HCA Florida Palms West Hospital

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

Based on record review and interview, the facility failed to provide nursing services according to nursing policies and procedures when removing a central venous catheter in 1 of 10 sample patients, (Patient #5).

The findings included:

On 08/08/16, the clinical record revealed Patient #5 was admitted for a narcotic overdose, non-cardiogenic pulmonary edema, respiratory distress and Rhabdomyolysis. The patient was intubated in the emergency room and admitted to the Intensive Care Unit (ICU).

On 08/15/16, the Critical Care Progress note, revealed Patient #5 was successfully liberated from the ventilator and was stable for transfer out of ICU.

On 08/18/16 at 10:35 AM, the clinical notes revealed Patient #5 was able to ambulate and performed standing exercises by the edge of his bed with no loss of balance. The patient was alert, talking and eating.

On 08/18/16 at 1:15 PM, the nurses notes revealed the Left Intravascular Jugular (LIJ) catheter was removed without difficulty. The patient started to complain about burning in the middle of his chest with associated shortness of breath and diaphoresis. The patient's oxygen saturation (pulse oximeter reading) dropped to the 70's. The patient was placed back in bed.

On 08/18/16 at 2:20 PM, the critical care progress note by the physician revealed Patient #5 suddenly became very agitated, hypoxemic, and oxygen saturation dropped to 70% after removal of Central Venous Line from Left Intravascular Jugular per the Registered Nurse (RN). The patient was intubated for respiratory failure. The nursing note revealed: will get a chest x-ray stat - suspect air embolism / pulmonary embolism. The patient was placed on a ventilator.

On 08/21/16 at 2:06 PM, the hospitalist note revealed the prognosis is guarded; Patient is off sedatives, currently unresponsive, in deep coma from anoxic brain [DIAGNOSES REDACTED]; No corneal reflexes; Highly likely brain death; and the family declined any further tests, requested to proceed with withdrawal of care in AM.

Review of the Brief Death Summary Note, dated 08/22/16, revealed the patient passed away at 8:50 AM with the parents at the bedside.

Review of the Autopsy Report revealed the cause of death as complications of probable air embolism following removal of central venous catheter due to treatment of opiate overdose.

During an interview with Staff A (a registered nurse), on 06/26/17 at approximately 10:00 AM, she stated that she has been a registered nurse (RN) for 31 years. She stated that she has been working at this hospital since October 2014, in the Intensive Care Unit (ICU). She stated that Patient #5 was in the Intensive Care Unit (ICU) and she was assigned to care for the patient. She stated the patient was sitting in the chair and a family member was in the room. She stated she took out the central venous catheter while the patient was sitting in the chair. She stated that removing the line while the patient was sitting in a chair is not the appropriate way. She stated the appropriate way is to have the patient lay down flat in the bed and hold their breath. She stated the patient, all of a sudden, grabbed his chest and said he was having a lot of pain. She stated that the patient was breathing, and she and another nurse helped the patient stand and get into his bed. She stated the intensivist intubated the patient.

During an interview with the Director of the ICU, on 06/26/17 at approximately 9:45 AM, she stated that Staff A's action of removing the central venous line while the patient was sitting in a chair, was very surprising. She stated that when she was made aware of the autopsy report in January 2017, she spoke to Staff A and told her there was a possibility the patient expired due to the pulling of the central line while the patient was sitting up in a chair. She stated that Staff A admitted removing the line while the patient was sitting up in a chair. She stated the appropriate way and according to hospital policy is to have the patient in a Trendelenburg position, not sitting upright in a chair.

During an interview with the Chief Nursing Officer, on 06/26/17 at approximately 3:00 PM, she stated that she was informed about this case when the autopsy results came back in January. She stated that she does not remember who told her or who was involved in making the decision to not initiate an incident report when they found out about the autopsy report.

Review of the policy and procedure for the removal of Removal of Central Venous Catheters includes: 'place the patient in Trendelenburg position, if not contraindicated. Turn head to opposite side of central line.'

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

Based on record review and interview, the facility failed to supervise and evaluate the nursing care in accordance with hospital policy in removing a central venous catheter in 1 of 10 sample patients, (Patient #5).

The findings included:

On 08/08/16, the clinical record review revealed Patient #5 was admitted for a narcotic overdose, non-cardiogenic pulmonary edema, respiratory distress and Rhabdomyolysis. The patient was intubated in the emergency room and admitted to the Intensive Care Unit (ICU).

On 08/15/16, the Critical Care Progress note, revealed Patient #5 was successfully liberated from the ventilator and was stable for transfer out of ICU.

On 08/18/16 at 10:35 AM, the clinical notes revealed the patient was able to ambulate and performed standing exercises by the edge of his bed with no loss of balance. He was alert, talking and eating.

On 08/18/16 at 1:15 PM, the nurses notes revealed the Left Intravascular Jugular (LIJ) catheter was removed without difficulty. The patient started to complain about burning in the middle of his chest with associated shortness of breath and diaphoresis. The patient's oxygen saturation (pulse oximeter reading) dropped to the 70's. The patient was placed back in bed.

On 08/18/16 at 2:20 PM, the critical care progress note by the physician revealed the patient suddenly became very agitated, hypoxemic, and the oxygen saturation dropped to 70% after removal of Central Venous Line from Left Intravascular Jugular per the Registered Nurse. The patient was intubated for respiratory failure. The note revealed: will get a chest x-ray stat - suspect air embolism / pulmonary embolism. The patient was placed on a ventilator.

On 08/21/16 at 2:06 PM, the hospitalist note revealed the prognosis is guarded; Patient is off sedatives, currently unresponsive, in deep coma from anoxic brain [DIAGNOSES REDACTED]; No corneal reflexes; Highly likely brain death and the family declined any further tests, and requested to proceed with withdrawal of care in AM.

Review of the Brief Death Summary Note of 08/22/16 revealed the patient passed away at 8:50 AM with the family members at the bedside.

Review of the Autopsy Report revealed the cause of death as complications of probable air embolism following removal of central venous catheter due to treatment of opiate overdose.

During an interview with Staff A, a registered nurse, on 06/26/17 at approximately 10:00 AM, she stated that she has been a registered nurse (RN) for 31 years. She stated that she has been working at this hospital since October 2014, in the Intensive Care Unit (ICU). She stated that Patient #5 was in the Intensive Care Unit (ICU) and she was assigned to care for the patient. She stated the patient was sitting in the chair and a family member was in the room. She stated she took out the central venous catheter while the patient was sitting in the chair. She stated that removing the line while the patient was sitting in a chair is not the appropriate way. She stated the appropriate way is to have the patient lay down flat in the bed and hold their breath. She stated the patient, all of a sudden, grabbed his chest and said he was having a lot of pain. She stated that he was breathing and she and another nurse helped the patient stand and get into his bed. She stated the intensivist intubated the patient.

During an interview with the Director of the ICU, on 06/26/17 at approximately 9:45 AM, she stated that Staff A's action of removing the central venous line while the patient was sitting in a chair, was very surprising. She stated that when she was made aware of the autopsy report in January 2017, she spoke to Staff A and told her there was a possibility the patient expired due to the pulling of the central line while the patient was sitting up in a chair. She stated that Staff A admitted removing the line while the patient was sitting up in a chair. She stated the appropriate way and according to hospital policy is to have the patient in a Trendelenburg position, not sitting in a chair.

During an interview with the Chief Nursing Officer, on 06/26/17 at approximately 3:00 PM, she stated that she was informed about this case when the autopsy results came back in January. She stated that she does not remember who told her or who was involved in making the decision to not initiate an incident report when they found out about the autopsy report.

Review of the policy and procedure for the removal of Removal of Central Venous Catheters includes: 'place the patient in Trendelenburg position, if not contraindicated. Turn head to opposite side of central line.'

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

Based on clinical record review, policy review and interview the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, Chapter 464.003(5) for 3 of 10 sampled patients (Patient #2, #3 and #9) as evidenced by failure to accurately assess wounds for Patient #2 and #3 and failure to complete nursing reassessment as specified in the facility policies and procedures for Patient #9.

The findings included:

Facility policy titled Assessment and Reassessment last revised 05/2015 documents, Each patient is assessed by appropriate disciplines beginning at the time the patient enters the hospital service and progressing through discharge. Assessments contain data for analysis and support treatment decisions. All assessments are documented in the patient's medical record.

Reassessments by the Registered Nurse and other disciplines of patient needs and response shall occur at regular intervals as determined by the policy of each discipline or established unit standards.

Medical surgical and telemetry units:

Each patient is reassessed as the patient condition warrants and every 12 hours and the plan of care is reviewed and updated as applicable by a registered nurse. Reassessment includes a biophysical and psychosocial assessment of the patient's current plan of care/problem list. Additionally each patient is reassessed when there is a change in condition or diagnosis, on patient transfer to another level of care. Notify the physician with any change in condition, document in Meditech in physician notification screen.

Facility policy Skin and Wound care policy last revised 12/2015 documents skin will be assessed upon admission and at every shift. Skin alterations will be photographed on discovery, weekly and with any significant change in status. Nursing will document presence of wounds in the wound site field. Notify the physician of any changes in skin integrity and nosocomial skin breakdown and obtain dressing orders.

Clinical record review conducted on 04/12/2016 revealed Patient #3 was admitted to the facility on [DATE] for an elective surgical procedure. The record indicates Patient #3 developed a pressure wound to the buttocks on 02/22/2016.

Dermatology consult dated 02/22/2016 documents, there is a partial thickness loss of skin involving epidermis and dermis that appears as an open shallow ulcer with a pink wound bed located on the buttocks and mid back. Unless the presentation changes, will consider Stage II decubitus ulcer, will treat topically with Silvadene twice a day.

Review of the nursing shift assessments and nurses' notes dated 02/26/2016, 02/27/2016, 02/28/2016 and 02/29/2016 failed to document wound assessments as per guidelines.

Photographic evidence dated 02/26/2016 documents a change in the wound condition from a stage II to a wound with yellow slough. The photographic wound documentation noted the wound as a stage II pressure ulcer despite of the yellow slough; there are no measurements written by the assessor. Photographic wound documentation dated 02/29/2016 does not include documentation of an assessment of the wound; slough and eschar is visible on the picture. The wound is unstageable. Photographic wound documentation dated 03/02/2016 verified the wound is now unstageable. There is no assessment or measurements documented by the assessor.

The clinical record failed to provide evidence of documented measurements of the wound from 02/23/2016 thru 03/04/2016, when the wound was surgically debrided.

Physician's order dated 02/22/2016 documents Silver Sulfadiazine (Silvadene) apply twice a day. The order does not specify the location the cream is to be applied.

Administration Record documents the prescribed cream was apply to the coccyx wound and it was not administered on 02/25/2016.

Patient #3 had a new treatment order prescribed on 03/05/2016 with Dakin's solution 0.25% topical daily. The record documents the Silvadene cream was applied on 03/06/2016 and 03/08/2016 to the buttocks. The clinical record failed to provide clarification if both treatments were to be implemented simultaneously.

Further review of the administration records indicate the Silvadene cream was applied to the upper arm and generalized areas on 03/10/2016 and 03/14/2016. No indication for the use was documented.

Plastic Surgery consult dated 03/01/2016 documents patient needs pre albumin measured. The record failed to provide evidence a pre albumin level was obtained.

Interview with the Director of Patient Safety on 04/12/2016 at 12:26 PM while navigating the electronic record revealed there is no evidence of a comprehensive wound assessment on the days identified above; there are no measurements of the wound and there is no evidence the physician was notified of the change of wound status on 02/26/2016. The Director confirmed there is no pre albumin record on file.

Interview with the Director of Medical Surgical Services, Director of Intensive Care and Director of Patient Safety on 04/13/ at 9:10 AM revealed the facility does not have a policy for wound assessments; the facility follows Lippincott guidelines and provided a copy. In addition, Director of Medical Surgical Services explained photographic evidence is obtained weekly and placed in the chart for physician review. The photographic documentation is not a wound assessment; the assessment is documented on Meditech as part of the shift assessments.

Lippincott, Wound Assessment procedures document as follows: A thorough wound assessment should consist of objective criteria and measurements that promotes accurate consistent comparisons to determine the extent of the wound and the effectiveness of wound healing. You should complete a comprehensive wound assessment during every dressing change and compare the results to the previous assessment so you can monitor, communicate, treat and document healing progression or complications. Wound assessment includes wound drainage description, wound color and measurements. Documentation: Record the general appearance of the patient ' s skin and bony prominence; the location, size and appearance of the wound site; whether there are drains or tubes are present; and whether drainage is present. Include the color, type, amount and odor of any drainage. Document the date and time of the assessment.

2) Clinical Record review conducted on 04/12/2016 revealed Patient #2 was admitted to the facility on [DATE]. The record indicates the patient developed a stage II pressure ulcer on 02/12/2016.

Treatment order for Mepilex was initiated on 02/12/2016. Further review of the record failed to provide evidence of a comprehensive wound assessment, including measurements, on the days the Mepilex was changed. Patient #2 was discharged home on 02/23/2016 with the Mepilex dressing in place. The discharge instructions did not address the status of the wound and treatment or follow up care if needed.

Interview with the Director of Patient Safety on 04/12/16 at 11:22 AM who was navigating the electronic record confirmed there is no comprehensive assessment of the stage II ulcer, no documented measurements and discharge instructions did not address the pressure wound.

3) Clinical record review conducted on 04/13/2016 revealed Patient #9 was admitted to the facility on [DATE]. Review of the record failed to provide evidence a nursing reassessment was completed every twelve hours, there is no record of a reassessment for 04/12/2016 night shift.

Interview with the Director of Patient Safety and the Director of the 4th floor on 04/13/2016 at approximately 12:15 PM revealed there is no record of the assessment, they have attempted to contact the nurse but have not heard back, most likely it was human error.

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

Based on record reviews and interviews, it was determined the Registered Nurse (RN) failed to review and revise the plan of care based on the assessed needs of 1 of 10 sampled patients (Patient #4).

The findings include:

1) The facility policy for reassessment of a patient is as follows: Reassessments occur in the Telemetry Unit as the patient condition warrants and every 4 hours and the Plan of Care is reviewed and updated as applicable by an RN, at least every 24 hours.

The Director of the Medical Surgical/Telemetry Unit 2 East stated at 1120 hours on 2/25/14 the RN assessments are documented electronically every four hours and as needed. The plan of care is updated every day.

Patient #4 was admitted to the facility on [DATE] with complaints of abdominal and left flank pain. The patient had an Upper Endoscopy and a Colonoscopy on 1/23/14. There is an order by the physician at 1048 hours to notify the provider if Oxygen Saturation less than 92%.

Review of the plan of care dated 1/23/14 at 1049 hours reveals the nurse was to notify if any of the following occur: respiratory distress, desaturation, chest pain, hypotension, persistent hemoptysis, abdominal pain, excessive distension or rectal bleeding.

The patient's Oxygen Saturation was recorded approximately every 4 hours 1/22/14 through 1023 hours on 1/24/14 is 93% - 98% on room air. A nurse documented on 1/24/14 at 0409 hours on 1/24/14 Oxygen is being delivered per Nasal Cannula. There was no Liter flow documented for the Oxygen.

On 1/26/14 at 0750 hours the RN documented the patient's Oxygen Saturation was 78 % on room air. The patient is receiving Oxygen at 2 Liters per minute via a Nasal Cannula. At 0800 the patient's Oxygen Saturation is recorded at 78%. The nurse documents the patient's Oxygen Saturation increased to 96% with 2 Liters of Oxygen. The nurse documents the patient was advised that she needed to wear it (Oxygen).

The PCP visits at 1133 hours on 1/26/14 and documents the patient's Oxygen Saturation is 93- 97 %. The clinical record lacked documentation to support a physician was made aware of the change in the patient's condition.

At 1304 hours on 1/26/14 the Oxygen Saturation is 79%. The nurse writes the patient took the Oxygen off and was educated again. The patient's Oxygen saturation recorded at 2354 hours on 1/26/14 reveals the Oxygen Saturation is 92% on 2 Liters of Oxygen.

The PCP writes in a 1/27/14 progress note Oxygen hourly and no shortness of breath (SOB).

At the time of the survey the medical record lacked documentation of Oxygen Saturation measurements 1/27/14 through 1637 hours on 1/28/14. The clinical record lacked documentation to support the PCP was aware of the desaturation without the administration of Oxygen.

On 1/28/14 at 1820 hours the nurse documented Oxygen Saturation decreased to 83%, heart rate 119 and patient SOB. A Rapid Response was called 1820 - 1840 hours.

On 1/28/14 at 1840 hours the physician writes here to see the patient. Patient just developed SOB. The patient is transferred to Intensive Care Unit (ICU). Pulmonary Embolus (PE) should be ruled out.

The findings were verified by the Director and Nurse Manager of the Medical/Surgical/ Telemetry Unit on 2/26/14 at 1400 hours.

The RN failed to review and revise the plan of care based on the assessed needs of the patient (alteration in the patient's respiratory status) after 1/23/14, in accordance with the Standard of Care: Assessment, Problem Identification, Outcome Identification and Planning and facility policy.

Based on observations, reviews of clinical records, Policies and Procedures, Medical Staff Rules and Regulations, Physician On-Call lists, recorded conversations, Palm West Hospital Transfer electronic Log, Medicare Database worksheet and interviews, it was determined the facility failed to accept from a transferring hospital an appropriate transfer of an individual who required such specialized capabilities or facilities for whom a request for pediatric specialty services (pediatric gastroenterology) was made for 1 of 17 sampled patients (Patient #10). Refer to findings in tag 2411.

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

Based on observations, reviews of clinical records, Policies and Procedures, Medical Staff Rules and Regulations, Physician On-Call lists, recorded conversations, Palm West Hospital Transfer electronic Log, Medicare Database worksheet and interviews, it was determined the facility failed to accept from a transferring hospital an appropriate transfer of an individual who required such specialized capabilities or facilities for whom a request for pediatric specialty services (pediatric gastroenterology) was made for 1 of 17 sampled patients (Patient #10).

The findings are:

Observations on 1/29/14 at 3:00PM revealed a sign posted on the outside wall above the ED Entrance reads: The Children's Hospital at Palms West.

Review of the Medicare Hospital Data Base Worksheet revealed Pediatric Services and Pediatric Intensive Care Services are provided by the facility.

Review of the Palms West Hospital's EMTALA Transfer Policy reveals the following:

This policy reflects guidance under EMTALA and associated State laws only.

Each hospital CEO (Chief Executive Officer) must designate in writing the position of the hospital representative who is authorized along with the Emergency physician to accept or deny transfers of individuals with EMC's (emergency medical conditions) from other facilities. The Administrator On Call (AOC) or House Supervisor is the only individual authorized to accept or refuse a transfer of an individual from another facility on behalf of the receiving hospital. A Transfer Center may facilitate but does not take place of the CEO's designee.

The Transfer Center must first contact the facility DED (dedicated emergency department) and the CEO designee to verify with the facility that it does not have the capacity or capability to accept the transfer.

Recipient Hospital Responsibilities:

A participating hospital that has specialized capabilities or facilities, including facilities such as burn units, shock-trauma units; neonatal intensive care units, or regional referral centers in rural areas, may not refuse to accept an appropriate transfer from a transferring hospital within the boundaries of the United States, of an individual who requires such specialized capabilities or facilities if the receiving facility has the capacity to treat the individual.

The Transfer Policy reveals the Administrator On Call (AOC) or House Supervisor along with the Emergency physician is the only individuals authorized to accept or refuse a transfer of an individual from another facility on behalf of the receiving hospital.

The Pediatric subspecialties identified on the On-Call List and offered 24/7 include Peds(pediatric) Gastro; Peds General Surgery; Peds Neurosurgery and Peds Orthopedics. Additional Pediatric services are identified under Plastic (Adult and Peds); Podiatry (Adult and Peds) and Psychiatry (Adult and Peds). There are Pediatric Intensivists on staff. Review of the Hospital's Medical Staff Rules and Regulations: Section 9, Emergency Services Section 20.0 Emergency Department Call reveals: Call Rotation: The distribution and maintenance of the ED call list will be coordinated by the Medical Staff Office. On call rotation schedules shall be maintained in the ED.

Duration of Call Schedule: When a physician is scheduled for a particular day/date for coverage, he/she is on call from 7:30 a.m. until the following morning at 7:30 a.m., unless otherwise noted. He/she is responsible for the patient according to the time that the Emergency Department (ED) physician determines the need for consultation, not according to the time of arrival in the ED.

Verification of Availability: The hospital will contact the on-call specialist daily for verification of availability. The Medical Staffing Rules and Regulations reveal: Once the schedule is finalized and circulated it cannot be changed by Medical Staffing Services unless written confirmation is received from all parties involved.

Review of the On-Call List for the past 6 months verified the availability of Pediatric Services to include the subspecialty Pediatric Gastroenterology on a 24/7 basis.

The On-Call ED coverage for Peds Gastroenterology posted on 12/30 -12/31/13 was as follows:

Dr. G___, 12/30 07:00 - 12/31/13 17:00; Dr. S___, 12/31/13 17:00 - 1/1/14 07:00 and Dr. S___, 1/1 07:00 -1/2/14 07:00.

Interview with the CEO (chief executive officer) at 9:30 AM on 1/29/14 revealed requests for transfer of patients to the Palm West Hospital ED (emergency department) go through a Transfer Center. The CNO (chief nursing officer) stated at 9:40 AM on 1/29/14 that the call center/transfer center is in Broward County. She stated the transfer center contacts the ED physicians and they discuss the transfer ED to ED. In an interview with the risk manager at 10:15AM on 1/29/14, she stated all calls for transfers come through the HCA (Hospital Corporation of America) Call Center. During a telephone interview with the risk manager on 1/28/14 related to an emergency access survey conducted on 1/27/14 for the same concern, the risk manager stated the HCA One Step Transfer Center is a 3rd party service located off site in Broward County that coordinates emergency transfers for HCA facilities.

Review of the clinical record revealed Patient #10 was a pediatric patient who (MDS) dated [DATE] at 11:00 p.m. The History and Physical revealed in part, History of Present illness The patient presents with accidental ingestion and pt. brought in by mother ...may have ingested an unknown amount of Drano. Pt. now a present with vomiting ... the onset was just prior to arrival ...Physical Examination: General ...actively vomiting ...Impression and Plan: Accidental Toxic caustic ingestion ... Calls- Consults- Poison Control, observation with transfer to pediatric center with pediatric GI.

On 12/31/13 at 1121 hours the transferring hospital contacted the One Step Transfer Center seeking transfer for Patient #10. The Transfer Center (TC) contacted Palms West Hospital. The ED Physician at the transferring hospital requested the services of Pediatric Gastroenterology.

When the TC contacted Palms West Hospital at 2335 hours; the ED Physician at Palms West Hospital informed the ED Physician at the transferring hospital that Pediatric GI services ended at 5:00 PM and there was no additional coverage until 7:00 AM.

Review of the Palms West electronic Transfer Log dated 12/31/13 at 2325 hours for Patient #10 reveals the following:

Specialty Service Request: Other: Pedi GI.

Description of Problem: CAUSTIC INGESTION

PWH Specialist contacted: PEDI ED MD

Instructions given: No Pedi GI past 5 PM

Disposition Given: Accepted/Declined.

Reason for Decline:

Other (explain): Once Dr. D___ (Physician at Transferring Hospital), was told no Pedi GI he stated that was what he needed and hung up the phone. Review of the transfer form revealed that patient #10 was accepted and transferred on 12/31/2013 to another acute care local hospital.

A recording of the conversation between the ED physician from the transferring hospital and ED physician at Palms West Hospital was played for this surveyor on 1/29/14 at 1110 hours. The ED Physician at the transferring hospital stated he needed Peds GI. The physician ended the call.

Review of a letter to the Florida Agency for Healthcare Administration on Palms West Hospital letterhead documented as from the CEO dated 1/10/2014 Re: Self Reporting by Palms West Hospital of possible Right to Access non-compliance regarding sampled Patient #10 revealed in part:

At 0155 hours on 1/1/14 the Transfer Center (TC) contacted Palms West Hospital and spoke with the nursing supervisor. The TC informed the nursing supervisor that she had contacted the transferring hospital to check if the patient had been transferred to another local hospital. The patient had been transferred. The TC indicated from her reading of the On-Call list that Palms West Hospital did have Pediatric GI available. The nursing supervisor reviewed the On-Call list and agreed .....and it seemed the ED Physician (Palms West) misread the On-Call list. The supervisor notified the Administrator on Call regarding the incident.

The facility failed to accept Patient #10 on 12/31/13, an appropriate transfer who required the specialty services of Pediatric GI.

Interview with the ED Director on 1/29/14 at 0930 hours reveals the Pediatric Services are provided twenty four hours a day, seven days a week (24/7).

The Medical Staffing Manager stated at 1030 hours on 1/29/14 there are 2 Pediatric Gastroenterology (GI) groups that alternate to provide ED On-Call coverage. They provide their own scheduled times to provide services 24/7. On weekends and holidays the coverage is 1700 - 0700 and 0700 to 1700. The Medical Staffing Manager stated at 1030 hours on 1/29/14 verification with the On-Call Physician is made the day before the scheduled coverage. The schedules are requested to be submitted by the 15th day of the previous month.

The Risk Manager stated at 1045 hours on 1/29/14 the process regarding the unavailability of an On-Call physician is outlined in the Medical Staffing Rules and Regulations. The process is when the practitioner practicing the specialty is unavailable; it is the on-call physician's responsibility to find alternative coverage. The Chief of the Department will be notified by the ED physicians and/or hospital administrator, and involved in this process as needed.

The facility self-reported the incident.

In the self report the CEO writes:

1. The ED Physician misread the On-Call List and denied the transfer when the receiving hospital had the capability to accept the patient.

2. Per protocol, the Transfer Center has a copy of the On-Call List available. The Transfer Center employee accepted our ED Physician's statement about there being no coverage for Pediatric GI service and did not reference her copy of the On-Call List until approximately two hours after the initial contact. The Transfer Center employees are to use these lists when contacting hospitals about transfers.

3. Per protocol, if a transfer is denied, the Transfer Center employee is to immediately contact the AOC or the Nursing Supervisor at the receiving facility. The Transfer Center employee did not follow procedure and only contacted us when she realized that she had not reviewed the On-Call List, making an attempt for Palms West to rectify the transfer in a timely manner impossible.

The CEO verified the findings in the self-report on 1/29/14 at 0930 hours.

There was a lapse of approximately 2 hours before the facility recognized the subspecialty On - Call Pediatric Gastroenterology Service is available 24/7.

The ED Physician and the Transfer Center failed to communicate with the Administrator On- Call and the Nursing Supervisor to facilitate the transfer to the receiving hospital which had the capability and capacity to provide services for Patient #10 on 12/31/2013. The facility failed to follow their transfer decision protocols by failing to communicate with all parties.

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

Based on record reviews and interviews, it was determined the RN failed to conduct an assessment in accordance with accepted standards of practice and hospital policy for 1 of 9 sampled patients (Patient #9).

The findings include:

1) The facility policy for reassessment of a patient is as follows: Each patient is reassessed and the plan of care is reviewed by an Registered Nurse (RN) at least once every 12 hours. Each patient is reassessed according to established unit time frames, when there is a change in condition or diagnosis, on patient transfer to another level of care.

The Director of Risk Management stated on 4/29/13 at 1140 hours the Registered Nurses (RNs) chart electronically every twelve hours on the 4 East Unit, Medical/Surgical Telemetry.

Patient #9 was admitted to the facility on [DATE] with diagnoses of Hypertension and Congestive Heart Failure and various other conditions. The patient's vital signs in the Emergency Department at 1252 hours were: Blood Pressure (B/P) 126/54, pulse 79 and respirations (R) 24. At 1442 hours the B/P 131/50, pulse 60 and R 18.

The patient's vital signs at 1739 hours: B/P 138/61, Pulse 62, and R 18.

The patient was transferred to 4 East Medical Surgical Telemetry at 1949 hours on 4/3/13. The RN assessed the patient's vital signs at 1958 hours: B/P 135/63, Pulse 65 and R 20.

The patient is receiving the following medications that can cause a decreased blood pressure and/or decrease in the heart rate: Nitro-Bid (Nitroglycerine) 1 ointment to the chest wall every 6 hours, Correg 3.125 mg. by mouth twice a day; Norvasc 5 mg. by mouth daily and Altace 2.5 mg. by mouth daily. There were no parameters for holding the medications.

The RN conducted a shift assessment for the (1900- 0700) hours on 4/3/13 at 2000 hours. The patient's vital signs are: B/P 136/63, pulse 65 and R 20.

The patient received the Nitro-Bid at 2100 hours on 4/3/13. At 2236 hours the nurse administered Coreg 3.125 mg. by mouth. The RN documented that she held the midnight dose of Nitro-BID because the patient ' s blood pressure was 85/50. The nurse administered 1 of Nitro-BID at 0600 hours on 4/4/13.

Review of the 4/4/13 Medication Summary revealed the RN administered Norvasc 5 mg. at 1129 hours on 4/4/13. The nurse documents a B/P of 91/48. The RN gives Correg 3.125 mg. at 1128 hour, and Nitro-BID 1 at 1130 hours and 1939 hours on 4/4/13. It was unclear if the physician was made aware of the change in the patient's blood pressure.

The Pharmacy Director and the Pharmacy Clinical Manager stated at 1150 hours that they would not expect decrease in blood pressure with Nitroderm patch 0.2 micrograms (mcg) release over 24 hours. If it is the Nitropaste, I would expect a decrease in the blood pressure.

The physician stated on 4/29/13 at 1445 hours, the nurses know to hold the medication usually for a systolic blood pressure 90/60 or less and pulse less than 60 or Heart Block. The doctor ordering the medication always gives a range for the medication, according to the physician. The physician was made aware that the patient's blood pressure on 4/4/13 was recorded at 91/48. The physician stated the nurse always call to clarify the order.

Further review of the medical record on 5/1/13 revealed the record lacked documentation of a shift assessment by the RN for the 0700 - 1900 hours shift on 4/4/13. A call was placed to the facility on [DATE] at approximately 1000 hours to request a copy of the shift assessment with assessment of the patient's vital signs.

The Risk Manager and the Vice President of Patient Safety stated at 1127 hours they could not find the shift assessment documented by the RN for 4/4/13 (0700 - 1900 hours). The Risk Manager stated the nursing assistant did the vital signs every 4 hours. A copy of the vital signs was received at 1145 hours on 5/2/13.

The certified nursing assistant documented the following vital signs on 4/4/13:

0754 hours - B/P 91/48, pulse 63 and respirations 20.

1218 hours - B/P 94/48, pulse 60, and respirations 20.

1700 hours - B/P 93/50, pulse 59, and respirations 20.

1934 hours - B/P 89/44, pulse 68, and respirations 18.

The RN administered the medications (Coreg , Norvasc, Nitro-BID) based on a vital signs documented 3.5 hours earlier. The RN administered the second dose of Nitro-BID 1 at 1939 hours. The B/P was 89/44 at 1934 hours. The RN failed to clarify the physician's orders. The RN gave the Nitro-BID with a systolic pressure less than 90.

The RN failed to notify the physician of the change in blood pressure.

The RN failed to clarify the physician's orders.

The RN failed to conduct an assessment of the patient's needs as in accordance with the Standard of Care: Assessment, Problem Identification; Outcome Identification and Planning and facility policy.

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

Based on clinical record reviews and interviews the facility failed to inform 2 of 5 sampled patients of their rights, in advance of furnishing or discontinuing care as evidenced by failure to provide Medicare notices as required.

The findings include:

Patient # 11, insured by Medicare, was admitted to the facility on [DATE]. Document titled The Important Message from Medicare About Your Rights (IM) was presented and signed by the patient on 11/27/12. The facility did not present the copy of the IM within two calendar days before the patient's discharge on 12/04/12.

Patient # 12, insured by Medicare, was admitted to the facility on [DATE]. The record failed to provide the evidence of the document titled The Important Message from Medicare About Your Rights. The patient was discharged on [DATE].

Facility policy titled Procedure for the Important Message From Medicare effective 09/01/12 documents In compliance with CMS regulations, all patients admitted as in patients will be requested to date and sign the Important Message from Medicare at or near admission, but not later than two calendar days following the date of admission to the hospital. The policy did not address that notices should be given within two calendar days prior to discharge.

Interview with the Case Manager (CM) was conducted on 12/13/12 at 8:48 AM. The CM explained it is the responsibility of the case manager to provide the Medicare Notices; the notices are given to patients every three days.

Subsequent interview with the Risk Manager (RM) and the Vice President of Quality was conducted on 12/13/12 at approximately 11:30 AM. The RM was not able to locate the notice pertaining to Patient # 12 and the Vice President of Quality acknowledged the notice given to Patient # 11 was not presented within two calendar days from discharge.

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

Based on clinical record review and interview the facility failed to arrange for post hospital services and care for 1 of 5 sampled patients (Patient # 1).

The findings include:

Clinical record review conducted on 12/12/12 revealed Patent # 1 was admitted to the facility on [DATE] with diagnosis of Rhabdomyolysis, Elevated Troponin and Leukocytosis. The past medical history includes alcohol use, malnutrition and abnormal liver function.

Emergency Department Record dated 11/03/12 documents the patient was laying on the floor for two days prior to the fire rescue arrival.

Initial Nursing assessment dated [DATE] documents Patient # 1 was admitted with a decubitus ulcer to the buttocks, assessed as stage II.

Wound Care Note dated 11/12/12 documents Patient noted to be saturated with clear yellowish exudate from buttocks. Soiled linens removed. Area cleansed and patient place on ultrasorb pad. Yellow slough area to buttock noted very thin with pink tissue noted. Blackened necrotic area noted at fleshy part of buttock, peri wound area noted to be red possibly due to moisture.

Case Management Notes dated 11/12/12 document the case manager spoke to the physician, patient can be discharged to rehab but patient does not have insurance. Unable to check with Veterans (VA) Hospital for placement in their rehab facility because they are closed for veterans day.

Physician Progress Notes dated 11/13/12 document the patient has an appointment with primary care provider at the VA, so will discharge today and his primary care provider will arrange for further testing.

Physical Therapy Notes dated 11/13/12 documents patient was seen today for continuation of physical therapy services. I got a lot of stuff in my mind . Patient was able to walk 100 feet with rolling walker but requested to go back to his bed, complained of dizziness. Discharge recommendations noted skilled nursing facility for placement and rolling walker.

Physician order dated 11/13/12 documents Discharge patient to home, Case Management Consult for Durable Medical Equipment, rolling walker and Physical therapy for gait training and therapeutic exercises.

Case Management Notes dated 11/13/12 documents Patient to be discharged to rehabilitation center, spoke with representative at the Veterans (VA) transportation center for possible placement in the VA rehab. The representative stated since the patient has been hospitalized for what appears to be several new medical conditions for which he has not received treatment previously at the VA, the patient would be better served if he is evaluated by his primary medical doctor. Patient will be given appointment at the VA where he will be seen immediately after discharge from hospital ... Spoke to physician regarding suggestion from VA for evaluation by his primary medical doctor upon discharge. After evaluation the VA physician will make arrangements for further care as needed and for rehab placement at the VA.

Case Management Notes dated 11/13/12 documents Received order for discharge home, so patient will be able to keep his scheduled appointment at the VA with his primary care physician. Inform representative from the VA that the patient will be transported at the scheduled time. Faxed copies of discharge orders. Patient given discharge instructions, prescriptions and medication reconciliation sheet.

Discharge instructions date 11/13/12 documents Patient # 1 to be discharged home, has follow up appointment with the VA at 2 PM. The discharge instructions did not specify if any assistance was needed. No referrals to community resources, supplies, equipment or instructions for wound care were documented.

Interview with the Case Manager (CM) assigned to Patient # 1 was conducted on 12/12/12 at 12:26 PM. The CM explained Patient # 1 was originally to be transferred to the Veterans Hospital as an inpatient; during the course of the hospitalization the patient improved and it was then determined that he would be a good candidate for rehabilitation. The patient requested to be placed at the VA rehabilitation center. She then contacted the VA and was advised the best way to expedite the transfer to the rehabilitation unit, was for the patient to be assessed by a VA provider. The Case Manager stated she then arranged for a follow up appointment and the patient was transported from the facility to the doctor's office. The Case Manager was asked what was her intent upon discharge and she replied the patient was transferred to the VA rehabilitation unit, she followed the instructions given, but she acknowledged that she was never told the VA had rehabilitations beds available; the information given to her was the fact that the VA facility had no open beds for outside referrals at the time. The Case Manager was asked if she was aware of the patient's prior living arrangements and the fact that he was lying on the floor for two days prior to the paramedic's arrival; the case Manager stated she was not aware of the history, but the spouse visited frequently and appeared to be a willing participant in his care. The Case Manager was then asked if the physician order for durable medical equipment was implemented; and replied she did not see the order. In addition the case managers was not able to explain if the physical therapy orders written on the day of discharge were orders for post hospital care. Neither could she explain why wound care follow up was not addressed as part of the discharge. The Case Manager reiterated her intention was to discharge the patient to the VA rehabilitation unit. She expected the VA physician to complete the needed referrals and obtain immediate placement.

During interview with the Director of Case Management on 12/12/12 at 1:47 PM, the Director stated she recalled Patient # 1; the facility has a VA Liaison; most likely the Liaison is contacted for in patient to in patient transfers. The Director acknowledged the knowledge of the available veteran's services is limited, as they rarely have veterans in the facility. The Director was not aware the patient had a wound upon discharge, but explained the discharge plan was discussed during the care conference and the case manager followed instructions given by the VA representative. The Director acknowledged the Liaison was not contacted to arrange further services for Patient # 1 and her understanding was that the patient was discharged home with a follow up appointment with the VA physician.

Phone interview with the Health System Specialist Veterans Services was conducted on 12/14/12 at 9:48 AM. The Specialist explained the facility has a navigator, who should be notified of all admissions so they can facilitate transfer or assists with needed services if they have no capacity. Patient # 1 is one hundred percent covered for home health services, skilled nursing and palliative care. The VA Rehabilitation facility had no open beds at the time of discharge and if the facility would have asked for placement or other services, the patient could have been placed in any nursing facility of choice, home health services and equipment would be covered as well; the facility never requested any services. The only request made was for a follow up appointment. The clinical presentation provided by the case manager noted the patient was ambulatory, two hundred feet and needed additional rehabilitation services. The patient arrived with a prescription for wound care; the extent of wound was not provided prior to arrival. When the patient arrived to his appointment; the physician determined the patient ' s wound needed more than skilled nursing services or home health. The patient was admitted and diagnosed with Necrotic Fasciitis and underwent a deep debridement. The patient remains hospitalized .

Facility policy titled Discharge Planning Assessment documents Discharge planning is a systematic coordinated program that is designed to bring about the timely discharge of a patient from a hospital to the next level of care or to return to his/her normal living situation. Based on information obtained during the initial evaluation, the Case Manager Coordinator will make recommendations for post hospital services or placement needed. Once a physician order is obtained, the case Manager Coordinator will arrange services and placement requested. Case Management Coordinator meets with patent, family and or significant other regarding requested equipment. If a patient does not have equipment at home they are asked if they have a preference to company used. Depending on insurance company, the Case Manager will inform patient/family of company supplying the equipment and when to expect delivery.

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

Based on record reviews & interview, the facility did not ensure medications (drugs) were administered in accordance with the orders of the physicians responsible for the patient's care, accepted standards of practice, and with the facility's policies related to medication, for 4 of the 11 clinical records reviewed, (patient #1, #7, #9, and #10). Accepted standards of practice include maintaining compliance with applicable Federal and State laws, regulations and guidelines governing drug and biological use in hospitals, as well as, standards and recommendations promoted by nationally recognized professional organizations.

The findings include:

Review of the facility policies & procedures revealed: 1. Patient ' s Own Medication From Home: ...allows patients to use their own medications(s) from home while in the hospital ...an order must be received in the pharmacy that the patient may use their own medication(s) ...Home medications are to be brought to the pharmacy to be properly identified, entered into MediTech according to complete prescribing information and given a barcode for scanning purposes prior to patient administration. 3. Medication Reconciliation: guidelines for medication reconciliation in the interest of patient safety & advocacy. All inpatients will have all medications reconciled within 24 hours. The outcome of this activity is to generate the most accurate medication list available ....The list of patient ' s home medications ...are documented in the nursing assessment and on the home medication reconciliation form ...Physicians are responsibly for signing ALL medication reconciliation orders. Physicians are responsible for resuming or suspending medication on the Patient Home Meds list within 24 hours of admission and upon discharge... 4. Under the Procedure section: All home medications must be addressed within 24 hours of admission ...When compiled, the nurse must print and place the Admission Med Reconciliation form on top of the Physician Orders for the physician to review, reconcile authorize and sign ...Once all medications are reconciled, the form is faxed to Pharmacy to initialize the patient ' s medication profile ...

Interview with the Assistant Pharmacist Clinical Manager on 12/12/2011 at approximately 1:10 PM and on 12/13/2011 at approximately 11:20 AM revealed the Admission Med Reconciliation form is considered to be a physician order form.

1. Review of the clinical record for Patient #1 revealed the patient was admitted on [DATE] with diagnoses that included psychogenic muscular-skeletal disease, attention deficit with hyperactivity (ADHD), anxiety, tremor, bipolar disorder, autistic disorder, & adverse effect anticonvulsant. The Admission Medication (Med) Reconciliation form of 10/21/2011 was completed and signed by the physician that listed Lexapro 20 mg daily; Concert 54 mg daily, and Remeron 30 mg daily as to be continued while in hospital. Review of the admission orders of 10/20/11 revealed orders that included: Admit to telemetry, seizure precautions, medications: Keppra 500 mg IV q12hr x 2 doses then orally, Ativan 1 mg IV q4 hr as needed for seizure breakthrough; Tylenol 650 mg q6h as needed for Headache, Concerta 54 mg daily and Remeron 30 mg daily. The physician orders were dated and signed initially and as a 24 hour check by the nurse for 10/20/11, 10/21/2011, and 10/23/2011.

Review of the documentation (e-MAR = electronic medication administration record) revealed the order for Concerta was scanned to Pharmacy on 10/21/2011 at 00:39 AM & entered on the eMAR and Pharmacy had responded to the order on the eMAR & documented Clarification of Order Needed...Patient own med - arrange for patient to bring in and send to Pharmacy for verification - Also requires a written MD order to include: ok for patient to take own medication drug, dose, route, and frequency information. Please rescan to Pharmacy. The order & pharmacy response was acknowledged by the nurse on 10/21 at 1:20 AM .

Further review of order for Concerta on the eMAR dated 10/21/2011 with administration time of 9:00 AM to Pharmacy revealed Pharmacy's documentation as above remained on the eMAR but there was no evidence (initial) the nurse had given the med. Further review revealed the order was deactivated on 10/21/11 at 00:38 AM by Pharmacy. The order was edited by the physician on 10/21/11 at 10:00 AM. The same (as 10/21/11) was documented on the 10/22/2011 eMAR but no nurse initial or acknowledgement. On 10/23/11, the Concerta (drug) order was on the eMAR as being discontinued/deactivated by pharmacy. There was an additional nursing order taken (hand-written order) on 10/23/2011 that included to have parent bring home medications in tonight, ok to use own medication Concerta 54 mg daily...patient may titrate meds as needed, and may use own Lexapro 20 mg daily, Patient & family do not want sent. The order was edited by the physician on 10/24/11 and reactivated in Pharmacy on 10/24/2011.

Further review of the eMAR of 10/24/2011 revealed the ordered Lexapro 20 mg daily was not administered by the nurse or no evidence the nurse had administered this medication or the reason for not administering it.

Interview was conducted with the clinical pharmacy manager, with the Vice President (VP) of Quality & Patient Safety present on 12/12/2011 at 2:21 PM, related to what happened with the Concerta medication, revealed: the hospital does not carry Concerta in the hospital and it is not on the formulary: pharmacy lets nursing know it is not available and to have it brought in from home (see above 10/21/11 note from pharmacy). Nursing must see and acknowledge it needs to be brought in from home & requires MD / physician order; pharmacy is not responsible to notify the physician; and you cannot assume the MD / physician does not want it. The clinical pharmacist manager & the VP of Quality agreed there was a gap between the order date of 10/21/11 and 10/23/11 when an additional order is written for mother to bring meds from home. Review of information provided by the pharmacy revealed that on 10/24/11 Patient #1 ' s home medications were sent to pharmacy for verification & identification.

Review of the nursing notes of 10/21/11 at 1:30 AM (admission) revealed the Home Medications were listed and it included the Concerta.

Interview with the Manager of Telemetry (where Patient #1 had been) and the assistant Manager of Med Surg & Telemetry units, on 12/12/2011 at 2:27 PM revealed: there is no documentation or evidence in the record (nursing notes or eMAR) related to the Concerta, as to whether the family was asked to bring in the medication when pharmacy initially sent the note to the unit on 10/21/11. They agreed there was no evidence the medication, Concerta, was administered from 10/21 to 10/24/2011. Review of the eMAR revealed Concerta was administered on 10/25/2011 at 6:06 AM. The patient was discharged on [DATE].

There was documentation in the nursing notes of 10/25/11 at 1:43 PM, of dialogues between nursing and pharmacy, in which the home medications could not be located - they were eventually located in the pharmacy department. Further interview with the Assistant Manager at 3:16 PM revealed the nurses should document the family was notified to bring in meds in the nursing notes, but there is no related documentation in the record. She verbalized there is also no documentation or evidence the nurses documented on the eMAR as to why the medication was not administered (i.e. not available or waiting for family to bring in).

2. Review of the clinical record for Patient #7 revealed the patient was admitted to PICU at 10:17 PM on 11/30/2011 with a diagnosis that included Seizures. Review of the Admission Med Reconciliation form revealed the form was completed which listed the medication Risperdal, but the forms was otherwise blank with no nurse or physician signature. Review of the brief physician admit note for Patient #7 on 11/30/11 at 11:31 PM revealed the home meds were listed as Risperdal (risperidone) 1 mg q AM and 0.5 mg at noon daily. (Risperidone is listed on the formulary so available from pharmacy). Review of the eMARs revealed there was no evidence or documentation that Risperdone was administered during the patient ' s stay in hospital (11/30 thru 12/2/2011). Interview with the VP of QA and the PICU RN on 12/13/2011 at approximately 10:45 AM revealed that typically the intensivist / physician will discharge all home meds for the work-up while in hospital but there was no documentation by the physicians of this.

3. a). Review of the clinical record for Patient #9 revealed the patient was admitted on [DATE] at 6:44 PM, as a transfer from another facility with possible appendicitis. Review of the Admission Mediation Reconciliation form revealed there were 3 Home Meds listed on the form: one routine med (Bacid tablet twice daily), one 'as needed' med (Tylenol), and topical cream (Cod Liver oil / Zinc oxide). There was no evidence the form was reviewed by nursing or the physician. There were no signatures and no indication whether the physician wanted the home-meds to be continued or stopped while in hospital.

b). Review of the physician order for patient #9 revealed an order dated 11/15/2011 at 12:20 PM for ' PPN' (Pediatric Parenteral Nutrition). The nurse documented review of the order at 2:05 PM, and was faxed to pharmacy at 2:06 PM. Interview with the Pharmacist Clinical Manager on 12/13/2011 at 11:24 AM revealed the PPN was not available and the order was missed by nursing & the pharmacy so it was not administered on 11/15/11 as ordered.

Review of the facility report revealed that a PPN order was faxed to the pharmacy at 2 PM (the drug not identified on the report, but interview with the pharmacist clinical manager on 12/13/11 at 12:13 PM revealed it was for PPN / TPN). She further verbalized that when the nurse wanted to give the PPN at 10:00 PM, it was not available and the report documented that pharmacy had not gotten the order.

Review of the eMAR revealed there was no evidence or documentation the patient received the PPN the evening of 11/15/11.

Further interview with the Pharmacist on 12/13/11 at 12:15 PM revealed the patient did not get the PPN on this day (11/15/11 at 2200 hr = 10 PM). She stated the order was faxed to the pharmacy and was never followed through. Further interview with the Pharmacist revealed that PPN is not prepared at this facility so the cut off time was passed (2 PM) when the order was faxed (2:08 PM), and was put on hold by the entry pharmacist. She verbalized it was not realized that it was missed; so they could not get it that evening, but it was obtained the next day (11/16). She verbalized the physician was notified. Review of the physician notes of 11/15/2011 at 11:37 PM revealed that the physician was notified by nursing that the pharmacy had not received the fax for PPN, the order had been faxed, but could not be found. The patient was maintained on current IV Fluids and PPN would be started in the AM .

4. a). Review of the clinical record for Patient #10 revealed the patient was admitted on [DATE] for cardiac catheterization. Review of the physician orders revealed an order of 11/21/2011 at 7 PM for IV Heparin as per Pharmacy please; discontinue IV Heparin at 6 AM . Review of the pharmacy documentation revealed the order was received in pharmacy at 7:32 PM and completed at 8:18 PM. The nurse acknowledged the order on the MAR on 11/21/2011 at 8:30 PM. Review of the MARS for Patient #10 revealed an order entry on 11/21/2011 for Heparin 25,000 units/ D5W 500 ml bag at 17 mls / hour (concentration of 50 units / ml as directed). There was no evidence or documentation in the record or on the eMARs the Heparin drip was administered to the patient. The VP of Quality reviewed the eMARs with the surveyor and agreed it was not given. The eMARs were reviewed with the Charge nurse of Telemetry & the Nurse Manager on 12/13/2011 at 1:01 PM and they agreed the Heparin drip was not documented as being administered. Review of the nursing notes revealed the physician was notified. Further interview with the Charge nurse revealed the nurse did not know about the order until she was doing her shift notes near the morning, and then notified the physician. There were no additional orders from the physician. The Nurse manager stated she needs to follow up with the agency as she was a traveling nurse.

b). Further review of the file for Patient #10 revealed a Home Medication Reconciliation form completed by the nurse and signed by the physician. The form documented to continue with the Omega 3s and the MultiVitamins. Review of the eMARs revealed they were not listed on the MAR and were not administered. Interview with the VP of Quality on 12/13/2011 revealed the signed Admission Medication Reconciliation form is supposed to be faxed to pharmacy as an order.

Based on record reviews & interview, the facility did not ensure medications (drugs) & biologicals were procured, distributed and administered in accordance with the orders of the physicians responsible for the patient's care for 1 of 11 sampled patients (#9). Pharmaceutical Services would include: The procuring, dispensing, ordering, distributing, and administering of all medications.

The findings include:

1. Review of the physician order for patient #9 revealed an order dated 11/15/2011 at 12:20 PM for ' PPN' (Pediatric Parenteral Nutrition). The nurse documented review of the order at 2:05 PM, and it was faxed to the pharmacy at 2:06 PM.

Review of the facility report revealed that a PPN order was faxed to the pharmacy at 2 PM (the drug not identified on the report, but interview with the pharmacist clinical manager on 12/13/11 at 12:13 PM revealed it was for PPN / TPN). She further verbalized that when the nurse wanted to give the PPN at 10:00 PM, it was not available and the report documented that pharmacy had not gotten the order.

Further interview with the Pharmacist on 12/13/11 at 12:15 PM revealed the patient did not get the PPN on this day (11/15/11 at 2200 hr = 10 PM). She stated the order was faxed to the pharmacy and was never followed through. Further interview with the Pharmacist revealed that PPN is not prepared at this facility so the cut off time was passed (2 PM) but we give an approximate 10 minute leeway for orders coming in little after 2 PM. The nurse documentation revealed the order was faxed (2:06 PM), and review of the eMAR (electronic medication administration record) revealed it was put on hold by the entry pharmacist. The Pharmacist verbalized it was not realized that it was missed soon enough, so they could not get (procure & distribute) it that evening, but it was obtained the next day (11/16). She verbalized the physician was notified. Review of the physician notes of 11/15/2011 at 11:37 PM revealed that the physician was notified by nursing that the pharmacy had not received the fax for PPN, the order had been faxed, but could not be found. The patient was maintained on current IV Fluids and PPN would be started in the AM .

Interview with the Pharmacist Clinical Manager on 12/13/2011 at 11:24 AM revealed the PPN was not available and the order was missed by nursing & pharmacy so it was not administered on 11/15/11 as ordered.

Review of the eMAR revealed there was no evidence or documentation the patient received the PPN the evening of 11/15/11.

Based on review of medical records, policies and procedures, emergency room (ER) on call Schedules, transfer logs, credentialing files, medical staff by-laws, EMTALA training and staff interviews the facility failed to accept from a transferring hospital an appropriate transfer of an individual who required the facility's orthopedic specialized capability and capacity to treat 1 of 20 (#1) sampled patients. Refer to A 2411

Based on review of medical records, policies and procedures, emergency room (ER) on -call schedules, transfer logs, credentialing files, medical staff by-laws, EMTALA training and staff interviews the facility failed to accept from a transferring hospital an appropriate transfer of an individual who required the facility's orthopedic specialized capability and capacity to treat 1 of 20 (#1) sampled patients.

The findings included:

Review of the current facility policy titled, EMTALA--Transfer Policy Addendum revealed that all requests for transfer into the facility will be directed to the nursing supervisor. All information will be documented in the transfer log. The process is as follows: the call is received from the transferring hospital to the nursing supervisor. The nursing supervisor will determine the specialty and determines if the service is available. The patient is then accepted or denied.

Patient #1's medical record from the transferring hospital was reviewed. Review of the Physician Documentation form dated 9/10/11 at 3 :57 p.m. revealed that patient #1 arrived to the ER at 3:48 p.m., in a private car, indicating in part, fell 4 d (days) ago, hit Rt (right) face, arm, and Rt leg. Has pain and swell to Rt femur. No LOC (loss of consciousness)...Symptoms came on gradually and became progressively worse...Patient describes quality of symptoms as aching. Patient states symptoms are of mild severity. Documentation by the ER physician's review of the Radiology x- Ray report, indicated that patient #1 was diagnosed with an Acute non-displaced intertrochanteric right hip fracture. The transferring hospital's ER/Transfer/Communication Log dated 9/10/11 at 5:16 p.m. was reviewed . Review of this log verified that Palms West Hospital was called and had spoken to the nursing supervisor on 9/10/2011. Further review indicated that at 5:38 p.m., Patient #1 was denied transfer to Palms West Hospital because, No Ortho(Orthopedic) on call. Patient #1 was appropriately transferred to another facility and received the emergent care that was needed.

Review of the transfers log entry for patient #1 from 9/10/11 revealed that a transferring hospital requesting a transfer for orthopedic specialty for this patient with a hip fracture. Patient #1 was refused based on no Orthopedic surgeon on call who could complete the procedure. Review of the hospital's September 2011 ER on- call schedule revealed that on 9/10/11 there was an orthopedic surgeon on call who was credentialed to perform the procedure. The facility failed to ensure that specialized orthopedic services were provided that were within the capability and capacity of hospital for patient #1 on 9/10/2011, as this resulted in delay of treatment.

Interview on 9/15/11 at 9:15 am with the risk manager, quality manager and the nursing supervisor revealed that a Registered Nurse (RN) was training with the current nursing supervisor to be a nursing supervisor. She had worked in the facility for more than 20 years. The supervisor had been a nursing supervisor for 10 years and was a more than 20 year employee. The call came to the nursing office on 9/10/11 at 5:20 p.m. from the hospital requesting transfer of an orthopedic patient with a fractured hip in need of surgery. The supervisor and the trainee looked at the on call calendar for September and found an orthopedic surgeon on call. The physician on call specializes in complex hand surgeries, but is credentialed for core orthopedic procedures. The supervisor and the trainee were aware that the physician did hand surgery and they called the practice to ensure that there was a backup physician for the hip surgery. The answering service had the Advanced Registered Nurse Practitioner (ARNP) for the practice return the call. She informed the trainee that the on call physician only did hand surgeries and that they would have to call someone else. The transfer was refused by the nursing supervisor trainee in a call to the requesting hospital.

When the transfer log was reviewed the following day by the nursing management staff, they discovered that the patient was refused. Risk management and quality management investigated and spoke with the supervisor and the trainee. They reported that they (the supervisor and the trainee) had called the service of the practice to verify that the on call physician would come to the ER. The ARNP for the practice answered the call and stated that the physician was on call but only does hand surgery and occasionally an ankle if it is really simple. When the ARNP was asked who the backup surgeon was for the on call physician, they were told by the ARNP that there was no backup. The supervisors then refused the patient.

Review of the physician's credential file and interview with the medical staff manager on 9/15/11 at 10 am revealed that the orthopedic surgeon was initially credentialed on 10/27/97 for all orthopedic procedures and especially complex hand procedures. She was re-credentialed last on 8/2/10 for orthopedic core procedures and complex hand procedures. The physician conducts procedures on adults and children over the age of 8. The physician's medical license expires on 1/31/12. The physician's ARNP was credentialed by the facility to assist the physicians in the practice and as first assist in the Operating Room (OR). She has a current Florida license which expires on 4/30/13.

Review of the medical staff by laws and interview with the medical staff manager on 9/16/11 at 11 am revealed that the active staff physicians must take call in the ER. Between all of the physicians on the service the month must be covered daily.

Review of the EMTALA education revealed that on 4/24/09 and 9/3/10 the nursing supervisor trainee completed the facility's EMTALA training.

Interview with the nursing supervisor on 9/15/11 at 11:05 am revealed that she was aware that the nursing supervisor trainee had made the call to the orthopedic surgeon on call, and that the ARNP did not have the physician on call return the call.

Interview with the nursing supervisor trainee on 9/15/11 at 11:15 am revealed that when the call came in from the hospital requesting transfer, the required physician on call was identified. A call was placed to the answering service of the physician and they identified the ARNP as being the one to take the calls for the practice. The ARNP returned the call and told the trainee that the physician on call was unable to do hip surgery. The supervisor trainee did not ask for a backup surgeon. The ARNP did not offer a surgeon for backup and she did not have the physician on call return the facility's call.

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

Based on record review and interview the facility staff failed to notify the physician for a change in the condition of the patient and a change in the provision of a medication ordered by the physician for 1 of 3 (#3) patients. The findings included:

Review of the clinical record of patient #3 on 4/11/11 at 1 pm with the quality management and the acting chief nursing officer (CNO) revealed that the patient came to the facility on [DATE] with shortness of breath for the past 8 weeks, progressively worsening. The medical screening examination was conducted and the ER physician noted labored breathing and inability to breathe well lying down. The patient had an EKG with changes and mild labored breathing. The laboratory test for magnesium was 1.5 (norm is 1.6-2.4) and the cardiac enzymes were within normal limits. Liver function tests were abnormal. Cardiology and pulmonology were consulted. The patient was admitted to telemetry on oxygen. On admission the nursing assessment documented that the patient's skin was flushed. On 2/21/11 the physician ordered 3 grams of magnesium to be given in 200 cc of D5W by IV over 3 hours. Steroids and mild sedation were given for the breathing difficulties.

Interview on 4/11/11 at 12:30PM with the director of pharmacy revealed that the administration of magnesium can cause flushing of the skin. It is a side effect with a short term effect. The average dose of magnesium is 3 grams by IV and usually over 3 hours. Slowing down the IV will not create problems but the dosage and the time were determined by the manufacturer for the best absorption.

Interview on 4/11/11 at 12:30 pm with both the CNO and the director of pharmacy revealed that the manufacturer of the medication sends the medication in divided doses; 2 grams in 50 cc of D5W and 1 gram in 100 cc of D5W to follow. The IV for patent #3 was begun on 2/22/11 at 12:37 pm with the 2nd bag to follow. The IV was restarted part way through the IV doses because it was leaking. The IV was discontinued at 8:30 pm after the medication was given. Review of the nurse's notes on 2/22/11 confirmed that the patient was flushed with no itching when the IV was completed, and 5 hours later the flush appeared to be lessened. Review of the nurse's notes revealed that the patient had a flushed, ruddy appearance on 2/21/11 at 8 am, 2/21/11 at 8 pm, and on 2/22/11 at 8 am.

Interview on 4/11/11 at 12 noon with the risk manager revealed that a complaint was received on 3/9/11 from patient #3 regarding his care in the facility. The letter was sent to the CEO. The risk manager was asked to investigate the allegations and called the pharmacy to ask about the concentration of magnesium in an IV. The risk manager also spoke with the telemetry nurses. The IV ran over several hours and the patient got the entire dose. Several hours later the patient complained of a red face and high blood pressure. The patient ' s blood pressure was not elevated and there was no itching noted by the nurse. Review of the clinical record of patient #3 with the risk manager revealed that the patient had a flush to the skin when the medication was infusing and for hours thereafter. There was no evidence in the notes or anywhere in the record that the physician was called and notified that the patient was complaining or flushed. The nurse ' s notes did not contain notification to the physician of a possible medication reaction or slowing of the IV to accommodate the patient. There was no evidence in the notes of the IV coming out during the infusion and no information under IV monitoring.

Interview on 4/14/11 at 1:15 pm with the director of telemetry revealed that she had spoken to the nurse who administered the IV medication to patient #3. The nurse stated that the patient was flushed on admission, and with the IV medication the flush had not worsened. The nurse did slow down the IV for the patient but did not call the physician for a new IV flow order or to inform him regarding the patient ' s complaints or condition.