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Based on record review and interviews the Governing body failed to ensure that Condition for Patient Rights were ensured, that the Medical Staff and Nursing Services ensured that a change in patient condition is assessed and that Outpatient Services meet the same standards as inpatient care.

Findings:

1. Reference A 0115 Patient Rights: Based on record review and interviews the facility failed to ensure for 4 of 4 patients, rights to participate in care and discharge planning, for 1 of 4 patients (#1) the facility failed to ensure they followed their own policy and procedures regarding restraints. These failures resulted in the Condition of Participation for Patient Rights not to be met.

2. Reference A 0338 Medical Staff: Based on record review and interviews, the facility failed to have medical staff to provide medical services to 4 of 4 sample patients after anesthesia and failed to follow the facility's own policy and procedure regarding assessment of patients in restraints. This failure resulted in the Condition of Participation under Medical Staff not to be met.

3. Reference A 0385 Nursing Services: Based on record review and interview the facility failed to ensure that the nurses provide services to evaluate a change in a patient's condition, follow established plans of care and to ensure the safe and appropriate post-anesthesia care of it's patients. These failures resulted in the Condition of Participation under Nursing Services not to be met.

4. Reference A 1076 Outpatient Services: Based on record review and staff interview the facility failed for 3 of 4 (patient #1, #2, and #4) patients to ensure that Outpatient Surgical Services are fully integrated with inpatient services and provide services at the same, acceptable standard of care. These failures resulted in the Condition of Participation under Out Patient Services not to be met.

Based on record review and interviews the facility failed to ensure for 4 of 4 patients, rights to participate in care and discharge planning, for 1 of 4 patients (#1) the facility failed to ensure they followed their own policy and procedures regarding restraints. These failures resulted in the Condition of Participation for Patient Rights not to be met.

Findings:

Reference: A 0130: Based on medical record review, staff and family interviews the facility failed to ensure for 1 of 4, (patient #1) participated in the implementation of her pain management plan by failing to respond to the patient's verbalization of pain. The facility also failed for 3 of 4 (#2, #3, and #4) patients to ensure the patients participated in post operative (post op) care planning as the facility failed to conduct any post operative assessments prior to discharge.

Reference:A 0168: Based on patient record and policy and procedure review the facility failed for 1 of 4 patient, (patient #1), to ensure that the use of restraints were ordered by a physician as described in the facility's own policy and procedures.

Reference:A 0172: Based on medical record and policy and procedure review the facility failed to ensure for 1 of 4 (patient #1) record reviewed that patient's performed a face-to-face evaluation of the patient's need for restraints, as per the facility's own policy and procedure.

Based on medical record review, staff and family interviews the facility failed to ensure for 1 of 4, (patient #1) participated in the implementation of her pain management plan by failing to respond to the patient's verbalization of pain. The facility also failed for 3 of 4 (#2, #3, and #4) patients to ensure the patients participated in post operative (post op) care planning as the facility failed to conduct any post operative assessments prior to discharge.

Findings:

Review of the medical record for patient #1 revealed she had a medical history of abdominal pain resulting in multiple hospitalizations for the treatment of Clostridium difficile (C. Diff). The patient elected to undergo a colonoscopy with fecal bacterial therapy. The procedure was scheduled for 03/24/2011 to be performed as an outpatient procedure at Brooksville Regional Hospital.

Review of the pre-operative forms revealed that a "Pain Management Flowsheet" that was dated 03/24/2011 which stated the patient was free of pain prior to the procedure. The form has several spaces for the evaluation of pain to be completed post procedure, as needed. The form utilized a 0-10 pain scale with a rating of 10 being the highest rating of pain and 0 being no pain. Review of the pre-operative forms titled Interdisciplinary Plan of Care revealed section #15 completed and signed by the nurse. The section contained under Interventions, "Assess pain and utilize Pain Scale".

The patient completed the pre-procedure work up and the procedure was performed as planned. Review of the medical record revealed a Post Anesthesia Care Unit, (PACU), nursing note dated 03/24/2011 at 10:05 AM "Received patient from Endo via stretcher accompanied by anesthesia post colonoscopy with fecal bacteria therapy". Review of the nursing note at 10:33 AM revealed "Patient yelling out with complaint of pain in stomach medicated with 0.25 Dilaudid IV as ordered". Review of the nursing note at 10:38 AM revealed, "Continues to complain of pain, medicated as ordered, VVS [Vital Signs Stable], Patient placed on left side".

Review of the nursing note at 10:50 AM revealed Patient expelling flatus, VVS, continues to complain of pain". Review of nursing note at 10:58 AM revealed, "Medicated for pain". Review of the nursing note at 11:05 AM revealed "Continues to complain of pain, expelling flatus, VVS, [named physician] paged". Review of the PACU nursing note written at 11:12 AM revealed "Spoke with [named physician] and informed of patient complaining of pain in abdomen and yelling out. Instructed to have the patient up and walk when fully awake to expel flatus". Review of the nursing note at 11:40 AM revealed "Patient awake and complaining of feeling pain, VVS, explained to patient on expelling flatus". The following PACU nursing note at 11:40 AM revealed "Report called to Same Day Surgery recovery, (SDS), Patient aware of Plan of Care". The last PACU nursing note at 11:42 AM revealed "Patient transferred to SDS".

Review of the anesthesia order dated 03/24/2011 at 10:10 AM revealed Dilaudid 0.5 [milligrams] mg IV [intravenous] Q [every] 5 minutes total of 1.0 mg PRN [as needed] for Pain 6-10". Review of the nursing medication documentation revealed that Dilaudid 0.25 mg IV was given at 10:33 AM, 0.25 mg IV at 10:30 AM, 0.25 mg IV at 10:58 AM and 0.25 mg at 11:05 AM for a total of 1 mg. Review of the medical record did not reveal that a pain scale was utilized or that an order was written for the different amount of each injection or the change in the timing of the administration of the pain medication.

Review of the medical record did not reveal that the Pain Management Flowsheet was utilized in the documentation of the pain the patient was experiencing while in the PACU.

Review of the medical record did not reveal that any physician, including the anesthesiologist or the physician that performed the procedure, examined the patient in the PACU. Review of the Perioperative Consultation form completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the anesthesiologist only sighed the Post-Anesthesia Discharge note, but did not completed the assessment part of the section or write a note confirming that he evaluated the patient for discharge from the PACU.

Interview with the named physician on 09/27/2011 at 10:15 AM revealed that the signs of a perforated bowel (large hole), peritonitis, symptoms would be immediate and that a small hole would take longer time to be apparent. Review of a admission History and Physical dictated by this physician, dated 03/24/2011 at 9:30 PM revealed "As a matter of fact, I did receive a call by the PACU nurse telling me that, (Patient #1), was having mild abdominal pain. I told the nurse that if the pain is mild, then patient can be discharged home. However, if the pain was sever, then keep the patient and obtain a CT [computerized tomography] scan of the abdomen." Review of Patient #1's medical record did not reveal that a CT of the abdomen was obtained or that the telephone order was written down or passed on to the SDS nurse during the patient transfer report.

Review of the medical record revealed nursing note from the SDS nurse dated on 03/24/2011 at 11:55 AM that revealed "Received patient for PACU via stretcher into bed #1. Patient alert and oriented. Monitoring vital signs per protocol. Patient complaining of abdominal pain. Report from PACU RN [Registered Nurse] stated that patient has been complaining of pain and that [the named physician] was called and he stated that she would have discomfort and patient was medicated for pain in the PACU".

Review of the medical record revealed that Pain Management Flowsheet was utilized to document the pain that the patient had complained of as documented in the 11:55 AM nursing note. The nursing note did not reflect where on the 0-10 pain scale the patient was suffering pain. The medical record did not reveal any comfort measures that the nurse had taken to reduce the pain the patient was suffering.

Interview on 09/27/2011 at 1:00 PM with the SDS nurse that took care of patient #1 revealed that the patient was assisted by herself and a Patient Care Technician to the bathroom and that she did help the patient by holding her under her arm.

Review of the nursing notes at 1:30 PM revealed, "Patient up, ambulated to bathroom, voided 300 cc of urine without difficulty. Patient assisted with getting clothes on. Ambulated back to room". Review of SDS nursing note at 1:45 PM revealed "Removed IV form Right FA [forearm]- no redness or swelling noted. Reviewed discharge instructions with patient, copy given to patient, but she refused to sigh chart copy". Review of the nursing note at 2:00 PM revealed that "Patient taken to car via wheelchair, assisted into vehicle - patient complaining of abdominal discomfort, I told the patient to wait and I would call [her physician]". Review of the next nursing note at 2:05 PM revealed "spoke with [named physician] - he ordered a CT scan". Review of the last SDS nursing note at 2:10 PM revealed "When back to the patient's vehicle informed her and daughter that [the physician] ordered a CT scan. Patient decided to go home rather that coming in for CT scan ". Review of the medical did not reveal that the potential consequences of leaving or the medical record did not reveal a "Left Against Medical Advice" had be completed.

Review of the medical record did not reveal that any member of the medical staff had examined the patient in the SDS recovery unit. Review of the medical record did not reveal that the nursing staff evaluated the patient's pain following the initial evaluation. Review of the Pain Management Flowsheet revealed that the form's only entry was done during the pre-operative process.

Interview with the patient's daughter on 09/27/2011 at 5:30 PM revealed that when she entered the SDS recovery area the patient as lying on her side grasping the bed rail yelling out in pain. The patient's daughter stated that when she told the nurse, the nurse told her it was just gas and was normal. Further interview with the patient's daughter revealed that when the patient was ambulated to the bathroom she was held up by two nurses one under each arm. The daughter stated that the patient yelled out in pain the whole time. According to the daughter the patient was in so much pain that she, was not able to sign the instructions and that she told the nurse that as soon as she got her mother home that she would have to call 911. Interview with the patient's daughter further revealed that after the nurse had went back to call the doctor a long period of time had went by so she returned to the SDS and spoke to the nurse. The daughter stated that the nurse told her that the doctor had ordered a CAT scan and other than that her mother was "good to go". The daughter stated that she felt the nurse was not taking the patient's complaint of pain serious and just wanted her to leave.

Review of the Fire Rescue Run Report revealed that 911 were called at 2:51 PM and at 3:03 PM at the home of the patient the paramedic rated the patient's abdominal pain to be 10 on a scale of 0-10.

The medical record revealed that the patient was transported to the Emergency Room and flowing an abdominal CAT scan the demonstrated a large amount of free air in the abdominal cavity. The patient underwent emergency exploratory abdominal surgery and it was determined that the patient had experienced a perforated bowel. The perforation was corrected and the patient was admitted to the intensive care unit (ICU) and placed on a ventilator. The patient failed to respond to treatment and continued to decline. On 04/06/2011 life support was withdrawn and the patient expired

Review of the Perioperative Consultation form for patient #2 completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the Post-Anesthesia Discharge note was blank and there was not a note confirming that he evaluated the patient for discharge from the PACU.

Review of the Perioperative Consultation form for patient #4 completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the Post-Anesthesia Discharge note was blank and there was not a note confirming that he evaluated the patient for discharge from the PACU.

Review of the medical records for patients #2 and #3 did not reveal that any member of the medical staff evaluated the patients following being transferred to PACU or SDS.

Review of the Pain Management Flowsheet for patients #3 and #4 revealed that the form's only entry was done during the pre-operative process and did not reveal that pain evaluation was documented post procedure.

Based on patient record and policy and procedure review the facility failed for 1 of 4 patient, (patient #1), to ensure that the use of restraints were ordered by a physician as described in the facility's own policy and procedures.

Findings:


Review of the medical record for patient #1 revealed an, "ACUTE MED-SURG RESTRAIN FLOW SHEET/INTERDISCIPLINARY OF CARE" dated 03/25/2011 at 12:40 AM that demonstrated the nursing staff place the resident, between the hours of 12:00 midnight to 6:00 AM in restraints of both right and left wrist.

Review of the physician order signed 03/25/2011 at 1:15 revealed that the physician did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the physician order for restraints for patient #1 for 03/25/2011 starting at 7:00 AM revealed that the physician signed the order on 03/25/2011 at 1:15 PM, but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the physician order for restraints for patient #1 for 03/26/2011 starting at 7:00 AM revealed that the physician signed the order on 03/28/2011 at 7:50 AM, (Greater than 24 hours from the time the restraints were initiated), but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the physician order for restraints for patient #1 for 03/27/2011 starting at 7:00 AM revealed that the physician signed the order on 03/27/2011 at 7:30 AM, but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the physician order for restraints for patient #1 for 03/28/2011 starting at 7:00 AM revealed that the physician signed the order on 03/28/2011 at 7:55 AM, but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used

Review of the physician order for restraints for patient #1 revealed for 03/29/2011 starting at 7:00 AM revealed that the physician signed the order on 03/29/2011 at 11:15 AM, but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the facility policy ADM112.2DOC, Subject: Non-Violent Restraints revealed under Medical Restraint #2 Physician Order: "A. If the physician is not available, a registered nurse may initiate restraint in advance of a physician's order and obtain order as soon as possible.
1) If restrain was necessary due to a significant change in the patient's condition, the attending physician shall be contacted immediately for an order.
2) The attending physician shall perform a face-to-face assessment of the patient within 24 hours of the initiation of the restraint, at which time he or she shall either discontinue or write an order for continuation of the restraint.
B. The attending physician shall perform an in-person assessment of the restrained patient at least once every calendar day, at which time restraint shall be either re-ordered or discontinued as indicated.
C. The physician's Order must include:
1) Specific type of device (such as wrist roll belt).
2) Clinical justification.
3) Order time limit, not to exceed 1 calendar day.
4) Authentication of the order within 24 hours. "

Based on medical record and policy and procedure review the facility failed to ensure for 1 of 4 (patient #1) record reviewed that patient's performed a face-to-face evaluation of the patient's need for restraints, as per the facility's own policy and procedure.

Findings:


Review of the medical record for patient #1 revealed an "ACUTE MED-SURG RESTRAIN FLOW SHEET/INTERDISCIPLINARY OF CARE" dated 03/26/2011 at 7:00 AM that demonstrated the nursing staff place the resident in wrist restraints.

Review of the physician order for restraints for patient #1 revealed for 03/26/2011 starting at 7:00 AM revealed that the physician signed the order on 03/28/2011 at 7:50 AM, (Greater than 24 hours from the time the restraints were initiated), but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the facility policy ADM112.2DOC, Subject: Non-Violent Restraints revealed under Medical Restraint #2 Physician Order: "A. If the physician is not available, a registered nurse may initiate restraint in advance of a physician's order and obtain order as soon as possible.
1) If restrain was necessary due to a significant change in the patient's condition, the attending physician shall be contacted immediately for an order.
2) The attending physician shall perform a face-to-face assessment of the patient within 24 hours of the initiation of the restraint, at which time her or she shall either discontinue or write an order for continuation of the restraint.
B. The attending physician shall perform an in-person assessment of the restrained patient at least once every calendar day, at which time restraint shall be either re-ordered or discontinued as indicated.
C. The physician ' s Order must include:
1) Specific type of device (such as wrist roll belt).
2) Clinical justification.
3) Order time limit, no to exceed 1 calendar day.
4) Authentication of the order within 24 hours. "

Based on record review and interviews, the facility failed to have medical staff to provide medical services to 4 of 4 sample patients after anesthesia and failed to follow the facility's own policy and procedure regarding assessment of patients in restraints. This failure resulted in the Condition of Participation under Medical Staff not to be met.


Findings:

Reference; A 0359: Based of staff interviews and record reviews the facility failed for 4 of 4 patients' records reviewed to ensure that post-anesthesia/procedure patients are evaluated by a member of the medical staff for changes in condition. The facility also failed to ensure that 1 of 4 (#1)patients was assessed by a member of the medical staff while on restraints, as per the facility's own policy and procedure.

Based of staff interviews and record reviews the facility failed for 4 of 4 patients' records reviewed to ensure that post-anesthesia/procedure patients are evaluated by a member of the medical staff for changes in condition. The facility also failed to ensure that 1 of 4 (#1)patients was assessed by a member of the medical staff while on restraints, as per the facility's own policy and procedure.

Findings:

1. Review of the medical record for patient #1 revealed she had a medical history of abdominal pain resulting in multiple hospitalizations for the treatment of Clostridium difficile (C. Diff). The patient elected to undergo a colonoscopy with fecal bacterial therapy. The procedure was scheduled for 03/24/2011 to be performed as an outpatient procedure at Brooksville Regional Hospital.

Review of the pre-operative forms revealed that a "Pain Management Flowsheet" that was dated 03/24/2011 which stated the patient was free of pain prior to the procedure. The form has several spaces for the evaluation of pain to be completed post procedure, as needed. The form utilized a 0-10 pain scale with a rating of 10 being the highest rating of pain and 0 being no pain. Review of the pre-operative forms titled Interdisciplinary Plan of Care revealed section #15 completed and signed by the nurse. The section contained under Interventions, "Assess pain and utilize Pain Scale".

The patient completed the pre-procedure work up and the procedure was performed as planned. Review of the medical record revealed a Post Anesthesia Care Unit, (PACU), nursing note dated 03/24/2011 at 10:05 AM "Received patient from Endo via stretcher accompanied by anesthesia post colonoscopy with fecal bacteria therapy". Review of the nursing note at 10:33 AM revealed "Patient yelling out with complaint of pain in stomach medicated with 0.25 Dilaudid IV as ordered". Review of the nursing note at 10:38 AM revealed, "Continues to complain of pain, medicated as ordered, VVS [Vital Signs Stable], Patient placed on left side".

Review of the nursing note at 10:50 AM revealed Patient expelling flatus, VVS, continues to complain of pain". Review of nursing note at 10:58 AM revealed, "Medicated for pain". Review of the nursing note at 11:05 AM revealed "Continues to complain of pain, expelling flatus, VVS, [named physician] paged". Review of the PACU nursing note written at 11:12 AM revealed "Spoke with [named physician] and informed of patient complaining of pain in abdomen and yelling out. Instructed to have the patient up and walk when fully awake to expel flatus". Review of the nursing note at 11:40 AM revealed "Patient awake and complaining of feeling pain, VVS, explained to patient on expelling flatus". The following PACU nursing note at 11:40 AM revealed "Report called to Same Day Surgery recovery, (SDS), Patient aware of Plan of Care". The last PACU nursing note at 11:42 AM revealed "Patient transferred to SDS".

Review of the anesthesia order dated 03/24/2011 at 10:10 AM revealed Dilaudid 0.5 [milligrams] mg IV [intravenous] Q [every] 5 minutes total of 1.0 mg PRN [as needed] for Pain 6-10". Review of the nursing medication documentation revealed that Dilaudid 0.25 mg IV was given at 10:33 AM, 0.25 mg IV at 10:30 AM, 0.25 mg IV at 10:58 AM and 0.25 mg at 11:05 AM for a total of 1 mg. Review of the medical record did not reveal that a pain scale was utilized or that an order was written for the different amount of each injection or the change in the timing of the administration of the pain medication.

Review of the medical record did not reveal that the Pain Management Flowsheet was utilized in the documentation of the pain the patient was experiencing while in the PACU.

Review of the medical record did not reveal that any physician, including the anesthesiologist or the physician that performed the procedure, examined the patient in the PACU. Review of the Perioperative Consultation form completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the anesthesiologist only sighed the Post-Anesthesia Discharge note, but did not completed the assessment part of the section or write a note confirming that he evaluated the patient for discharge from the PACU.

Interview with the named physician on 09/27/2011 at 10:15 AM revealed that the signs of a perforated bowel (large hole), peritonitis, symptoms would be immediate and that a small hole would take longer time to be apparent. Review of a admission History and Physical dictated by this physician, dated 03/24/2011 at 9:30 PM revealed "As a matter of fact, I did receive a call by the PACU nurse telling me that, (Patient #1), was having mild abdominal pain. I told the nurse that if the pain is mild, then patient can be discharged home. However, if the pain was sever, then keep the patient and obtain a CT [computerized tomography] scan of the abdomen." Review of Patient #1's medical record did not reveal that a CT of the abdomen was obtained or that the telephone order was written down or passed on to the SDS nurse during the patient transfer report.

Review of the medical record revealed nursing note from the SDS nurse dated on 03/24/2011 at 11:55 AM that revealed "Received patient for PACU via stretcher into bed #1. Patient alert and oriented. Monitoring vital signs per protocol. Patient complaining of abdominal pain. Report from PACU RN [Registered Nurse] stated that patient has been complaining of pain and that [the named physician] was called and he stated that she would have discomfort and patient was medicated for pain in the PACU".

Review of the medical record revealed that Pain Management Flowsheet was utilized to document the pain that the patient had complained of as documented in the 11:55 AM nursing note. The nursing note did not reflect where on the 0-10 pain scale the patient was suffering pain. The medical record did not reveal any comfort measures that the nurse had taken to reduce the pain the patient was suffering.

Interview on 09/27/2011 at 1:00 PM with the SDS nurse that took care of patient #1 revealed that the patient was assisted by herself and a Patient Care Technician to the bathroom and that she did help the patient by holding her under her arm.

Review of the nursing notes at 1:30 PM revealed, "Patient up, ambulated to bathroom, voided 300 cc of urine without difficulty. Patient assisted with getting clothes on. Ambulated back to room. " Review of SDS nursing note at 1:45 PM revealed "Removed IV form Right FA [forearm] - no redness or swelling noted. Reviewed discharge instructions with patient, copy given to patient, but she refused to sigh chart copy". Review of the nursing note at 2:00 PM revealed that "Patient taken to car via wheelchair, assisted into vehicle - patient complaining of abdominal discomfort, I told the patient to wait and I would call [her physician]". Review of the next nursing note at 2:05 PM revealed "spoke with [named physician] - he ordered a CT scan". Review of the last SDS nursing note at 2:10 PM revealed "When back to the patient's vehicle informed her and daughter that [the physician] ordered a CT scan. Patient decided to go home rather that coming in for CT scan ". Review of the medical did not reveal that the potential consequences of leaving or the medical record did not reveal a "Left Against Medical Advice" had be completed.

Review of the medical record did not reveal that any member of the medical staff had examined the patient in the SDS recovery unit. Review of the medical record did not reveal that the nursing staff evaluated the patient's pain following the initial evaluation. Review of the Pain Management Flowsheet revealed that the form's only entry was done during the pre-operative process.

Review of the Fire Rescue Run Report revealed that 911 were called at 2:51 PM and at 3:03 PM at the home of the patient the paramedic rated the patient's abdominal pain to be 10 on a scale of 0-10.

The medical record revealed that the patient was transported to the Emergency Room and flowing an abdominal CAT scan the demonstrated a large amount of free air in the abdominal cavity. The patient underwent emergency exploratory abdominal surgery and it was determined that the patient had experienced a perforated bowel. The perforation was corrected and the patient was admitted to the intensive care unit (ICU) and placed on a ventilator. The patient failed to respond to treatment and continued to decline. On 04/06/2011 life support was withdrawn and the patient expired

2. Review of the Perioperative Consultation form for patient #2 completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the Post-Anesthesia Discharge note was blank and there was not a note confirming that he evaluated the patient for discharge from the PACU.

3. Review of the Perioperative Consultation form for patient #4 completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the Post-Anesthesia Discharge note was blank and there was not a note confirming that he evaluated the patient for discharge from the PACU.

4. Review of the medical records for patients #2 and #3 did not reveal that any member of the medical staff evaluated the patients following being transferred to PACU or SDS.

5. Review of the Pain Management Flowsheet for patients #3 and #4 revealed that the form's only entry was done during the pre-operative process and did not reveal that pain evaluation was documented post procedure.

6. Review of the medical record for patient #1 revealed an, "ACUTE MED-SURG RESTRAIN FLOW SHEET/INTERDISCIPLINARY OF CARE" dated 03/25/2011 at 12:40 AM that demonstrated the nursing staff place the resident, between the hours of 12:00 midnight to 6:00 AM in restraints of both right and left wrist.

Review of the physician order signed 03/25/2011 at 1:15 revealed that the physician did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the physician order for restraints for patient #1 for 03/25/2011 starting at 7:00 AM revealed that the physician signed the order on 03/25/2011 at 1:15 PM, but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the physician order for restraints for patient #1 for 03/26/2011 starting at 7:00 AM revealed that the physician signed the order on 03/28/2011 at 7:50 AM, (Greater than 24 hours from the time the restraints were initiated), but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the physician order for restraints for patient #1 for 03/27/2011 starting at 7:00 AM revealed that the physician signed the order on 03/27/2011 at 7:30 AM, but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the physician order for restraints for patient #1 for 03/28/2011 starting at 7:00 AM revealed that the physician signed the order on 03/28/2011 at 7:55 AM, but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used

Review of the physician order for restraints for patient #1 revealed for 03/29/2011 starting at 7:00 AM revealed that the physician signed the order on 03/29/2011 at 11:15 AM, but did not assess the patient's behavior, specify a specific type of restraint to be used or specify a time limit that the restraint is to be used.

Review of the facility policy ADM112.2DOC, Subject: Non-Violent Restraints revealed under Medical Restraint #2 Physician Order: "A. If the physician is not available, a registered nurse may initiate restraint in advance of a physician's order and obtain order as soon as possible.
1) If restrain was necessary due to a significant change in the patient's condition, the attending physician shall be contacted immediately for an order.
2) The attending physician shall perform a face-to-face assessment of the patient within 24 hours of the initiation of the restraint, at which time he or she shall either discontinue or write an order for continuation of the restraint.
B. The attending physician shall perform an in-person assessment of the restrained patient at least once every calendar day, at which time restraint shall be either re-ordered or discontinued as indicated.
C. The physician's Order must include:
1) Specific type of device (such as wrist roll belt).
2) Clinical justification.
3) Order time limit, not to exceed 1 calendar day.
4) Authentication of the order within 24 hours.

Based on record review and interview the facility failed to ensure that the nurses provide services to evaluate a change in a patient's condition, follow established plans of care and to ensure the safe and appropriate post-anesthesia care of it's patients. These failures resulted in the Condition of Participation under Nursing Services not to be met.

Findings

1 .Reference A 0396: Based on record review and interviews nursing failed for 4 of 4 patients' records reviewed to ensure that post-anesthesia patients were assessed for change in condition by the nursing staff.

Based on record review and interviews nursing failed for 4 of 4 patients' records reviewed to ensure that post-anesthesia patients were assessed for change in condition by the nursing staff.

Findings:

1. Review of the medical record for patient #1 revealed she had a medical history of abdominal pain resulting in multiple hospitalizations for the treatment of Clostridium difficile (C. Diff). The patient elected to undergo a colonoscopy with fecal bacterial therapy. The procedure was scheduled for 03/24/2011 to be performed as an outpatient procedure at Brooksville Regional Hospital.

Review of the pre-operative forms revealed that a "Pain Management Flowsheet" that was dated 03/24/2011 which stated the patient was free of pain prior to the procedure. The form has several spaces for the evaluation of pain to be completed post procedure, as needed. The form utilized a 0-10 pain scale with a rating of 10 being the highest rating of pain and 0 being no pain. Review of the pre-operative forms titled Interdisciplinary Plan of Care revealed section #15 completed and signed by the nurse. The section contained under Interventions, "Assess pain and utilize Pain Scale".

The patient completed the pre-procedure work up and the procedure was performed as planned. Review of the medical record revealed a Post Anesthesia Care Unit, (PACU), nursing note dated 03/24/2011 at 10:05 AM "Received patient from Endo via stretcher accompanied by anesthesia post colonoscopy with fecal bacteria therapy". Review of the nursing note at 10:33 AM revealed "Patient yelling out with complaint of pain in stomach medicated with 0.25 Dilaudid IV as ordered". Review of the nursing note at 10:38 AM revealed, "Continues to complain of pain, medicated as ordered, VVS [Vital Signs Stable], Patient placed on left side".

Review of the nursing note at 10:50 AM revealed Patient expelling flatus, VVS, continues to complain of pain". Review of nursing note at 10:58 AM revealed, "Medicated for pain". Review of the nursing note at 11:05 AM revealed "Continues to complain of pain, expelling flatus, VVS, [named physician] paged". Review of the PACU nursing note written at 11:12 AM revealed "Spoke with [named physician] and informed of patient complaining of pain in abdomen and yelling out. Instructed to have the patient up and walk when fully awake to expel flatus". Review of the nursing note at 11:40 AM revealed "Patient awake and complaining of feeling pain, VVS, explained to patient on expelling flatus". The following PACU nursing note at 11:40 AM revealed "Report called to Same Day Surgery recovery, (SDS), Patient aware of Plan of Care". The last PACU nursing note at 11:42 AM revealed "Patient transferred to SDS".

Review of the anesthesia order dated 03/24/2011 at 10:10 AM revealed Dilaudid 0.5 [milligrams] mg IV [intravenous] Q [every] 5 minutes total of 1.0 mg PRN [as needed] for Pain 6-10". Review of the nursing medication documentation revealed that Dilaudid 0.25 mg IV was given at 10:33 AM, 0.25 mg IV at 10:30 AM, 0.25 mg IV at 10:58 AM and 0.25 mg at 11:05 AM for a total of 1 mg. Review of the medical record did not reveal that a pain scale was utilized or that an order was written for the different amount of each injection or the change in the timing of the administration of the pain medication.

Review of the medical record did not reveal that the Pain Management Flowsheet was utilized in the documentation of the pain the patient was experiencing while in the PACU.

Review of the medical record did not reveal that any physician, including the anesthesiologist or the physician that performed the procedure, examined the patient in the PACU. Review of the Perioperative Consultation form completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the anesthesiologist only sighed the Post-Anesthesia Discharge note, but did not completed the assessment part of the section or write a note confirming that he evaluated the patient for discharge from the PACU.

Review of a admission History and Physical dictated by this physician, dated 03/24/2011 at 9:30 PM revealed "As a matter of fact, I did receive a call by the PACU nurse telling me that, [Patient #1], was having mild abdominal pain. I told the nurse that if the pain is mild, then patient can be discharged home. However, if the pain was sever, then keep the patient and obtain a CT [computerized tomography] scan of the abdomen." Review of Patient #1's medical record did not reveal that a CT of the abdomen was obtained or that the telephone order was written down or passed on to the SDS nurse during the patient transfer report.

Review of the medical record revealed nursing note from the SDS nurse dated on 03/24/2011 at 11:55 AM that revealed "Received patient for PACU via stretcher into bed #1. Patient alert and oriented. Monitoring vital signs per protocol. Patient complaining of abdominal pain. Report from PACU RN [Registered Nurse] stated that patient has been complaining of pain and that [the named physician] was called and he stated that she would have discomfort and patient was medicated for pain in the PACU".

Review of the medical record revealed that Pain Management Flowsheet was utilized to document the pain that the patient had complained of as documented in the 11:55 AM nursing note. The nursing note did not reflect where on the 0-10 pain scale the patient was suffering pain. The medical record did not reveal any comfort measures that the nurse had taken to reduce the pain the patient was suffering.

Interview on 09/27/2011 at 1:00 PM with the SDS nurse that took care of patient #1 revealed that the patient was assisted by herself and a Patient Care Technician to the bathroom and that she did help the patient by holding her under her arm.

Review of the nursing notes at 1:30 PM revealed, "Patient up, ambulated to bathroom, voided 300 cc of urine without difficulty. Patient assisted with getting clothes on. Ambulated back to room. " Review of SDS nursing note at 1:45 PM revealed "Removed IV form Right FA [forearm] - no redness or swelling noted. Reviewed discharge instructions with patient, copy given to patient, but she refused to sigh chart copy". Review of the nursing note at 2:00 PM revealed that "Patient taken to car via wheelchair, assisted into vehicle - patient complaining of abdominal discomfort, I told the patient to wait and I would call [her physician]". Review of the next nursing note at 2:05 PM revealed "spoke with [named physician] - he ordered a CT scan". Review of the last SDS nursing note at 2:10 PM revealed "When back to the patient's vehicle informed her and daughter that [the physician] ordered a CT scan. Patient decided to go home rather that coming in for CT scan ". Review of the medical did not reveal that the potential consequences of leaving or the medical record did not reveal a "Left Against Medical Advice" had be completed.

Review of the medical record did not reveal that any member of the medical staff had examined the patient in the SDS recovery unit. Review of the medical record did not reveal that the nursing staff evaluated the patient's pain following the initial evaluation. Review of the Pain Management Flowsheet revealed that the form's only entry was done during the pre-operative process.

Interview with the patient's daughter on 09/27/2011 at 5:30 PM revealed that when she entered the SDS recovery area the patient as lying on her side grasping the bed rail yelling out in pain. The patient's daughter stated that when she told the nurse, the nurse told her it was just gas and was normal. Further interview with the patient's daughter revealed that when the patient was ambulated to the bathroom she was held up by two nurses one under each arm. The daughter stated that the patient yelled out in pain the whole time. According to the daughter the patient was in so much pain that she, was not able to sign the instructions and that she told the nurse that as soon as she got her mother home that she would have to call 911. Interview with the patient's daughter further revealed that after the nurse had went back to call the doctor a long period of time had went by so she returned to the SDS and spoke to the nurse. The daughter stated that the nurse told her that the doctor had ordered a CAT scan and other than that her mother was "good to go". The daughter stated that she felt the nurse was not taking the patient's complaint of pain serious and just wanted her to leave.

Review of the Fire Rescue Run Report revealed that 911 were called at 2:51 PM and at 3:03 PM at the home of the patient the paramedic rated the patient's abdominal pain to be 10 on a scale of 0-10.

The medical record revealed that the patient was transported to the Emergency Room and flowing an abdominal CAT scan the demonstrated a large amount of free air in the abdominal cavity. The patient underwent emergency exploratory abdominal surgery and it was determined that the patient had experienced a perforated bowel. The perforation was corrected and the patient was admitted to the intensive care unit (ICU) and placed on a ventilator. The patient failed to respond to treatment and continued to decline. On 04/06/2011 life support was withdrawn and the patient expired

2. Review of patient #2's record did not reveal a nursing assessment conducted prior to discharge. Review of the Perioperative Consultation form for patient #2 completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the Post-Anesthesia Discharge note was blank and there was not a note confirming that he evaluated the patient for discharge from the PACU.

3. Review of patient #4's record did not reveal a nursing assessment conducted prior to discharge. Review of the Perioperative Consultation form for patient #4 completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the Post-Anesthesia Discharge note was blank and there was not a note confirming that he evaluated the patient for discharge from the PACU.

4. Review of the Pain Management Flowsheet for patients #3 and #4 revealed that the form's only entry was done during the pre-operative process and did not reveal that pain evaluation was documented post procedure.

Based on record review and interview the facility failed for 3 of 4 (#1, #2 and #4) patients' records reviewed to ensure that post-anesthesia evaluation are performed.

Findings:

Review of the medical record for patient #1 revealed she had a medical history of abdominal pain resulting in multiple hospitalizations for the treatment of Clostridium difficile (C. Diff). The patient elected to undergo a colonoscopy with fecal bacterial therapy. The procedure was scheduled for 03/24/2011 to be performed as an outpatient procedure at Brooksville Regional Hospital.

The patient completed the pre-procedure work up and the procedure was performed as planned. Review of the medical record revealed a Post Anesthesia Care Unit, (PACU), nursing note dated 03/24/2011 at 10:05 AM "Received patient from Endo via stretcher accompanied by anesthesia post colonoscopy with fecal bacteria therapy". Review of the nursing note at 10:33 AM revealed "Patient yelling out with complaint of pain in stomach medicated with 0.25 Dilaudid IV as ordered". Review of the nursing note at 10:38 AM revealed, "Continues to complain of pain, medicated as ordered, VVS [Vital Signs Stable], Patient placed on left side".

Review of the nursing note at 10:50 AM revealed Patient expelling flatus, VVS, continues to complain of pain". Review of nursing note at 10:58 AM revealed, "Medicated for pain". Review of the nursing note at 11:05 AM revealed "Continues to complain of pain, expelling flatus, VVS, [named physician] paged". Review of the PACU nursing note written at 11:12 AM revealed "Spoke with [named physician] and informed of patient complaining of pain in abdomen and yelling out. Instructed to have the patient up and walk when fully awake to expel flatus". Review of the nursing note at 11:40 AM revealed "Patient awake and complaining of feeling pain, VVS, explained to patient on expelling flatus". The following PACU nursing note at 11:40 AM revealed "Report called to Same Day Surgery recovery, (SDS), Patient aware of Plan of Care". The last PACU nursing note at 11:42 AM revealed "Patient transferred to SDS".

Review of the anesthesia order dated 03/24/2011 at 10:10 AM revealed Dilaudid 0.5 [milligrams] mg IV [intravenous] Q [every] 5 minutes total of 1.0 mg PRN [as needed] for Pain 6-10". Review of the nursing medication documentation revealed that Dilaudid 0.25 mg IV was given at 10:33 AM, 0.25 mg IV at 10:30 AM, 0.25 mg IV at 10:58 AM and 0.25 mg at 11:05 AM for a total of 1 mg. Review of the medical record did not reveal that a pain scale was utilized or that an order was written for the different amount of each injection or the change in the timing of the administration of the pain medication.

Review of the medical record did not reveal that the Pain Management Flowsheet was utilized in the documentation of the pain the patient was experiencing while in the PACU.

Review of the medical record did not reveal that any physician, including the anesthesiologist or the physician that performed the procedure, examined the patient in the PACU. Review of the Perioperative Consultation form completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the anesthesiologist only sighed the Post-Anesthesia Discharge note, but did not completed the assessment part of the section or write a note confirming that he evaluated the patient for discharge from the PACU.

Interview with the named physician on 09/27/2011 at 10:15 AM revealed that the signs of a perforated bowel (large hole), peritonitis, symptoms would be immediate and that a small hole would take longer time to be apparent.

Review of the nursing note at 2:00 PM revealed that "Patient taken to car via wheelchair, assisted into vehicle - patient complaining of abdominal discomfort, I told the patient to wait and I would call [her physician]". Review of the next nursing note at 2:05 PM revealed "spoke with [named physician] - he ordered a CT scan". Review of the last SDS nursing note at 2:10 PM revealed "When back to the patient's vehicle informed her and daughter that [the physician] ordered a CT scan. Patient decided to go home rather that coming in for CT scan". Review of the medical did not reveal that the potential consequences of leaving or the medical record did not reveal a "Left Against Medical Advice" had be completed.

Review of the Fire Rescue Run Report revealed that 911 were called at 2:51 PM and at 3:03 PM at the home of the patient the paramedic rated the patient's abdominal pain to be 10 on a scale of 0-10.

The medical record revealed that the patient was transported to the Emergency Room and flowing an abdominal CAT scan the demonstrated a large amount of free air in the abdominal cavity. The patient underwent emergency exploratory abdominal surgery and it was determined that the patient had experienced a perforated bowel. The perforation was corrected and the patient was admitted to the intensive care unit (ICU) and placed on a ventilator. The patient failed to respond to treatment and continued to decline. On 04/06/2011 life support was withdrawn and the patient expired

2. Review of the Perioperative Consultation form for patient #2 completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the Post-Anesthesia Discharge note was blank and there was not a note confirming that he evaluated the patient for discharge from the PACU.

3. Review of the Perioperative Consultation form for patient #4 completed by the anesthesiologist revealed that Post-Anesthesia Report and Instructions section of the form was completed and signed by the anesthesiologist, but the Post-Anesthesia Discharge note was blank and there was not a note confirming that he evaluated the patient for discharge from the PACU.

Based on record review and staff interview the facility failed for 3 of 4 (patient #1, #2, and #4) patients to ensure that Outpatient Surgical Services are fully integrated with inpatient services and provide services at the same, acceptable standard of care. These failures resulted in the Condition of Participation under Out Patient Services not to be met.

Findings:

1. Reference A 1005: Based on record review and interview the facility failed for 3 of 4 (#1, #2 and #4) patients' records reviewed to ensure that post-anesthesia evaluation are performed.


2. Reference A1077: Based on record review and interview the facility failed to ensure integrated services of a computerized tomography (CT) scan for 1 of 4 out patients (#1) who was experiencing pain after an out patient procedure.

Based on record review and interview the facility failed to ensure integrated services of a computerized tomography (CT) scan for 1 of 4 out patients (#1) who was experiencing pain after an out patient procedure.

Findings:


1. Review of the nursing notes for Patient #1, after undergoing colonoscopy with fecal bacteria therapy, at 10:33 AM revealed, "Patient yelling out with complaint of pain in stomach medicated with 0.25 Dilaudid IV as ordered". Review of the nursing note at 10:38 AM revealed, "Continues to complain of pain, medicated as ordered, VVS [vital signs stable], Patient placed on left side". Review of the nursing note at 10:50 Patient expelling flatus, VVS, continues to complain of pain". Review of nursing note at 10:58 AM revealed, "Medicated for pain". Review of the nursing note at 11:05 AM revealed "Continues to complain of pain, expelling flatus, VVS, [named physician] paged". Review of the Post Anesthesia Care Unit (PACU) nursing note written at 11:12 AM revealed, "Spoke with [named physician] and informed of patient complaining of pain in abdomen and yelling out. Instructed to have the patient up and walk when fully awake to expel flatus". Review of the nursing note at 11:40 AM revealed, "Patient awake and complaining of feeling pain, VVS, explained to patient on expelling flatus". The following PACU nursing note at 11:40 AM revealed, "Report called to Same Day Surgery (SDS) recover, Patient aware of Plan of Care". The last PACU nursing note at 11:42 AM revealed, "Patient transferred to SDS".

Review of the anesthesia order dated 03/24/2011 at 10:10 AM revealed Dilaudid 0.5 [milligrams] mg IV [intravenous] Q [every] 5 minutes total of 1.0 mg PRN [as needed] for Pain 6-10". Review of the nursing medication documentation revealed that Dilaudid 0.25 mg IV was given at 10:33 AM, 0.25 mg IV at 10:30 AM, 0.25 mg IV at 10:58 AM and 0.25 mg at 11:05 AM for a total of 1 mg. Review of the medical record did not reveal that a pain scale was utilized or that an order was written for the different amount of each injection or the change in the timing of the administration of the pain medication

Review of the medical record revealed nursing note from the SDS nurse dated on 03/24/2011 at 11:55 AM that revealed "Received patient for PACU via stretcher into bed #1. Patient alert and oriented. Monitoring vital signs per protocol. Patient complaining of abdominal pain. Report from PACU RN [Registered Nurse] stated that patient has been complaining of pain and that [the named physician] was called and he stated that she would have discomfort and patient was medicated for pain in the PACU". Review of SDS nursing note at 1:45 PM revealed, "Removed IV [intravenous] form Right FA [forearm] - no redness or swelling noted. Reviewed discharge instructions with patient, copy given to patient, but she refused to sigh chart copy". Review of the nursing note at 2:00 PM revealed that "Patient taken to car via wheelchair, assisted into vehicle - patient complaining of abdominal discomfort, I told the patient to wait and I would call [named physician]". Review of the next nursing note at 2:05 PM revealed, "spoke with [named physician] - he ordered a CT scan".
Review of the last SDS nursing note at 2:10 revealed, "Went back to the patient's vehicle informed her and daughter that [named physician] ordered a CT scan. Patient decided to go home rather that coming in for CT scan". Review of the medical did not reveal that the potential consequences of leaving or the medical record did not reveal a "Left Against Medical Advice" had be completed.

2. Interview with the named physician on 09/27/2011 at 10:15 AM revealed that the signs of a perforated bowel (large hole), peritonitis, symptoms would be immediate and that a small hole would take longer time to be apparent.

Review of a admission History and Physical dictated by this physician, dated 03/24/2011 at 9:30 PM revealed "As a matter of fact, I did receive a call by the PACU nurse telling me that, [Patient #1], was having mild abdominal pain. I told the nurse that if the pain is mild, then patient can be discharged home. However, if the pain was sever, then keep the patient and obtain a CT [computerized tomography] scan of the abdomen." Review of Patient #1's medical record did not reveal that a CT of the abdomen was obtained or that the telephone order was written down or passed on to the SDS nurse during the patient transfer report.

3. Interview on 09/27/2011 at 1:00 PM with the SDS nurse that took care of patient #1 revealed that the patient was assisted by herself and a Patient Care Technician to the bathroom and that she did help the patient by holding her under her arm.

4. Interview with the patient's daughter on 09/27/2011 at 5:30 PM revealed that when she entered the SDS recovery area the patient as lying on her side grasping the bed rail yelling out in pain. The patient's daughter stated that when she told the nurse, the nurse told her it was just gas and was normal. Further interview with the patient's daughter revealed that when the patient was ambulated to the bathroom she was held up by two nurses one under each arm. The daughter stated that the patient yelled out in pain the whole time. According to the daughter the patient was in so much pain that she, was not able to sign the instructions and that she told the nurse that as soon as she got her mother home that she would have to call 911. Interview with the patient's daughter further revealed that after the nurse had went back to call the doctor a long period of time had went by so she returned to the SDS and spoke to the nurse. The daughter stated that the nurse told her that the doctor had ordered a CAT scan and other than that her mother was "good to go". The daughter stated that she felt the nurse was not taking the patient's complaint of pain serious and just wanted her to leave.

5. Review of the Fire Rescue Run Report revealed that 911 were called at 2:51 PM and at 3:03 PM at the home of the patient the paramedic rated the patient's abdominal pain to be 10 on a scale of 0-10.

The medical record revealed that the patient was transported to the Emergency Room and flowing an abdominal CAT scan the demonstrated a large amount of free air in the abdominal cavity. The patient underwent emergency exploratory abdominal surgery and it was determined that the patient had experienced a perforated bowel. The perforation was corrected and the patient was admitted to the intensive care unit (ICU) and placed on a ventilator. The patient failed to respond to treatment and continued to decline. On 04/06/2011 life support was withdrawn and the patient expired.