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Based on medical record review and interview, the facility failed to provide documentation addressing 2 (Patients #1 and #3) of 5 patients sampled of having been informed of their right to formulate advance directives upon admission and 1 (Patient #5) of having the facility staff comply with these advance directive decisions.The findings include:
1. A review of the medical record on 11/17/10 for Patient #1 who was admitted to the hospital on 11/13/10, revealed nursing documentation, dated 11/13/10 at 0319 (3:19 a.m.), for Advance Directives with the following notation: Does the Pt have an Advance Directive: NO. Pt has been provided (hospital name) written materials on advance directives: NO.

2. A review of the medical record on 11/17/10 for Patient #3 who was admitted to the hospital on 11/11/10, revealed nursing documentation, dated 11/11/10 at 2332 (11:32 p.m.), for Advance Directives with the following notation: Does the Pt have an Advance Directive: UNKNOWN with no further indication of any follow-up to this patient's right to formulate any Advance Directives upon admission to the facility. 3. A review of the medical record on 11/16/10 for Patient #5 who was admitted to the hospital on 11/13/10, revealed a physician's order, dated 11/13/10 at 1435 (2:35 p.m.), with the following notation: DNR (Do Not Resuscitate); No CPR (Cardiopulmonary Resuscitation); No Defibrillation; and No Intubation. This order was clarified on 11/13/10 with no time noted with the following entry: Yes to intubation. No to CPR, Defibrillation or Cardioversion. On 11/14/10 at 10:29 a.m., the nurse documented the following: "In the room with this pt. who's VS (vital signs) where stable converted from afib (atrial fibrillation) rate of 53 to v-fib (ventricular fibrillation). The intensivist was called and I (nurse) brought the code cart to the bedside...CPR was initiated..." Physician progress notes, dated 11/14/10 at 11:00 a.m., document the following notation: Called emergently to bedside...CPR being performed on my arrival. Pt is a DNR with No CPR/No defib/No cardioversion specifically written in orders..." The attending physician's History and Physical Examination, dated 11/13/10 and dictated at 1546 (3:46 p.m.), for this patient also confirmed in the Impression Section with the following documentation: "7. Do not resuscitate status."

4. An interview with the Intensive Care Director and Day Nursing Supervisor was conducted on 11/16/10 in the afternoon with Risk Management and Nursing Systems Director in the room. The medical record for Patient #5 was reviewed at the time of interview with the findings confirmed. The Intensive Care Director remarked that the nurse might have over reacted since most patients in the unit are full codes. It was also confirmed the nurse failed to review the physician's order for the code status. The Nursing Supervisor commented that her "gut" reaction was "this shouldn't have happened and we need to go from there."

Based on interview, and clinical record review, it was determined the facility failed to ensure (1) Nursing followed prescribed physician orders and honored patient's Advance Directive rights; (2) Nursing administered intravenous medications according to accepted standards of nursing practice and hospital policy; and (3) Nursing supervised and evaluated the nursing care and care plan for each patient.

Findings include: one of five medical records (Patient #5) reviewed failed to follow prescribed physician orders and honor patient's Advance Directive; one of five (Resident #1) failed to ensure nursing administered an intravenous medication according to hospital policy; and nursing completed 24-hour chart checks and failed to note current physician orders and assess the patient's care needs as it related to intravenous medication administration. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

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."

Florida Statutes, Chapter 464 Part 1 (3)(a) reads: " 'Practice of professional nursing' means the performance of those acts requiring specialized knowledge, judgment, and nursing skill based upon applied principles of biological, physical, and social sciences which shall include, but not be limited to:
1. The observation, assessment, nursing diagnosis, planning, intervention and evaluation, health teaching, and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others.
2. The administration of medications and treatments as prescribed or authorized by a licensed practitioner authorized by the laws of this state to prescribe medications and treatments.
3. The supervision and teaching of other personnel in the theory and performance of above acts. ..."

The findings include:

1. During record review on 11/17/10 for Patient #1 receiving intravenous (IV) medications in the Intensive Care Unit, it was revealed this patient had a peripheral IV site on the right forearm and a femoral sheath in the left iliofemoral artery. Documentation in the computerized nursing notes for 11/13/10 reported the IV site in the right forearm was "leaking" and was removed on 11/13/10 at 6:30 p.m. after a dose of Phenergan (medication used for motion sickness, nausea/vomiting, allergies and nighttime sedation) 6.25 mg IV push was administered. Further documentation in the medication administration record for 11/13/10 revealed the nurse administered Phenergan 6.25 mg IV push at 8:31 p.m. There was no documentation in the record to indicate there was another peripheral IV site at 8:31 p.m. for this patient in addition to the left femoral artery site already in place. The ICU and Surgical Unit Directors conducted a computer record review for this patient on 11/17/10 at approximately 1:00 p.m. This medication error was confirmed at that time during interview with Risk Management, Systems Nursing Director, ICU Director, and Surgical Unit Director. The ICU Director reported that hospital policy allowed only Heparin (an anticoagulant medication) and TPA (Tissue Plasminogen Activator - an anticoagulant medication) to be administered through the femoral arterial sheath. During an interview on 11/17/10 at 1:30 p.m.., the hospital requested the IV Therapist confirm the IV team go home at approximately 5:30 p.m. each day and return in a.m. The IV Therapist also reported she attempted a restart on 11/14/10 at 9:15 a.m. with documentation of the patient's refusal. Without documentation of a peripheral IV site, it would be impossible to assure this IV medication was administered per accepted standards of practice and hospital policy.

2. During record review on 11/16/10 for Patient #5 who was admitted to the hospital on 11/13/10, revealed a physician's order, dated 11/13/10 at 1435 (2:35 p.m.), with the following notation: DNR (Do Not Resuscitate); No CPR (Cardiopulmonary Resuscitation); No Defibrillation; and No Intubation. This order was clarified on 11/13/10 with no order time noted and the following entry documented: "Yes to intubation. No to CPR, Defibrillation or Cardioversion." On 11/14/10 at 10:29 a.m., the nurse documented the following: "In the room with this pt. who's VS (vital signs) where stable converted from Afib (atrial fibrillation) rate of 53 to v-fib (ventricular fibrillation). The intensivist was called and I (nurse) brought the code cart to the bedside...CPR was initiated..." Physician progress notes, dated 11/14/10 at 11:00 a.m., documented the following notation: "Called emergently to bedside...CPR being performed on my arrival. Pt is a DNR with No CPR/No defib/No cardioversion specifically written in orders..." The attending physician's History and Physical Examination, dated 11/13/10 and dictated at 1546 (3:46 p.m.), for this patient also confirmed in the Impression Section with the following documentation: "#7. Do not resuscitate status." Therefore, the CPR was provided without benefit of a physician's order.
During various administrative interviews throughout the survey process, it was confirmed nursing failed to ensure prescribed physician orders were followed including patient's Advance Directive rights; nursing failed to administer intravenous medications according to hospital policy; and nursing failed to supervise, update and evaluate the nursing care and care plan for these two patients.

Based on medical record review and interview, the facility failed to provide documentation addressing 2 (Patients #1 and #3) of 5 patients sampled of having been informed of their right to formulate advance directives upon admission and 1 (Patient #5) of having the facility staff comply with these advance directive decisions.The findings include:
1. A review of the medical record on 11/17/10 for Patient #1 who was admitted to the hospital on 11/13/10, revealed nursing documentation, dated 11/13/10 at 0319 (3:19 a.m.), for Advance Directives with the following notation: Does the Pt have an Advance Directive: NO. Pt has been provided (hospital name) written materials on advance directives: NO.

2. A review of the medical record on 11/17/10 for Patient #3 who was admitted to the hospital on 11/11/10, revealed nursing documentation, dated 11/11/10 at 2332 (11:32 p.m.), for Advance Directives with the following notation: Does the Pt have an Advance Directive: UNKNOWN with no further indication of any follow-up to this patient's right to formulate any Advance Directives upon admission to the facility. 3. A review of the medical record on 11/16/10 for Patient #5 who was admitted to the hospital on 11/13/10, revealed a physician's order, dated 11/13/10 at 1435 (2:35 p.m.), with the following notation: DNR (Do Not Resuscitate); No CPR (Cardiopulmonary Resuscitation); No Defibrillation; and No Intubation. This order was clarified on 11/13/10 with no time noted with the following entry: Yes to intubation. No to CPR, Defibrillation or Cardioversion. On 11/14/10 at 10:29 a.m., the nurse documented the following: "In the room with this pt. who's VS (vital signs) where stable converted from afib (atrial fibrillation) rate of 53 to v-fib (ventricular fibrillation). The intensivist was called and I (nurse) brought the code cart to the bedside...CPR was initiated..." Physician progress notes, dated 11/14/10 at 11:00 a.m., document the following notation: Called emergently to bedside...CPR being performed on my arrival. Pt is a DNR with No CPR/No defib/No cardioversion specifically written in orders..." The attending physician's History and Physical Examination, dated 11/13/10 and dictated at 1546 (3:46 p.m.), for this patient also confirmed in the Impression Section with the following documentation: "7. Do not resuscitate status."

4. An interview with the Intensive Care Director and Day Nursing Supervisor was conducted on 11/16/10 in the afternoon with Risk Management and Nursing Systems Director in the room. The medical record for Patient #5 was reviewed at the time of interview with the findings confirmed. The Intensive Care Director remarked that the nurse might have over reacted since most patients in the unit are full codes. It was also confirmed the nurse failed to review the physician's order for the code status. The Nursing Supervisor commented that her "gut" reaction was "this shouldn't have happened and we need to go from there."

Based on interview, and clinical record review, it was determined the facility failed to ensure (1) Nursing followed prescribed physician orders and honored patient's Advance Directive rights; (2) Nursing administered intravenous medications according to accepted standards of nursing practice and hospital policy; and (3) Nursing supervised and evaluated the nursing care and care plan for each patient.

Findings include: one of five medical records (Patient #5) reviewed failed to follow prescribed physician orders and honor patient's Advance Directive; one of five (Resident #1) failed to ensure nursing administered an intravenous medication according to hospital policy; and nursing completed 24-hour chart checks and failed to note current physician orders and assess the patient's care needs as it related to intravenous medication administration. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

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."

Florida Statutes, Chapter 464 Part 1 (3)(a) reads: " 'Practice of professional nursing' means the performance of those acts requiring specialized knowledge, judgment, and nursing skill based upon applied principles of biological, physical, and social sciences which shall include, but not be limited to:
1. The observation, assessment, nursing diagnosis, planning, intervention and evaluation, health teaching, and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others.
2. The administration of medications and treatments as prescribed or authorized by a licensed practitioner authorized by the laws of this state to prescribe medications and treatments.
3. The supervision and teaching of other personnel in the theory and performance of above acts. ..."

The findings include:

1. During record review on 11/17/10 for Patient #1 receiving intravenous (IV) medications in the Intensive Care Unit, it was revealed this patient had a peripheral IV site on the right forearm and a femoral sheath in the left iliofemoral artery. Documentation in the computerized nursing notes for 11/13/10 reported the IV site in the right forearm was "leaking" and was removed on 11/13/10 at 6:30 p.m. after a dose of Phenergan (medication used for motion sickness, nausea/vomiting, allergies and nighttime sedation) 6.25 mg IV push was administered. Further documentation in the medication administration record for 11/13/10 revealed the nurse administered Phenergan 6.25 mg IV push at 8:31 p.m. There was no documentation in the record to indicate there was another peripheral IV site at 8:31 p.m. for this patient in addition to the left femoral artery site already in place. The ICU and Surgical Unit Directors conducted a computer record review for this patient on 11/17/10 at approximately 1:00 p.m. This medication error was confirmed at that time during interview with Risk Management, Systems Nursing Director, ICU Director, and Surgical Unit Director. The ICU Director reported that hospital policy allowed only Heparin (an anticoagulant medication) and TPA (Tissue Plasminogen Activator - an anticoagulant medication) to be administered through the femoral arterial sheath. During an interview on 11/17/10 at 1:30 p.m.., the hospital requested the IV Therapist confirm the IV team go home at approximately 5:30 p.m. each day and return in a.m. The IV Therapist also reported she attempted a restart on 11/14/10 at 9:15 a.m. with documentation of the patient's refusal. Without documentation of a peripheral IV site, it would be impossible to assure this IV medication was administered per accepted standards of practice and hospital policy.

2. During record review on 11/16/10 for Patient #5 who was admitted to the hospital on 11/13/10, revealed a physician's order, dated 11/13/10 at 1435 (2:35 p.m.), with the following notation: DNR (Do Not Resuscitate); No CPR (Cardiopulmonary Resuscitation); No Defibrillation; and No Intubation. This order was clarified on 11/13/10 with no order time noted and the following entry documented: "Yes to intubation. No to CPR, Defibrillation or Cardioversion." On 11/14/10 at 10:29 a.m., the nurse documented the following: "In the room with this pt. who's VS (vital signs) where stable converted from Afib (atrial fibrillation) rate of 53 to v-fib (ventricular fibrillation). The intensivist was called and I (nurse) brought the code cart to the bedside...CPR was initiated..." Physician progress notes, dated 11/14/10 at 11:00 a.m., documented the following notation: "Called emergently to bedside...CPR being performed on my arrival. Pt is a DNR with No CPR/No defib/No cardioversion specifically written in orders..." The attending physician's History and Physical Examination, dated 11/13/10 and dictated at 1546 (3:46 p.m.), for this patient also confirmed in the Impression Section with the following documentation: "#7. Do not resuscitate status." Therefore, the CPR was provided without benefit of a physician's order.
During various administrative interviews throughout the survey process, it was confirmed nursing failed to ensure prescribed physician orders were followed including patient's Advance Directive rights; nursing failed to administer intravenous medications according to hospital policy; and nursing failed to supervise, update and evaluate the nursing care and care plan for these two patients.