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Based on record reviews and administrative interviews, it was determined the hospital does not have an effective governing body legally responsible for the conduct of the hospital as an institution as it relates to Condition of Participation at A0263 Quality Assurance Performance Improvement, A0385 Nursing Services and A1123 Rehab Services. Standards at A0395; A0404 Nursing Services and A1125 Rehab Services. The governing body is responsible for the conduct of the hospital as an institution.

These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

The findings include:

1. "Quality Assurance Performance Improvement" related to lack of program as it pertains to Nursing Services and Rehabilitation Services.

2. "Nursing Services" related to lack of communications, documentation and medication standards not being met.

3. "Rehabilitation Services" related to lack of a qualified Director.

Based on interviews with the Corporate Medical Director and Corporate Quality Director, observations and review of facility Quality Assurance Performance Improvement (QAPI) program, it has been determined the facility failed to ensure the Quality Assessment Performance Improvement efforts were implemented in Nursing Services and Rehabilitation Services. Failure to demonstrate the hospital's governing body as being responsible and accountable for ensuring on-going specific Quality Assurance Performance Improvement program requirements are being met. Failure to implement a Quality Assessment Performance Improvement program to ensure accountability and addressed priorities for improved quality of care by all departments of the hospital.

The findings include:

1. The Quality Assessment Performance Improvement (QAPI) program minutes of 5/11/10 were reviewed with the Corporate Quality Director on 5/20/10 at 10:00 a.m. The minute's documented under Nursing Discussion/ Conclusion reveal "Nursing developing new indicators." Recommendations/Actions "Continue to Monitor nursing documentation on a weekly basis. Weekly Nursing meetings are being held to improve education and communication with nurses." Validation of weekly monitoring of nursing documentation was not available for review during the survey. The only Nursing Department minutes that were available for review during the survey were dated 4/30/10. Documentation under Lab Discussion "Begin to monitor when lab results are faxed to facility." Recommendations/Actions "Developing monitoring system." No monitoring system had been implemented to date. This information was confirmed by the Quality Director.

The Corporate Medical director stated, during an interview on 5/19/10 at 3:41 p.m., that the form to monitor lab results had not been implemented to date.

During an interview with the Corporate Medical Director, Chief Operating Officer and review of the personnel file of the employee appointed to be the Director of Rehabilitation Services on 5/19/10 at 3:41 p.m., it was confirmed that the employee appointed did not have the knowledge and experience to properly supervise the rehabilitation services.

Refer to A0385, A0395, A0404, A1123 and A1125 for additional information.

Based on clinical record reviews, interviews and reviews of policies and procedures, it was determined the hospital does not have an effective organized Nursing Department that provides 24-hour services to maintain the health, safety and well-being of the patients it serves as it relates to the Condition of Participation and Standard A0395 and A0404.
This failure presents substantial probability to adversely affect all patients' physical health, safety and well-being.
The findings include:
1. Observation, interview and clinical record review, revealed that the facility failed to ensure that the nursing care for each patient is supervised by a registered nurse for 5 (Patients #31, #32, #36, #43 and #46) of 16 sampled patients. This is evidenced by lab work not obtained as ordered by the physician for Patients #31, #32, #36, #43 and #46 and failing to notify the physician that the lab work was not completed as ordered.
2. Based on observation, interview and clinical record review, the facility failed to prepare and administer drugs and biologicals in accordance with Federal and State laws, the orders of the practitioner responsible for the patients care of 9 (Patients #30, #47, #48, #49, #50, #51, #52, #53 and #55) of 13 sampled patients and under acceptable standards of practice.

3. Based on observation, interview and clinical record review, 4 (Patients #39, #40, #54 and #55) of 16 sampled patients the facility failed to ensure that their care needs were assessed by a registered nurse when the patient was transferred from the facility 100 wing after being detoxed) to the 200 wing (once stable).

Based on observation, interview and clinical record review, the facility failed to ensure nursing care for each patient is supervised by a registered nurse for 5 (Patients #31, #32, #36, #43 and #46) of 16 sampled patients. This is evidenced by lab work not obtained as ordered by the physician for 5 (Patients #31, #32, #36, #43 and #46) and failing to notify the physician that the lab work was not completed as ordered.
Additionally 4 (Patients #39, #40, #54 and #55) of 16 sampled patients admitted to the 200 Unit lacked documentation that their care needs were assessed by a registered nurse when the patient was transferred from the facility 100 wing (Detox) to the 200 wing (stable)
The findings include:
1. Patient #31 was admitted on 5/12/10 and discharged 5/17/10. Review of the clinical record on 5/19/10, reveal that admission orders of 5/12/10 included to obtain the following labs; Urinalysis, CBC with Differential, CMP, Amylase/Lipase, CPK, TSH, T3 Uptake, T4,T7, RPR and a Liver Function Profile and a HCG in a.m. The clinical record contained the results of the U/A which was completed on 5/13/10. No blood lab work was found in the record. Review of the facility's Lab Log shows that the client was scheduled for a blood draw on 5/14/10 however there is a notation on the log of " No needles." In addition, the log did not include the lab test for HCG. Review of the clinical record does not show that the physician was notified that the order was not completed.

Interview with nursing staff on 5/19/10 at approximately 2:15 p.m., revealed that the lab technician ran out of needles to perform the tests.

An interview with the Chief Operating Officer (C.O.O.) was conducted on 5/19/10 at 2:35 p.m. The interview revealed that the provision of supplies for lab work is the responsibility of the facility and the needles did not arrive as ordered. The C.O.O. confirmed that the patient did not have blood work results in the record. On 5/20/10, the patient's physician reviewed the record and confirmed that the lab work was not done as ordered and he did not receive notification.

2. Patient #32 was admitted on 5/12/10 and discharged 5/17/10. Review of the clinical record on 5/19/10, reveal that admission orders of 5/12/10 included to obtain the following labs; Urinalysis, UDS, CBC with Differential, CMP, Amylase/Lipase, CPK, TSH, RPR and a Liver Function Profile. The clinical record contained the results of the U/A and UDS, which were completed on 5/12/10. No blood lab work was found in the record. Review of the facility's Lab Log shows that the client was scheduled for a blood draw on 5/14/10, however there is a notation on the log of " No needles" and there is no evidence that the lab work was completed. The clinical record does not show that the physician was notified that the laboratory work was not completed.

3. Patient #43 was admitted on 5/10/10 and receives Coumadin, a blood thinner. Review of the clinical record on 5/19/10, revealed that on 5/11/10 at 11:45 a.m., an order for a STAT INR was written by the physician. Review of the record on 5/19/10 shows that the INR was completed on 5/12/10, not on 5/11/10 as ordered. The facility Policy and Procedure for Lab Tests dated 3/01/10 was reviewed and shows that upon receiving a STAT order the R.N. transcribes the order onto the Lab Slip and telephones the vendor laboratory to inform them that there is a STAT laboratory test order. The policy shows that STAT results are reported within four to six hours of the laboratory receiving notification of the order.
On 5/19/10 at approximately 2:15 p.m., the Registered Nurse reviewed the record and confirmed that the order for the stat INR was not noted until 8:00 p.m. and it was not completed timely.
Interview with the Registered Nurse on 5/20/10, revealed that at times the patient charts are not on the unit to ensure that orders are transcribed timely.
4. Review of the clinical record of Patient #36 on 5/19/10 at 10:45 a.m., found that the patient was admitted to the facility on 5/11/10 and the physician admission orders included nine blood work studies. The blood was not drawn from the patient on 5/12/10 because the laboratory accession book documented "No needles." The blood work was not completed until 5/17/10. There was no documentation in the clinical record that the physician had been notified of the delay.
5. Review of the clinical record of Patient #46 on 5/20/10 at 10:30 a.m., found that the patient was admitted to the facility on 5/10/10 and the physician admission orders included nine blood work studies. The laboratory accession book documented "No needles" on 5/13/10. There was no documentation in the clinical record that the physician had been notified of the delay
During an interview with the Director of Nursing (DON) on 5/19/10 at approximately 2:00 p.m., he/she stated that there was no policy or procedure available for review during the survey regarding the documentation required when a patient is transferred from one unit to the other.
During review of 4 (Patients #39, #40, #54 and #55) of 17 sampled medical records on 5/20/10 at 10:30 a.m., found no documentation of the patient's care needs or health status by a Registered Nurse when the patient was transferred from the facility 100 wing (Detox) to the 200 wing (stable).

During an interview with the 200 wing charge nurse at this time he/she stated, "We usually document information on the patient's clinical record when they are transferred."

Based on observation, interview and clinical record review, the facility failed to prepare and administer drugs and biologicals in accordance with Federal and State laws , under acceptable standards of practice and by the orders of the practitioner responsible for the patients care for 9 (Patients #30, #47, #48, #49, #50, #51, #52, #53 and #55) of 13 sampled patients.

Professional Standard of Care is defined in Chapter 766.102 as, "The prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers."

The Florida Nurse Practice Act, Chapter 464.003 defines the "Practice of professional nursing" as "The performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: the administrations of medications and treatments as prescribed or authorized by a duly licensed practitioner; "Practice of practical nursing" as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or informed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist."

The findings include:

A review of the Medication Administration Record (MAR) of 9 (Patients #30, #47, #48, #49, #50, #51, #52, #53 and #55) of 16 sampled patients on 5/20/10 at 10:00 a.m., found numerous medications circled on days between 5/15/10 and 5/20/10 with documentation of initials and "ref and N/A." The Charge Nurse interviewed at this time stated that the circled initials were that of the nurse administering the medications. N/A meant not available and ref meant refused. The MAR's contained no legend pertaining to either N/A or ref. Review of the facility Nursing Department Medication Administration policy and procedure found documented the following: "Administering Medications: 6. If a medication is refused or omitted, circle initials and write explanatory note and place in medical record. For doses refused or omitted, the physician is to be notified." The policy and procedure documented no reference to "ref." or "N/A." Review of the clinical records of the 9 patients at this time found no documentation that the patient had refused the medication or the physician had been notified in the clinical record.

Based on interviews the facility failed to meet the Conditions of Participation as demonstrated by failure to have a Rehabilitation Department that is organized and staffed to ensure the health and safety of patients. The Rehabilitation Department does not have a qualified, designated director.

The findings include:

During an interview with the Corporate Medical Director and Chief Operating Officer and review of the personnel file of the employee appointed to be the Director of Rehabilitation Services on 5/19/10 at 3:41 p.m., it was confirmed that the employee appointed did not have the knowledge and experience to properly supervise the services. The employee was credentialed as a psychiatrist.

Based on interviews and review of a personal record, the facility failed to have a qualified Director of Rehabilitation services responsible to oversee the services and staff providing physical therapy to patients.

The findings include:

During an interview with the Corporate Medical Director and Chief Operating Officer and review of the personnel file of the employee appointed to be the Director of Rehabilitation Services on 5/19/10 at 3:41 p.m., it was confirmed that the employee appointed did not have the knowledge and experience to properly supervise the services. The employee was credentialed as a psychiatrist. There was no Director job description or policies and procedures available for review during this survey.