CMS-HCA-Florida-Ocala-Hospital

Based on interview, review of the policy and procedure, and review of the Central Log the facility failed to ensure patients presenting to the Emergency Department (ED) for treatment were documented on the Central Log for 1 (#1)of 20 patients sampled, Patient #1.

Findings:

Review of the event description on 04/08/18 at 7:50 AM for Patient #1 showed the Patient presented to the ED with her significant other to the waiting room. Patient #1 was new to the area and asked a friend which hospital had obstetric services because her water broke. The friend informed her of the hospital across the street had obstetric services, but had dropped her at this facility. Patient #1 asked the paramedic at the desk which facility this was and asked if it had obstetric services. The paramedic at the desk informed it did not. The triage RN (Registered Nurse) had the charge nurse speak with the patient. The charge nurse informed patient #1 that the physician at this facility could see her and then if needed, she could be transported to the facility across the street. Patient #1 refused and asked about getting EMS (Emergency Medical Services) to transport her to the other facility. Staff stayed with the patient until EMS arrived and advised EMS that this facility would have taken care of her, but patient #1 had refused.

Review of Central Log for 04/08/18 showed that Patient #1 did not sign in to the Central Log.

Review of the facility's policy and procedure titled EMTALA - Definitions and General Requirements (Emergency Medical Treatment and Labor Act) revised 02/01/16 showed it is a log that the facility is required to maintain on each individual whether she refused treatment or if treatment was given. The purpose of the Central Log is to track care provided to each individual where EMTALA is triggered.

Review of the facility's policy and procedure titled Florida EMTALA - Central Log Policy revised 02/01/2016 showed the purpose is to establish guidelines for tracking the care provided to each individual seeking care in a dedicated emergency department for a medical condition. The hospital will maintain a Central Log containing information on each individual who requests emergency services. Whether he/she left before medical screening or refusal of treatment. The Central Log at a minimum must contain the name of the individual and if that individual refused treatment.

During an interview on 05/29/18 at 9:23 AM with the Director of Quality it was stated that she remembered this case. The patient did refuse care, many attempts were made from the RNs (Registered Nurses) to have the patient be checked and the patient refused. This facility should have had her sign in or had more than one RN witness the refusal.

During an interview on 05/29/18 at 10:10 AM with Staff A, RN, who was triage RN when patient #1 presented to the ED (Emergency Department), she stated the Patient presented to triage. The paramedic in triage, was advised by the patient that her water broke and the triage RN went to get the Charge Nurse. Staff A states she did not put Patient #1's name on the Central Log or have the patient sign any refusal form.

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Based on review of policies and procedures and staff interviews it was determined the facility failed to take reasonable steps to secure the individuals written informed refusal by failing to document the individual had been informed of the risks and benefits of the examination or treatment or both for 1 (#1) of 20 sampled patients to the emergency department.

Findings were:

The facility's policy and procedure titled, Against Medical Advice (AMA), Patient Leaving/Elopement, PolicySTATID: 56; Effective: 4/12/2015; Approved: 4/16/2018 was reviewed. The policy revealed in part, PURPOSE: Establish criteria for documentation of patients leaving AMA (against medical against). POLICY ... 3. If after an explanation of potential consequences, the patient still wishes to leave AMA, request the patient sign the AMA form.

The facility's Policy and procedure titled, Florida EMTALA- Medical Screening Examination and Stabilization Policy PolicyStatID: 98; Effective: 4/1/2018; Approved: 4/1/2018 was reviewed. The policy specified in part, Refusal to consent to Treatment: Written Refusal- Partial Refusal of Care or Against Medical Advice. If a physician or QMP has begun the MSE or any necessary treatment and an individual refuses to consent to a test, examination or treatment or refuses any further care and is determined to leave against medical advice, after being informed of the risks and benefits of the hospital's obligation under EMTALA, reasonable attempts shall be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individuals refusal to sign the Partial Refusal of Care or the Against Medical Advice Form ...The medical record must contain a description of the screening and the examination or both if applicable, that was refused by or on behalf of the individual ...Documentation of Information. If an individual refuses to sign a consent form, the physician of nurse must document that the individual has been informed of the risks and benefits of the examination and/or treatment but refused to sign the form.

During an interview on 05/29/18 at 9:23 AM with the Director of Quality it was stated that she remembered this case. The patient (#1) did refuse care, many attempts were made from the RNs (Registered Nurses) to have the patient (#1) be checked and the patient refused. This facility should have had her (patient #1) sign in or had more than one RN witness the refusal.

During an interview on 05/29/18 at 10:10 AM with Staff A, RN, who was triage RN when patient #1 presented to the ED (Emergency Department), she stated the Patient presented to triage. The paramedic in triage, was advised by the patient that her water broke and the triage RN went to get the Charge Nurse. Staff A states she did not have Patient #1 sign any refusal form.

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Based on review of patient care report (ambulance report), facility's Event Description Report and Policy and procedure it was determined the facility failed to appropriately transfer 1 (Patient #1) of 20 sampled patients who presented to the emergency department in active labor.

Findings were:

1. Ambulance Report for Patient #1

A review of the Patient #1's Patient Care Report dated 4/8/2018 at 7:58 was reviewed. The report revealed the patient's chief complaint was, water broke at 7 am someone dropped them off at Ocala Regional. We are transporting the patient to Hospital B (Acute care hospital). The patient's vital signs were listed as Blood Pressure 150/83; Heart rate: 93; Respirations:20; and oxygen saturation: 98% on room air. Further review of the report revealed the patient was in active labor. The section of the note titled Additional Comments specified in part, Rescue ...dispatched urgently to ORMC (Ocala Regional Medical Center) for a transfer to Hospital B, 37 y.o.f (year old female) was in their waiting room due to her water breaking at 7 AM, they told her that they can't treat her due to not having a labor and Delivery service at that hospital. Pt. stood up and pivoted to the stretcher. Patient monitored en route to Hospital B. She is a G6P5, her contractions are approximately 5 minutes apart. Pt had no changes throughout transport. Once at Hospital B, pt. taken straight to L & D (labor and delivery).

2. Event Description Report

Review of the event description on 04/08/18 at 7:50 AM for Patient #1 showed the Patient presented to the ED with her significant other to the waiting room. Patient #1 was new to the area and asked a friend which hospital had obstetric services because her water broke. The friend informed her of the hospital across the street had obstetric services, but had dropped her at this facility. Patient #1 asked the paramedic at the desk which facility this was and asked if it had obstetric services. The paramedic at the desk informed patient #1, it did not. The triage RN (Registered Nurse) had the charge nurse speak with the patient. The charge nurse informed patient #1 that the physician at this facility could see her and then if needed, she could be transported to the facility across the street. Patient #1 refused and asked about getting EMS (Emergency Medical Services) to transport her to the other facility. Staff stayed with the patient until EMS arrived and advised EMS that this facility would have taken care of her, but patient #1 had refused.

3. Policy and Procedure

The facility's policy and procedure titled Florida EMTALA- Transfer Policy PolicyStatID: 12; Effective: 2/1/2016; Approved: 2/1/2016 was reviewed. The policy revealed in part , POLICY: Any transfer of an individual with an EMC (Emergency Medical Condition) must be initiated wither by a 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 certification as required under EMTALA. EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC apply to any emergency department (ED) ...1. Transfer of Individuals Who Have Not Been Stabilized. A. if an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer and meets the following conditions:

1. Transfer of Individuals Who Have Not Been Stabilized

a. If an individual who has come to the emergency department has an EMC that has been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer and meets the following conditions:

1. The individual or a legally responsible person on the individual's behalf requests the transfer, after informed of the hospital's obligations under EMTALA and or the risks and benefits of such transfer. The request must be in writing and indicate the reasons for the request as well as indicate that the individual is aware of the risk and benefits of transfer.

b. A transfer will be appropriate transfer if:

i. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child;

ii. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment;

iii. The transferring hospital sends the receiving hospital copies of all medical records related to the EMC for which the individual requested emergency services that are available at the time of transfer ...;

iv. The transfer is effected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transport.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to:

a. Document that patient #1 was aware of the risk and benefits of transfer;

b. To provide medical treatment that was within its capacity to minimize the risk to patient #1 who was in labor and the health of her unborn child; and

c. Notify the receiving facility (Hospital B) to ensure they had space and qualified personnel to provide treatment for patient #1 and had agreed to accept patient #1 for treatment on 4/8/2018.

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

Based on interview, record review and policy and procedure review, the facility failed to ensure patient's rights were provided to the patient or responsible party for 1 of 5 sampled patients, Patient #1.

Findings:

Record review of the History and Physical for Patient #1 showed dated 03/14/2017, This is an [AGE] year old gentleman, demented severely.

Record review of the Conditions of Admission of Consent for Outpatient Care showed dated 03/13/2017 under Patient/Patient Representative Signature: Patient unable to sign. With two staff witnessing the form.

Record review of the History and Physical - Medical Clearance showed dated 04/08/2017 80- year-old male with history of dementia presents to the emergency department from The Vines for medical clearance. Staff from the memory care facility states patient was combative and swinging at nurses, so he was Baker Acted. History and physical limited due to patient's condition (dementia).

Record review of the Conditions of Admission of Consent for Outpatient Care showed dated 04/08/2017 under Patient/Patient Representative Signature: Patient unable to sign. With two staff witnessing the form.

Record review of the Diagnoses Admit Diagnoses showed dated 06/12/2017 Dementia.

Record review of the Conditions of Admission of Consent for Outpatient Care showed dated 06/13/2017 under Patient/Patient Representative Signature: Agitated. With two staff witnessing the form.

During an interview on 08/11/2017 at 3:58 PM with the Director of Patient Financial Services (DPFS) when asked if patient's rights are part of the Conditions of Admission of Consent for Outpatient Care, the DPFS stated, Yes, they are. The Conditions of Admission of Consent for Outpatient Care were reviewed with the DPFS for Patient #1. When asked why the patient's spouse was not provided with the information the DPFS stated, When a patient is not able to sign all we have to do is have two witnesses to show the patient is not able to sign. When asked in the case of a severely demented patient, an agitated patient, or if a patient is unable to sign should the responsible party be made aware of the patient's rights, and the Conditions of Admission the DPFS stated, Was she here to the hospital? Again, when asked when there is a medical condition that does not allow for the patient to sign as having received their patient's rights and Conditions of Admission should their responsible party be provided the information the DPFS did not answer. .

During an interview on 08/11/2017 at 4:50 PM with the Registered Nurse/Chief Nursing Officer she stated, There is no verification the patient's wife was informed of the patient's rights.

During an interview on 08/11/2017 at 5:32 PM with the Chief Executive Officer West Marion (CEO) when the concerns of the complaint investigation were completed she stated, Two people witnessed the resident wasn't able to sign the paperwork for the conditions of admission. When asked if the responsible party should have been notified of the patient's rights, and be provided the admission paperwork the CEO stated, Was she here in the hospital? The CEO stated, Well, I guess we could send it through the mail.

Record review of the Policy and Procedure titled, Informed Consent Effective: 03/01/2000, Approved: 12/28/2016 showed Policy: A general consent form signed by or on behalf of every patient admitted to the hospital, must be obtained at the time of admission and is valid for the duration of hospitalization .

Record review of the Policy and Procedure titled, Florida Model Statement of Patient Rights and Responsibilities Effective: 10/17/2016, Approved: 10/17/2016 showed Patient Rights: Each individual shall be informed of the patient's rights and responsibilities in advance of administering or discontinuing patient care.

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Based on interview, record review, and policy and procedure review, the hospital failed to ensure nursing care and services were provided as needed for wound care instructions at the time of discharge for 2 of 5 sampled patients, Patients #1 and #7.

Findings:

1.) During an interview on 5/2/2017 at 3:06 PM via telephone with the Patient #1's spouse she stated, I didn't notice the blister during the admission it was some time that week. He got the blister while he was there. I'm not sure of the day that it developed. I did report it to the nurse and she came in and looked at it. I noticed the wound on the 21st or the 22nd. I will have to look at my calendar; it was the 22nd. I called his primary care giver, and they told me it would be a couple of days before he could be seen. I told them he was a diabetic and that he had an open wound. They were able to get him in the afternoon that I called. The doctor ordered home health, and the home health nurse came out and did wound care. It was a stage II pressure ulcer. There was no information on the discharge paperwork about the pressure ulcer; no wound care or home health to take care of it.

Record review of Nursing Reassessment showed, dated 3/17/2017, Stage II to right buttocks. Use foam wedge for <30 degree lateral positioning. Dated: 3/20/2017 at 7:30 AM Mepilex to right buttock pressure ulcer Stage II. There was no additional documentation by the nursing staff related to the pressure ulcer.

Record review of the discharge instructions showed, dated 3/20/2017 at 3:02 PM, there were no instructions or documentation of a pressure ulcer to the buttock.

Record review of the Skin Risk Interventions showed, dated 3/17/2017 and 3/20/2017 - Manage moisture, avoid drying the skin, manage nutrition, maintain good hydration, manage friction and shear, no massage of reddened bony prominences, reposition every 2 hours as needed, offer toileting when turning, pericare as needed, use moisture barrier; body wash and lotion routinely, maximal remobilization-up chair for meals when appropriate, protect (offload) heels, use turn sheets to reduce friction/shear, Head of bed , <30 degrees unless medically contraindicated, consider pressure relieving surface (if bed or chair bound), provide education on pressure ulcers to patient and family, assess nutrition status, obtain nutrition consult as needed, use foam wedges for 30 degree lateral positioning, consider trapeze if indicated, monitor all body folds for moisture, yeast, rash, irritation.

During an interview on 5/3/2017 at 3:07 PM with the Director of Quality (DOQ) she stated, There is a point where I will argue and there is a point where I wouldn't even try, I looked at everything and there is nothing there that I can find. I don't see any documentation from the physician. There are no discharge instructions regarding the wound.

During an interview on 5/3/2017 at 6:50 PM with the Director of Nursing (DON) she stated, When a patient is discharged who has a pressure ulcer the discharge instructions will document whatever wound care is needed under the discharge instructions. When discharged home, to an institution or facility, the discharge transfer, instructions and notes will be provided.

2.) Record review of the Nursing Reassessment for Patient #7, dated 3/30/2017, showed left buttock pressure ulcer Stage II. Dated: 4/1/2017 Left buttock pressure ulcer Stage II. Opticel ZGuard, dry with old drainage. Dated: 4/2/2017 showed there was no documentation of the pressure ulcer.

Record review of the discharge instructions showed, dated 4/2/2017 at 12:53 PM there were no instructions provided for wound care or documentation of the wound.

Record review of the Skin risk interventions showed, dated 3/30/2017 and 4/1/2017, Manage moisture, avoid drying the skin, manage nutrition, maintain good hydration, manage friction and shear, no massage of reddened bony prominences, reposition every 2 hours as needed, offer toileting when turning, pericare as needed, use moisture barrier; body wash and lotion routinely, maximal remobilization-up chair for meals when appropriate, protect (offload) heels, use turn sheets to reduce friction/shear, Head of bed , <30 degrees unless medically contraindicated, consider pressure relieving surface (if bed or chair bound), provide education on pressure ulcers to patient and family, assess nutrition status, obtain nutrition consult as needed, use foam wedges for 30 degree lateral positioning, consider trapeze if indicated, monitor all body folds for moisture, yeast, rash, irritation. Supplement regular turns with small position shifts. Consult specialty support bed algorithm for support surface. Monitor bony prominences, wounds; use pillow for offloading.

Record review of Additional Interventions: showed dated 3/30/2017, Must check him all the time/he will not call to be changed due to the pain of wiping him. Must turn him even if he says no. His back side is getting worse.

During an interview on 5/3/2017 at 4:26 PM with the DOQ, she stated there is no documentation on the date of discharge about the wound, and there is no documentation on the discharge instructions related to the wound, and the care that needed to be provided. They discussed it with his sister, maybe they told her he needed the wound care. When asked if instructions are to be documented on the discharge instruction sheets, the DOQ stated, Yes. When asked if the Stage II pressure ulcer could have healed in one day, the DOQ stated, No.

Record review of the Policy and Procedures titled, Discharge Process Effective: 2/1/1995 and Approved: 12/28/2016, showed Procedure 3. Patients and parents or guardian of neonates, children, adolescents and adults discharged from the hospital, will receive instructions and individualized teaching prior to discharge. Such instructions and/or teaching as well as patient and/or family verbalization or demonstration of understanding will be documented in the medical record. All discharge instructions will be consistent with the responsible physicians' instructions, and will be age appropriate.

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

Based on observation, interview and record review, the facility failed to provide wound care treatment intervention to 1 of 30 sampled patients, Patient #15

Findings:

Observation on 3/17/2014 at 2:20 PM revealed the facility's wound nurse with the assistance of another Registered Nurse approached Patient #15 in ICU 200 F and explained that she is going to do his wound dressing. Observation of the pressure ulcer wound revealed an unstageable wound with black tissues (80% eschar) that were not present 2 days ago as evidenced by the wound photo taken on 3/15/2014 at 1713. Wound bed is moist with irregular edges. The wound nurse measured the wound and obtained 9 cm x 10 cm x 0.5 cm. Wound nurse concurred that the wound now has 80% eschar formation. Wound nurse cleansed the area with a gauze soaked with normal saline, patted it dry. She covered the wound with a gauze moistened normal saline and an ABD pad, then covered with occlusive dressing. Wound nurse stated that the treatment was for wet to dry normal saline until seen by the wound Doctor.

Interview with the wound nurse on 3/17/2014 at 2:25 PM stated that Patient # 15 came in from a skilled nursing facility with an unstageable wound in the coccyx area. She stated that the Physician ' s order for wound care include wet to dry normal saline until seen by a wound specialist for wound debridement.

Record review of Patient # 15 revealed an admission date of [DATE]. The facility took a photo of the wound upon admission on 3/15/2014 at 17:13. emergency room notes revealed a visualized open draining wound.

Review of the physicians order history provided by the Director of Critical Care Services dated from admission 3/15/2014 through 3/17/2014 did not reveal any wound dressing treatment orders to the coccyx area.

Interview with the RN Director of Critical Services on 3/17/2014 at 3:10 PM stated that when a new patient is admitted to the intensive care unit, an initial assessment is made by a Registered Nurse (RN). She stated that it is the facility ' s protocol to take wound pictures upon admission and upon discharge. She said that the admission nurse will request a wound consult physician and a consult with the hospital's wound nurse and if the wound consulting physician and wound nurse are not available on the weekends, the admission nurse will call the physician for wound orders. Director of Critical Care stated when asked if the admission nurse was notified and obtained an order for wound care treatment upon admission for Patient # 15, she replied; I don ' t think he got an order . The Director of Critical Care Services concurred on 3/17/2014 at 3:27 PM that there was a breakdown of the units' protocol and unable to provide a documentation of a treatment order. When asked if she could provide documentation that the unstageable wound dressing was changed on 3/16/2014, she replied she has none and was not able to provide any documentation that the dressing was changed on 3/16/2014. She stated that the admission nurse was a Premium Pool nurse and works whenever days he is needed in no specific unit.

Interview with the wound nurse on 3/17/2014 at 3:05 PM stated that she has a wound protocol and notifies the physician for orders. The wound nurse provided a physician's order entered on 3/17/2014 at 15:02, today after Surveyor intervention that revealed a dressing change order that reads: Cleanse coccyx wound with sterile saline and apply saline moistened dressing wet to dry BID.

Review of Patient # 15 plan of care dated 3/15/2014 revealed under Integumentary: Goal: Skin intact without breakdown. Wounds healing. Intervention includes: Focused care is Integumentary, see risk assessment documentation for patient specific interventions.

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Based on observation, interview and facility policy and procedure review, the facility failed to implement appropriate sanitary techniques and failure to adhere to infection control practices in 3 of 30 sampled patients. Patient # 12, # 15 and # 16.

Findings:

During medication observation pass on 3/18/2014 at 9:00 AM revealed the primary nurse for Patient # 12 was preparing to administer the morning medications for this patient. The primary nurse first administered all oral medications. Then the primary nurse donned a pair of gloves and administered the nasal spray. Nurse removed her gloves and proceeded to the computer that was on top of a rolling cart near the foot of the patient's bed. Then nurse used the hand sanitizer near the door, pushed her rolling cart and exited the patien'ts room. Primary nurse failed to wash her hands after removing her gloves and before exiting the patient's room. Interview with the primary nurse on 3/18/2014 at 9:30 AM stated and concurred that she did not wash her hands after removing the gloves and replied; I used the hand sanitizer:

Observation on 3/17/2014 at 2:55 PM revealed the Laboratory phlebotomist approached the patient in room G - Patient # 16 and identified patient by asking her name and date of birth. She explained that she is going to draw blood for cardiac enzymes. She donned a pair of gloves, applied a tourniquet on left wrist. She prepped the dorsum of right hand with alcohol prep. She opened a butterfly needle and proceeded to do a needle stick. Obtained a 4 ml of blood using a green top tube. She pulled the butterfly needle, briefly applied pressure on the puncture site. She labeled the tube, removed her gloves and thanked the patient. She sanitized her hands with an antiseptic hand gel, carried her lab tray and exited the unit. She did not wash her hands before and after removing her gloves per facility policy.

Observation on 3/17/2014 at 2:20 PM revealed the wound nurse with the assistance of another Registered Nurse approached Patient # 15 in ICU 200 F and explained that she is going to do his wound dressing. Nurse donned personal protective equipment (PPE), such as mask, gloves and gown. Patient was turned to his right side to expose the coccyx wound. Nurse removed a duoderm dressing and tossed in trash can. Observation of the pressure ulcer wound revealed an unstageable wound with black tissues (80% eschar). e. The wound nurse measured the wound and obtained 9 cm x 10 cm x 0.5 cm. Wound nurse cleansed the area with a gauze soaked with normal saline, patted it dry. She covered the wound with a gauze moistened normal saline and an ABD pad, then covered with occlusive dressing. Wound Nurse discarded all the used dressings in the trash can, removed her gloves. Nurse used the hand gel sanitizer from the wall and exited the room. Wound Nurse did not wash her hands before and after removing the gloves and after patient care. Both nurses did not wash their hands before direct contact with the patient as indicated in the facility ' s hand washing policy.

Interview with the facility's Infection Control Nurse on 3/19/2014 at 3:30 PM revealed that she provides the infection control educational training during orientation and annually and in between as needed. When asked what is the facility's policy regarding hand washing, she replied; Even if you just enter a patients room and say Good morning, you have to wash your hands before leaving the room, staff also must wash their hands before and after removing gloves.

Review of Ocala Regional Medical Center Hand Hygiene Policy with an effective date of 11/11 and a review date of 04/2013 revealed on page 1 of 3 under Policy reads:

A. Hand washing - wash with soap and water for a minimum of 20 seconds when:

Before and after having direct contact with patients

After removing gloves

Upon every entry and exit from a patient room or patient area.

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Based on record review and interview the hospital failed to ensure that 1 (#12) of 10 discharged patients sampled of a total sample of 20 patients received the services ordered by her physician at discharge.

Findings:

During record review for Patient #12 revealed that on 5/27/13 she was admitted to the hospital after a motorcycle accident. Review of the physician ' s orders dated 6/14/13 the patient was discharged home with home health services, physical therapy, occupational therapy and speech therapy. Review of the case management notes dated 6/14/13 at 2:55 PM revealed that no home health agency had accepted the patient at the time of discharge. The patient was discharged in the company of her daughter on 6/14/13 at 4:09 PM.

Review of the discharge summary dated 6/14/13 the physician documented that the patient was unable to be placed in rehabilitation. All arrangements have been made for outpatient therapy, home health therapy, speech therapy, follow-up with Neuropsychiatry, and occupational therapy.

Interview with the case manager on 7/17/13 at 10 AM stated that she made several facility and home health referrals on Patient #12 ' s behalf. She stated that none of the providers would accept the patient ' s insurance. She stated that Patient #12 did not qualify for indigent care services as she had insurance. She stated that she felt that the patient was discharged to a safe environment as she had a daughter and a significant other to care for her. She stated that the daughter and the patient ' s significant other were to provide 24 hour supervision when she was discharged home as she continued to suffer the effects of her traumatic brain injury.

There is no documentation in the medical record that the patient ' s physician was notified that the home health and therapy services were not arranged. It is noted that the patient did not appeal discharge from the hospital as she and her daughter accepted discharge based on home health and therapy ordered services in the home.

Review of the hospital policy titled Discharge Planning reviewed and revised on 1/2013 revealed on page 2 #G. The case manager or social worker will arrange for the implementation of the discharge plan. The policy does not address notifying the patient's physician if the ordered services cannot be provided.

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Based on medical record and facility policy review the the facility failed for 3 of 44 patients, (WM#13, WM#14 and WM#15), to ensure that all medical entries were timed as required by the Medical Staff Rules and Regulations.

Findings:

1. Review of the medical record for patient #WM#13 revealed physician orders dated 11/21/2011, 11/18/2011, 11/17/2011,(2 entries), 11/15/2011,(2 entries), 11/13/2011,(2 entries), and 11/12/2011 that did not include a time the orders were written.

2. Review of the medical record for patient #WM#14 revealed physician orders dated 11/21/2011,(3 entries), that did not include a time the orders were written.

Review of the medical record for patient #WM#14 revealed physician progress notes dated 11/22/2011, 11/21/2011, 11/21/2011,(Infectious Disease), 11/20/2011, and 11/19/2011 that did not include a time the progress notes were written.

3. Review of the medical record for patient #WM#15 revealed physician orders dated 11/16/2011, 11/15/2011,111/14/2011,(2 entries), that did not include a time the orders were written. Further review revealed a Total Parenteral Nutrition Monitoring Order form signed by the physician and a pharmacist without either the date or time documented on order form.

4. Review of the Medical Staff Rules and Regulations page 11 of 33, Section 2 : Orders revealed under #1 A verbal order shall be considered to be in writing if dictated to a duly authorized person functioning within his/her sphere of competence. Verbal orders must be dated and timed at the time they are taken. They must be authenticated in written or electronic form by the person (identified by name and discipline) who is responsible for ordering, providing or evaluation the service provided within 48 hours and may be authenticated by another practitioner responsible for the care of the patient. (10/24/07).

5. Review of the Medical Staff Rules and Regulations page 11 of 33, Section 2 : Orders revealed under C, All clinical entries in the patient's medical record shall be legible, dated timed and authenticated in written or electronic form by whomever is responsible for ordering or providing services. (7/28/2011).

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Based on medical record and facility policy review the the facility failed for 3 of 44, ( #WM 13, WM#14 and WM#15), to ensure that all physician orders are timed as required by the Medical Staff Rules and Regulations.

Findings:

1. Review of the medical record for patient #WM#13 revealed physician orders dated 11/21/2011, 11/18/2011, 11/17/2011,(2 entries), 11/15/2011,(2 entries), 11/13/2011,(2 entries), and 11/12/2011 that did not include a time the orders were written.

2. Review of the medical record for patient #WM#14 revealed physician orders dated 11/21/2011,(3 entries), that did not include a time the orders were written.

Review of the medical record for patient #WM#14 revealed physician progress notes dated 11/22/2011, 11/21/2011, 11/21/2011,(Infectious Disease), 11/20/2011, and 11/19/2011 that did not include a time the progress notes were written.

3. Review of the medical record for patient #WM#15 revealed physician orders dated 11/16/2011, 11/15/2011,111/14/2011,(2 entries), that did not include a time the orders were written. Further review revealed a Total Parenteral Nutrition Monitoring Order form signed by the physician and a pharmacist without either the date or time documented on order form.

4. Review of the Medical Staff Rules and Regulations page 11 of 33, Section 2 : Orders revealed under #1 A verbal order shall be considered to be in writing if dictated to a duly authorized person functioning within his/her sphere of competence. Verbal orders must be dated and timed at the time they are taken. They must be authenticated in written or electronic form by the person (identified by name and discipline) who is responsible for ordering, providing or evaluation the service provided within 48 hours and may be authenticated by another practitioner responsible for the care of the patient. (10/24/07).

5. Review of the Medical Staff Rules and Regulations page 11 of 33, Section 2 : Orders revealed under C, All clinical entries in the patient's medical record shall be legible, dated timed and authenticated in written or electronic form by whomever is responsible for ordering or providing services. (7/28/2011).

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

Based on record review and interview, the facility failed to insure for 2 of 10 patients,(Patients #1 and #2), that they developed, revise and implement a plan of care for the prevention and treatment of pressure sores for patient #1 and a discharge plan to an appropriate facility that could meet the needs of patient #2.

Findings:

1. Review of patient #1's record revealed that the patient was admitted on [DATE] following a fall at home that resulted in a fractured right hip. Further review of the record revealed that the same day as admission the, patient underwent surgery to repair the fractured hip.

Review of the both the emergency room and 4th floor nursing admission assessments revealed that the patient was free of any pressure sores or skin tears. Review of the pre-anesthesia assessment, surgical history and physical and surgical nursing assessments revealed that the patient was free of pressure sores and skin tears. Review of the post-anesthesia and post-surgical evaluations did not reveal any concerns related to pressure sores or skin tears.

Review of the nursing notes and shift assessments/reassessments for the remainder 07/01/2011 and all of 07/02/2011 revealed the skin was free of pressure sores and skin tears.

Review of the shift assessment/reassessment for 07/03/2011 at 7:30 AM revealed Wound Location: Right Buttock, Wound Type: Skin Tear, Wound Condition: Healing, Dressing Type: Zinc Oxide. Review of the medical record revealed the following Plan of Care was put in place--Skin interventions: Manage moisture. Avoid drying the skin, Manage nutrition. Maintain good hydration, Manage friction and shear, No massage of reddened bony prominence, Reposition every 2 hours and as needed (PRN), offer toileting when turning, Pericare PRN, Use moisture barrier: body wash and lotion routinely, Maximal remobilization-up in chair for meals when appropriate, Protect (offload heels), Use turn sheets to reduce friction/shear, head of bed (HOB) greater than 30 degrees unless medically contraindicated, Consider pressure relieving surface (if bed or chair bound), Provide education on pressure ulcers to patient, and Assess nutritional statue, Obtain nutrition consult PRN.

Review of the medical record revealed a physician order dated 07/03/2011 at 12:45 PM Zinc Oxide - apply topically to Right buttock and coccyx area.

Review of the shift assessment/reassessment for 07/04/2011 at 9:25 AM revealed Wound Location: Right Buttock, Wound Type: Skin Tear, Wound Condition: Healing, Dressing Type: Zinc Oxide and under Ulcer Location: Coccyx, Ulcer Stage: Suspected Tissue Injury, Ulcer Condition: Slough Dressing Type: Zinc.

Review of the shift assessment/reassessment for 07/05/2011 at 12:52 PM revealed Ulcer Location: Mid Buttock Right, Ulcer Stage: II, Ulcer Condition: Moist Slough Dressing Type: Zinc Oxide. The nursing documentation for the shift does not address the second wound.

Review of the medical record revealed a Wound Care Consult from the wound care nurse dated 07/05/2011 at 12:50 PM that stated, This patient is noted to have a stage II Pressure Ulcer in the mid buttock area that measures 8.5 [centimeter] cm [by] x 5.5 cm x 0.1 cm. Moderate red drainage is noted from the wound. Cleanse the wound with Betasept daily a follow the orders of the patient's family doctor for zinc oxide. Review the Wound and Skin Treatment Orders, (standing orders completed by the wound care nurse), dated 7/5/2011 and Authenticated by the physician on 07/23/2011, (18 days), revealed the above orders and under additional orders, This patient is incontinent of bowel and bladder. It would be extremely difficult to keep a dressing on the area. Keep positioning him off the area.

Review of the shift assessment/reassessment for 07/05/2011 at 8:00 PM revealed Ulcer Location: Right Buttock R, Wound Type: Skin Tear, Wound Condition: Draining, Dressing Type: OTA and PROSHIELD. The medical record did not reveal that nurse on duty had reviewed either the wound care consult/physician orders or the nursing assessment for earlier that day. Review of the medical record did not reveal a physician order or a consult recommendation for OTA or Proshield. Review of the Plan of Care dated 07/05/2011 at 8:00 PM revealed that the Plan of Care was not updated to reflect the patient's wound care needs.

Review of the shift assessment/reassessment for 07/06/2011 at 7:45 AM revealed 1. Wound Location: Right Buttock, Wound Type: Skin Tear, 2. Wound Location LFA, Wound Type: Skin Tear, Wound Condition: Healing, Dressing Type: TEGADERM, Dressing Condition: Dry and Intact, Dressing Changed: Y, and under Ulcer Location: Coccyx, Ulcer Stage: III, Ulcer Condition: Necrotic Dry, % Necrosis: 50, Ulcer Margins: Intact Dressing Type: Zinc, Dressing Condition: Dry/Intact, Dressing Changed: Y.

Review of the Medical record revealed a Nursing note dated 07/06/2011 at 2:19 PM Patient incontinent of stools. Patient placed in supine. Assisted CNA with cleaning. Rolling total assist. Patient left in supine. Left with CNA. Call button table phone in reach. Review of the medical record revealed a physician order dated 07/05/2011 that stated This patient is incontinent of bowel and bladder. It would be extremely difficult to keep a dressing on the area. Keep positioning him off the area.

Review of the shift assessment/reassessment for 07/07/2011 at 9:44 AM revealed 1. Wound Location [left forearm] LFA, Wound Type, Wound Condition: Bruising, Dressing Type: Occlusive, Dressing Condition: Dry and Intact, 2. Wound Location: Bilateral Arms, Wound Type Bruising, Wound Condition: Bruising, and under Ulcer Location: Mid Buttocks, Ulcer Stage: II, Ulcer Condition: Moist Slough Dressing Type: Zinc,

Review of the Medical Record did not reveal evidence that the Plan of Care was evaluated or updated to reflect patient #1's changing skin condition or if the Plan of Care was effective or being followed.

Review of patient #1's medical record did not reveal that the patient was placed in anything other the standard bed which is used by the hospital.

Review of the medical record revealed the patient was transferred to a local Skilled Nursing Facility, (SNF), on 07/07/2011. Review of the Medical Certification for Nursing Facility/Home and Community-based Services Form, (AHCA MEDSERV V ) dated 07/07/2011 revealed under Skin Condition a Stage II decubitus 8 ? cm by 5 ? cm.. The form did not reflect the wound measurements at the time of transfer; instead the facility reported the wound description from 07/05/2011.

Review of patient #1's medical record at the SNF revealed a Admission Nursing Note dated 07/07/2011 at 7:30 PM that states, Left lateral forearm old skin tear scabbed over approximately 8 cm by 6 cm, ...Right buttocks and mid coccyx open area approximately 6 cm x 5 cm , depth could not be determined. According to the documentation, the area was dark in color, left lateral heel area dark intact approximately 5 cm x 4 cm dark in color, Right medial heel dark area approximately 2 cm x 2 cm intact ...

Review of the, (hospital), medical record did not reveal that the patient had any concerns related to the skin condition of his heels. Review of the medical record did not reveal that any of the Plan of Care Approaches was performed either at all or on a consistent basis.

Interview of a Patient Care Technician, (CNA), on the 4th floor on 09/07/2011 at 12:15 PM revealed when asked how she learned what were the care needs of her patients, the CNA stated that the CNA leaving would tell her about the patients.

Interview with a Registered Nurse on the same floor on 09/07/2011 at 12:30 PM revealed that the CNA was told about the care needs by the nurse.

2. Review of the medical record for patient #2 revealed that the patient was transferred on 05/31/2011 to the facility from a Skilled Nursing Facility for the evaluation of headache and blurred vision, because of the patient's history of cerebrovascular accidents, (CVA). The patient was admitted to the facility to rule out a second CVA or a Transient Ishemic Attack (TIA). Review of the patient's medical history revealed [DIAGNOSES REDACTED]

Review of the Discharge Summary dictated on 06/7/2011 by the patient's attending physician revealed under, The plan was for him to return to the skilled nursing facility however secondary to sexual offense, no skilled nursing facility, (SNF), was willing to take him. [named SNF] was not willing to take him back and an assisted living facility referral was made and patient is subsequently to an assisted living facility, (ALF) in stable condition.

Interview on 09/07/2011 at 9:00 AM with the Case Manager that provided discharge planning for the patient revealed that the patient was on the state's sexual predator list and because of that, there were no skilled nursing homes that would take him.

Review of the Case Management note dated 06/02/2011 at 9:14 AM revealed Call from neuro [Neurology floor], floor director wants patient transferred today if possible ... Review of Case Management note date 06/02/2011 at 4:52 PM revealed D/C [discharge] order for today, no accepting facility.

Review of Case Management note dated 06/02/2011 at 4:53 PM revealed, Contacted Mary at Good Samaritan ALF for possible placement there. She will come see patient in the morning. [named] patient, who is very, very difficult to understand. He may require more assistance than Mary can provide with regards to dressing and toileting, but she will assess in the AM...

Review of the Case Management note dated 06/03/2011 at 1:58 PM revealed Mary here form Samaritan Comfort ALF to assess patient, feels he'll be appropriate and has observed him going to the bathroom, feeding himself, ETC. Mary requested RX's [prescriptions] be faxed to RX Care Pharmacy at [telephone number provided] for delivery to her home and states she is in a program which takes care of patient's copay's. Mary will transport patient.

Review of the current list of ALFs used by the facility for discharge planning did not include, Good Samaritan ALF, Samaritan Comfort ALF or any other ALF that could be understood as the ALF described in the medical record or staff interviews.

Review of State of Florida records revealed that the facility that Mary represents does not have ALF license or any other state license that would allow her to accept residents requiring assistance with medical needs and activities of daily living.

A search of the Florida Department of Business Professional Regulation's website at https://www.myfloridalicense.com/wl11.asp?mode=2&search=Name&SID=&brd=&typ=

failed to reveal that the address listed on patient #1's record is licensed as a, Rooming House

Interview with the Case Worker on 09/07/2011 at 9:00 AM revealed that she did not know that Samaritan Comfort was not a licensed ALF and after review the facility's referral list for ALFs stated it was not on the facility's list. The Care Worker stated that she did not remember how she came to know of Mary or were she obtained her telephone number when she called her.

Review of the medical record or staff interview did not reveal that the facility had a record of how it determined that Samaritan Comfort was a ALF or that it would be a safe and appropriate environment to discharge the patient to who the physician felt should have been returned to a SNF or ALF.

Show Text of Violation

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

Based on staff interview and record review the facility failed for 1 of 10 patents, (patient #2), develop a discharge plan, based on the physician's recommendation and the patient's discharged needs.

Findings:

Review of the medical record for patient #2 revealed that the patient was transferred on 05/31/2011 to the facility from a Skilled Nursing Facility for the evaluation of headache and blurred vision, because of the patient's history of cerebrovascular accidents, (CVA). The patient was admitted to the facility to rule out a second CVA or a Transient Ishemic Attack (TIA). Review of the patient's medical history revealed [DIAGNOSES REDACTED]

Review of the Discharge Summary dictated on 06/7/2011 by the patient's attending physician revealed under, The plan was for him to return to the skilled nursing facility however secondary to sexual offense, no skilled nursing facility, (SNF), was willing to take him. [named SNF] was not willing to take him back and an assisted living facility referral was made and patient is subsequently to an assisted living facility, (ALF) in stable condition.

Interview on 09/07/2011 at 9:00 AM with the Case Manager that provided discharge planning for the patient revealed that the patient was on the state's sexual predator list and because of that, there were no skilled nursing homes that would take him.

Review of Case Management note dated 06/02/2011 at 4:53 PM revealed, Contacted Mary at Good Samaritan ALF for possible placement there. She will come see patient in the morning. [named] patient, who is very, very difficult to understand. He may require more assistance than Mary can provide with regards to dressing and toileting, but she will assess in the AM...

Review of the Case Management note dated 06/03/2011 at 1:58 PM revealed Mary here form Samaritan Comfort ALF to assess patient, feels he'll be appropriate and has observed him going to the bathroom, feeding himself, ETC. Mary will transport patient.

Review of the current list of ALFs used by the facility for discharge planning did not include, Good Samaritan ALF, Samaritan Comfort ALF or any other ALF that could be understood as the ALF described in the medical record or staff interviews.

Review of State of Florida records revealed that the facility that Mary represents does not have ALF license or any other state license that would allow her to accept residents requiring assistance with medical needs and activities of daily living.

Interview with the Case Worker on 09/07/2011 at 9:00 AM revealed that she did not know that Samaritan Comfort was not a licensed ALF and after review the facility's referral list for ALFs stated it was not on the facility's list. The Care Worker stated that she did not remember how she came to know of Mary or were she obtained her telephone number when she called her.

Show Text of Violation

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

Based on record review and interview, the facility failed to ensure that 1 of 10 (#2) patients was discharged to an appropriate facility, as indicated by the patient's physician.