, an appropriate transfer may be affected by following the appropriate transfer provisions Review of the medical record for patient #1 revealed she was transferred via EMS to North Florida Regional Medical Center on 01/22/2014. Review of the Physicians Certification of Medical Necessity for Ambulance Transportation dated 01/22/2014 revealed: Destination: North Florida Regional Medical Center ER. Patient's physical condition and/or medical interventions that make transportation by ambulance medically necessary: Large gastric ulcer - weakness. Family wants transfer North Florida Regional. The transfer form was signed by the physician. The physician noted an accepting physician. On 02/07/2014 at 11:45 AM interview with the Emergency Department physician revealed the female patient was transferred to the facility via EMS from another hospital. She stated she called the transport center and determined the patient was to go to a different facility. The physician spoke with the ambulance driver and informed her patient was going to the other hospital. The physician stated patient never got out of the ambulance and was not examined. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to provide stabilizing treatment as required that was within the capability and capacity of the hospital for patient #1 on 1/22/2014.

30466 Based on review of policy and procedures, and staff interview the facility failed to ensure that their policy and procedures regarding transfers was followed by failing to appropriately transfer an individual by not ensuring that medical treatment was first provided that was within the capability and capacity of the hospital to minimize risks to the individual's health; and failed to ensure the receiving hospital was contacted, and had agreed to accept the patient and had space and qualified personnel available to for treatment of 1 (#1) of 34 sampled patients Findings are: Review of the Florida Transfer Policy effective 03/13 EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC (emergency medical condition) apply to any dedicated emergency department (DED) of a hospital whether located on or off the hospital campus and all other departments of the hospital located on hospital property. Transfer of individuals who are not medically stable Requirements prior to transfer: The following requirements must be met for any transfer of an individual with an EMC that has not been stabilized. i. Minimize the risk. Before any transfer may occur, the transferring hospital must first provide, within its capacity and capability, medical treatment to minimize the risks to the health of the individual or unborn child. ii. Any transfer to another medical facility of an individual with an EMC must be in initiated either by written request for transfer from the individual or the legally responsible person acting on the individual ' s behalf or by a physician order with the appropriate physician or QMP and Physician certification as required under EMTALA. iii. Medically necessary transfers shall be to the geographically closest hospital with service capability unless a prior arrangement is in place or the geographically closest hospital lacks capacity or refuses to consent to the transfer. iv. The transferring hospital must call the receiving hospital or the Transfer Center if the facility is part of a Transfer Center network, to verify the receiving hospital has available space and qualified personnel for the treatment of the individual. The receiving hospital must agree to accept the transfer and provide appropriate treatment. The transferring physician shall ensure that a receiving hospital and physician that are appropriate to the medical needs of the individual have accepted responsibility for the individual ' s medical treatment and hospital care. v. The transferring hospital must document its communication with the receiving hospital, including the request date and time and the name of the person accepting the transfer. vi. The transferring hospital must sent to the receiving hospital copies of all medical records available at the time of transfer related to the EMC and continuing care of the individual. vii. A physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonable expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred. viii. If a physician is not physically present at the time of the transfer a QMP may sign the certification, after consultation with a physician. A physician shall countersign it within 24 hours ix. Memorandum of transfer must be completed for every patient who is transferred to another separately licensed hospital. A copy of the memorandum of transfer shall be retained by the transferring and receiving hospitals. On 02/07/2014 at 3:45 PM a call to the Emergency Department Charge Nurse revealed she was in charge on January 22, 2014 when the patient was transferred to North Florida Regional Medical Center. She received a phone call from the nurse at the transferring hospital to give report. She determined the Emergency Department physicians had not accepted this patient. She told the transferring hospital to call the transport center and tell them the hospital they were to send the patient to. She and the ED physician went out to the ambulance when it arrived. The patient was then transported to another facility. The patient was not examined by the physician. The facility failed to ensure that their policy an procedure regarding the appropriate transfer of an individual was followed as evidenced by there was no medical record of treatments offered for patient #1. The patient was transported to another acute care facility without even getting out of the ambulance upon arrival to North Florida Regional Medical Center. The facility failed to contact the receiving hospital to obtain verbal confirmation that the receiving hospital had agreed to accept Patient #1 on 1/22/2014.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27676 Based on interview and record review the facility failed to ensure that nursing staff with competencies to meet the needs of the patient were assigned for 1 of 5 patients reviewed (#1) Findings: Record review for patient #1 reveals that the patient was admitted for an aortic femoral bypass graft and initially did well postoperatively was transferred from intensive care to the fourth floor for continuing care on [DATE] she had a change in condition on [DATE] at approximately 9:00 PM that was identified by the nurse, but not reported to the physician. The record reveals that the patient was diagnosed with a cerebral vascular accident on [DATE] and was transferred back to intensive care where she was treated with conservative medical treatment until she expired the record also reveals that the patient had consented to treatment and that she was assessed by a registered nurse and had a plan of care developed. Review of the nurses notes for patient #1 dated [DATE] reveals that the patient had ambulated in the hall three times. Further review reveals no notes dated for [DATE]. A note dated [DATE] and timed at 6:19 AM states that at 9:00 PM the patient was confused and trying to get out of bed and that as of 6:00 AM the patient is sleeping with no change in condition. A note dated [DATE] and time at 7:35 AM states that the daughter was called at 9:00 PM and that the daughter could not come in the note also indicates that the physician was call at 7:30 AM and told patient is confused. Note dated [DATE] at 08:15 states family expressed concern for mother condition. A note on [DATE] at 11:00 AM reveals family asking for physician and very concerned. A note dated [DATE] at 2:10 PM reveals that the family was still concerned and physician had ordered a scan. A note from the charge nurse dated [DATE] at 4:31 PM indicates that she was informed by the physician at 2:00 PM that patient #1 was not responding correctly and that he ordered a stat scan. Review of the physicians note date on [DATE] at 1:00 PM reveals that family stated patient became progressively more confused since prior to discharge from intensive care and that the physician was called at 7:00 AM and told patient was confused with no other issues. Review of the nursing assessment dated [DATE] at 08:00 AM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened spontaneously, that she was confused being disoriented to time and place, the assessment also reveals that the patient follows commands. Review of the nursing assessment dated [DATE] at 08:00 PM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened spontaneously, that she was confused being disoriented to time and place, the assessment also reveals that the patient follows commands. Review of the nursing assessment dated [DATE] at 08:00 AM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened never, that she could not be assessed for orientation, the assessment also reveals that the patient follows localizes pain and that her speech is incomprehensible. During interview with the nurse #3 who was the charge nurse on [DATE] at 10:45 AM she stated that she remembered the situation with patient #1 and that she had been asked on [DATE] to check on the patient's IV and found that it only needed to be repositioned and re-taped. She was asked to look at the patient #1's IV again on [DATE] and stated that she told the nurse that if it remained positional it would have to be restarted. She further stated that at that time she was asked by patient #1 ' s family if the patient had received medication that was making her lethargic. She stated that at that time she went to check the medication administration record and that by the time she had reviewed it that the physician had come in to examine the patient and found her to have severe confusion, right sided weakness, and slurred speech. She also stated the physician ordered a CAT Scan of the head and that patient #1 be transferred to intensive care. During interview with nurse #4 on [DATE] at 10:50 AM she stated that she had received in-service training on recognizing a stroke and that the signs and symptoms included slurred speech and single sided weakness. She also stated that if her patient had these signs and symptoms that she would call an STP. When asked what STP is she stated that it is the hospitals code for needing clinical assistance. During interview with the surgeon caring for patient #1 on [DATE] he stated that he had found the patient very lethargic, with no motor activity on the right side and unintelligible speech. He further stated that he had been called at 7:00 AM on [DATE] and given only information that the patient needed a sitter because she was restless. During an interview with the Director of Nursing on [DATE] at 2:30 PM she stated that the incident with patient #1 was on the agenda for nursing peer review and that the results would be reported to the Quality Assurance (QA) committee and then to medical executive committee and finally to the governing board. She also stated that agency nurses would have to complete the stroke training prior to the first shift working in the future and that the Clinical Nurse Director for the fourth floor had been demoted and transferred after review of the nursing competencies revealed several nurses on that floor had expired competencies and that a new clinical nurse had been hired. Review of the training record for the fourth floor reveals that a complete audit of all nurse trainings was conducted and that now all nurses are current. A review of the training record for the entire hospital reveals that all nurses are current and that the fourth floor was the only location with deficiencies prior to [DATE]. Review of the facility provided stroke overview and policy review reveals: If you suspect a patient in the hospital is having a stroke, notify the patient's nurse immediately. The nurse should notify the charge nurse of the unit. The charge nurse and the primary nurse should quickly evaluate the patient. If the determination is made that the patient may be experiencing a stroke or TIA the nurse should call the operator and notify of a STP ALERT on their unit The Abbreviation STP stands for stroke team protocol. The time of symptom onset should be determined and documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27676 Based on record review and interviews the facility failed to ensure that contract nursing staff had competencies to meet the needs of the patient they were assigned for 1 of 5 patients reviewed (#1) Findings: Record review for patient #1 reveals that the patient was admitted for an aortic femoral bypass graft and initially did well postoperatively was transferred from intensive care to the fourth floor for continuing care on [DATE] she had a change in condition on [DATE] at approximately 9:00 PM that was identified by the nurse, but not reported to the physician. The record reveals that the patient was diagnosed with a cerebral vascular accident on [DATE] and was transferred back to intensive care where she was treated with conservative medical treatment until she expired the record also reveals that the patient had consented to treatment and that she was assessed by a registered nurse and had a plan of care developed. Review of the nurses notes for patient #1 dated [DATE] reveals that the patient had ambulated in the hall three times. Further review reveals no notes dated for [DATE]. A note dated [DATE] and timed at 6:19 AM states that at 9:00 PM the patient was confused and trying to get out of bed and that as of 6:00 AM the patient is sleeping with no change in condition. A note dated [DATE] and time at 7:35 AM states that the daughter was called at 9:00 PM and that the daughter could not come in the note also indicates that the physician was call at 7:30 AM and told patient is confused. Note dated [DATE] at 08:15 states family expressed concern for mother condition. A note on [DATE] at 11:00 AM reveals family asking for physician and very concerned. A note dated [DATE] at 2:10 PM reveals that the family was still concerned and physician had ordered a scan. A note from the charge nurse dated [DATE] at 4:31 PM indicates that she was informed by the physician at 2:00 PM that patient #1 was not responding correctly and that he ordered a stat scan. Review of this patient's record revealed that nurse #1 and #2 took care of this patient prior to the physician determining that the patient had suffered a stroke. Review of the physicians note date on [DATE] at 1:00 PM reveals that family stated patient became progressively more confused since prior to discharge from intensive care and that the physician was called at 7:00 AM and told patient was confused with no other issues. Review of the nursing assessment dated [DATE] at 08:00 AM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened spontaneously, that she was confused being disoriented to time and place, the assessment also reveals that the patient follows commands. Review of the nursing assessment dated [DATE] at 08:00 PM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened spontaneously, that she was confused being disoriented to time and place, the assessment also reveals that the patient follows commands. Review of the nursing assessment dated [DATE] at 08:00 AM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened never, that she could not be assessed for orientation, the assessment also reveals that the patient follows localizes pain and that her speech is incomprehensible. During interview with the surgeon caring for patient #1 on [DATE] he stated that he had found the patient very lethargic, with no motor activity on the right side and unintelligible speech. He further stated that he had been called at 7:00 AM on [DATE] and given only information that the patient needed a sitter because she was restless. During an interview with the Director of Nursing on [DATE] at 0930 AM she stated nurse #2 was an agency nurse and that she was no longer used by the facility. When asked if this was the facilities decision or the nurses she stated that it was the facilities decision. During interview with the nurse #3 who was the charge nurse on [DATE] at 10:45 AM she stated that she remembered the situation with patient #1 and that she had been asked on [DATE] to check on the patient's IV and found that it only needed to be repositioned and re-taped. She was asked to look at the patient #1's IV again on [DATE] and stated that she told the nurse that if it remained positional it would have to be restarted. She further stated that at that time she was asked by patient #1 ' s family if the patient had received medication that was making her lethargic. She stated that at that time she went to check the medication administration record and that by the time she had reviewed it that the physician had come in to examine the patient and found her to have severe confusion, right sided weakness, and slurred speech. She also stated the physician ordered a CAT Scan of the head and that patient #1 be transferred to intensive care. During an interview with the Director of Nursing on [DATE] at 2:30 PM she stated that the incident with patient #1 was on the agenda for nursing peer review and that the results would be reported to the QA committee and then to medical executive committee and finally to the governing board. She also stated that agency nurses would have to complete the stroke training prior to the first shift working in the future and that the Clinical Nurse Director for the fourth floor had been demoted and transferred after review of the nursing competencies revealed several nurses on that floor had expired competencies and that a new clinical nurse had been hired. Review of the training record for the fourth floor reveals that a complete audit of all nurse trainings was conducted and that now all nurses are current. A review of the training record for the hospital reveals that all nurses are current and that the fourth floor was the only location with deficiencies prior to [DATE]. Review of the facility provided stroke overview and policy review reveals: If you suspect a patient in the hospital is having a stroke, notify the patient's nurse immediately. The nurse should notify the charge nurse of the unit. The charge nurse and the primary nurse should quickly evaluate the patient. If the determination is made that the patient may be experiencing a stroke or TIA the nurse should call the operator and notify of a STP ALERT on their unit The Abbreviation STP stands for stroke team protocol. The time of symptom onset should be determined and documented.