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Based on staff interview and record review, the Governing Board of the hospital, responsible for safe and proper operation of facility, failed to assure all patients receive care in accordance with the orders from a physician who is appointed to the medical staff of the hospital for 1 (Patient #13) of 60 patients reviewed; the facility failed to provide a complete assessment to include psychological well being and assess a patients emotional health and safety when presenting themselves to the facility after an unsuccessful suicide attempt. The clinical record failed to include a complete assessment and evaluation documented for 1 (Patient #45) of 60 sampled records.

The findings include:

1. The hospital accepted a patient onto a nursing unit without physician orders for providing care to the patient.

The attending physician did not provide orders for the care of a patient admitted to his service prior to or upon admission of the patient to an inpatient nursing unit. Orders were not received for 4 hours from time the patient was admitted to the inpatient medical/surgical nursing unit.

On 9/14/11, a review of the medical record for Patient #13 was conducted with the nursing unit manager, the division nursing Administrator and the hospital CEO. The record reveals the patient was admitted to the ECC on 9/11/11 at 10:58 p.m. with abdominal pain.

The medical record documents the ECC physician recommended the patient be admitted into the hospital on a medical/surgical floor at 3:30 a.m. The 'attending physician's' service was called and forwarded to the surgeon covering. The covering physician accepted the patient to the service of the designated attending physician at 4:16 a.m.

The medical record states the patient was transferred from the ECC at 6:10 a.m. on 9/12/11 and admitted to the hospital inpatient nursing unit at 6:12 a.m. The patient was assessed by nursing at 6:30 a.m.

The patient was admitted to the nursing unit without admission orders from the attending physician. The nurse placed a call to the physician at 7:00 a.m. No response was received. The medical record documents the nurse assessed the patient at 8:00 a.m. finding: "Patient awake in bed, tearful, just vomited approx 50 ml of brownish fluid. Pain level of 5* - standard: VAS under 4 or experiencing chronic pain that is effectively managed: NOT MET; - intervention: comfort measures given, will call MD."

The medical record dated 9/12/11 documents: "Physician Update - at 8:20 a.m. call placed to attending physician's office regarding orders for medications. Prior to calling office, overhead paged and surgery called to see if physician in surgery. Placed an additional call at 8:45 a.m. to physician's office to obtain orders." There was no response from the physician and no documentation of follow-up until surveyor intervention at 10:00 a.m.

At 10:00 a.m. the nurse assessed the patient and found the patient experiencing a pain level of 7. The physician was again called for orders. The medical record documents the physician called back at 10:10 a.m. placed verbal orders for Dilaudid, Phenergan and IV fluids. The medical record dated 9/12/11 documents: "Physician update - Dr (attending physician) called back; told him that patient is complaining of pain and nausea and wants medication. MD said this was the first that he heard that the patient was in the hospital or that he is the attending. MD placed orders and stated would be in later in the day."

The medication was administered at 10:55 a.m. the patient's pain was assessed at the time of administration at a level of 8 (severe pain).

The CEO acknowledged the facility failed to verify Patient #13 had an attending physician upon admission and acknowledged the hospital admitted a patient without orders for treatment from a physician with hospital privileges. The CEO acknowledged the patient had been the responsibility of the hospital and in need of care and services for 4 hours, until surveyor intervention, without being in the care of a physician with medical privileges at the hospital. The facility was unable to provide the needed care and services without the physician orders. The hospital failed to follow protocol and pursue other means of assigning a physician or obtaining orders for the care of the patient.

In an interview on 9/14/11 at 7:30 a.m., the chairman of the board of the hospital acknowledged the board has responsibility of the safe and proper operation of the facility in accordance with governing board by-laws, medical staff by-laws and board approved hospital policies and procedures.

2. On 9/13/11 review of the medical record for Patient #45 reveals he was brought to the emergency care center in North Port on 4/26/11 by the local police. Documentation by the physician on the Emergency Room Record dictation reveals the chief complaint as "Attempted suicide." Differential diagnosis are listed as "1. Suicide attempt, 2. Occult process, 3. Metabolic abnormality, 4. Cervical spine injury, 5. Rhabdomyolysis." A past medical history is documented as "Polysubstance abuse. Bilateral foraminol stenosis. Degenerative changes L4/5-S1." History of present illness lists multiple dog bites from the canine unit in the police department, longstanding history of polysubstance abuse and identifies the drugs as "Anything you put in front of me" and an unsuccessful suicide attempt when the cord broke.

Documentation continues with a physical assessment in a review of the systems, social and family history, immunizations, allergies, review of laboratory results which included a positive drug abuse panel for benzodiazepines, cocaine and THC. Treatment notes listed as procedure note and emergency department course identify treatment as the repair of the dog bite wounds completed without complication. The plan states. "The patient is medically appropriate for discharge and as such with the following instructions given: 1. Any problems, return to the Emergency Department. 2. Follow up with private M.D. for the stitches out in two weeks. 3. Augmentin, use as prescribed." There is no documentation by the physician of a psychiatric assessment regarding the mental status of the patient in relation to the attempted suicide. The documentation from the physician that would indicate the facility had been informed the patient would be placed on suicide watch when discharged to the custody of the police who would be taking the patient to jail was added as an adendem on the day of survey.

Review of documentation initially completed upon arrival to the facility reveals an area identified as "Brief Hx/Assessment/Tx." Documentation in the states, "That he has nothing to live for-then was running in the woods-chased by canine 8/10." An area identified as "Physician report" notes "Tried hanging himself @ home. took off. PD searched. found in woods dog, drugs "Anything you put in front of me." Discharge instructions on this form list "1. Any problems return to ED 2. F/U PMD sutures out in 2 wks 3. Augmentin as Rx." The area on this form for consult is blank.

Documentation lists laboratory results as a chemistry profile, A CPK (used to indicate muscle damage), An emergency drug abuse panel which was positive for benzodiazepines, cocaine, and tetrahydrocannabinol (THC) and a CT of the Cervical Spine for attempted hanging.

Documentation in the triage notes the "Chief complaint: "Trauma/Injury", Location: both legs. Precipitating factors: canine bites to lower legs." Under the section listed a "Medical and Surgical History: Pertinent Medical History: This patient's medical history is Back Problems. Additional Information pt apparently had attempted suicide but the rope broke, pt states that he wants to take his own life and he has had nothing to live for." An area listed on this document as "Safety Screens: Suicide/Homicide Risk Assessment: Does the patient have a history of, or current evidence of depression or mental health issues? No" and "Abuse Screening: Do you feel safe at home? Yes."

Nurses notes by the Registered Nurse (RN) in the Emergency Department documents at 8:30 p.m. "Note: received pt into care at this time with hand cuffs on, backboard and c collar on, numerous dog bites to lower extremities, pt co operative, also states that "He wants to take his own life, attempted hanging but apparently the rope broke." Assessments documented at this time include Peripheral IV Assessment, Intravenous Fluid and Blood products, Pain, Cardiac, Respiratory, Neurological, Gastrointestinal, Integumentary and Psychosocial. The Integumentary assessment notes the animal bites, laceration, puncture, scratch with bloody drainage. The Psychosocial assessment notes the "Behavioral assessment: Angry, Irrational" and notes the police at bedside. There is no documentation regarding the attempted suicide in the psychosocial assessment regarding the emotional or mental status of the patient. Nurse's notes timed at 8:40 p.m. document the patient was examined by the physician and orders were received. Notes continue at 9:00 p.m. that the patient went to x-ray for the CT scan of the cervical spine. At 9:20 p.m. documentation reveals the patient returned from x-ray with "Police at bedside, cuffs remain on, wounds cleansed to right lower leg." A nurse's note at 10:00 p.m. reveals the wounds were cleaned and closed by the emergency room M.D. and the physician removed the c collar and the back board. A discharge note by the registered nurse notes: "Patient ready for discharge. Discharge instructions reviewed with and given to patient, with understanding verbalized and encouraged to follow the instructions. Ambulated out with steady gait and home in stable condition, pt sent with police to jail in Sarasota county, patient gave nurse permission to call his mother and notify her of where pt was being taken to, writer spoke with (name of pt's mother) at (phone number) and gave information, called report to (name) at Sarasota county jail. The discharge summary documented by the emergency room RN notes a "Pain Scale: 3/10, Does the patient need discharge Vital Signs? No; IV No, Catheter Intact at Removal: Yes Condition at Discharge Stable. Disposition Jail. Patient Verbalized/Demonstrated Discharge Instructions Yes. Instructions given to Patient. Departure time 22:45 (10:45 p.m.)." There is no documentation after the initial triage assessment that the patient had been evaluated on the psychiatric, mental or emotional status regarding the attempted failed suicide which was noted as the chief complaint by the emergency department physician in his dictated note.

There is no documentation the physician or the emergency department staff discussed the attempted suicide with the police department. There is no documentation the patient would be placed on suicide watch at the jail when he was discharged into their custody. There is no documentation regarding follow up treatment with psychiatric physicians. There is no documentation regarding the emotional, mental or psychological status of the patient after the initial note of attempted suicide. There is no documentation this patient is no longer a danger to himself and would be safe for discharge psychologically.

Review of the police report obtained by the facility and presented for review reveals the account of the events prior to the patient being brought to the emergency department. The final sentence in the report notes: "After being release from the ER he was transported to the Sarasota County Jail." This report does not indicate the patient would be or was placed on suicide watch upon arrival to the jail.

Review of an addendum dictated by the emergency department physician who is no longer employed by the facility dated 9/15/11 at 2:00 a.m. reveals he is amending his documentation at the request of the facility. He states he is not able to review the file and this dictation is strictly from his memory. The dictation address the dog bites received by the patient and notes the patient history of polysubstance abuse. He states the patient "Freely admitted that he had tried to hang himself but the ligature immediately broke. There is clinical evidence to collaborate his story." He continues his dictation with notes regarding treatment of the dog bites. He notes a discussion with the attending officer regarding Baker Act and states the officer told him the patient would be placed on suicide watch while in custody. He further states he felt that discharge to jail under a suicide watch was appropriate. The notes continue to say "This is a young man who was brought to the Emergency Department to be treated for dog bite injuries and not for an attempted suicide." However, the physician's original documentation dictated on the day of treatment identified the chief complaint as "Attempted suicide." There is no notation in this addendum regarding the assessment of the emotional, mental or psychological status of the patient. There is no documentation of any treatment regarding the emotional, mental or psychological status of this patient. This addendum was obtained from the physician after surveyor requested information regarding documentation regarding the assessment and treatment of the mental, emotional and psychological status of the resident as noted on the date of the dictated report (9/15/11 0200).

On 9/13/11 an interview with the manager of the emergency department confirmed there was no documentation regarding the assessment and treatment of the emotional, mental and psychological status of Patient #45 while in the emergency department on 4/26/11. He also confirmed there was no documentation regarding a conversation between the physician or the nursing staff with police regarding the discharge status of the patient. He reported the physician no longer worked for the facility and he was not able to contact him. He stated there was no documentation or explanation as to why the documentation did not include the assessment or treatment plan in regards to the emotional, mental or psychological status of the patient.

Based on staff interviews, record reviews and Policy and Procedure review, the hospital failed to document investigation processes for Patient #61 and failed to provide written resolution to 5 (Patients #61, #62, #63, #64 and #65) of 5 sample patients that filed grievances with the hospital.

The findings include:

On 9/15/11, from 9:55 a.m. to 11:00 a.m., a review was completed of the grievance process at the hospital and revealed the following:

1. Patient #61 had a hospital visit on 12/17/10 and filed a grievance, on 3/24/11, related to failure of staff to timely attend to patient needs following surgery. The documentation for this grievance was reviewed in the electronic record system, with the Risk Management Clinician (RMC). The surveyor requested to see the documentation of the investigation and resolution of this grievance. There was no documentation in the electronic record system related to the investigation and the resolution. The RMC indicated the Clinician Manager assigned the grievance may have documentation. The RMC called the Clinical Manager (CM) for 9 Waldemere to ask if she had documentation related to Patient #61's grievance. There was a telephone interview conducted with the Clinical Manager (CM) for 9 Waldemere. The CM stated that she had met with Patient #61 on 4/8/11 and the grievance had been resolved during the meeting. The surveyor requested documentation related to the meeting and the resolution being confirmed with Patient #61. The CM stated she had not documented the meeting or the resolution of the grievance. When asked how the resolution of the grievance could be verified, the suggestion was to contact Patient #61 for verification. The CM and the RMC stated they had not provided Patient #61 with a written notice of the hospital's decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.

2. Patient #62 had a hospital visit on 12/14/10 and filed a grievance on 2/10/11.

3. Patient #63 had a hospital visit on 4/04/11 and filed a grievance on 4/11/11.

4. Patient #64 had a hospital visit on 4/22/11 and filed a grievance on 5/13/11.

5. Patient #65 had a hospital visit on 7/20/11 and filed a grievance on 7/20/11. The documentation for the grievances was reviewed in the electronic record system, with the Risk Management Clinician (RMC). The surveyor requested to see the documentation of the investigation and resolution of this grievance.

The surveyor requested to see the written resolution notice to Patients #62, #63, #64 and #65. The RMC stated they did not have documentation the hospital had provided Patient #62, #63, #64 and #65 with a written notice of the hospital's decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.

On 9/13/11, the policy and procedure for Sarasota Memorial Health Care System for grievance was reviewed. The policy titled "Sarasota Memorial Health Care System Corporate Policy Complaint/Grievance Management (Service Recovery), Policy # 00.RSK.17, Effective Date 10/20/97, Reviewed/Revised Date 1/30/08", documented on page 4 of 12 "4. Responsibilities a. The department director/manager is responsible for addressing complaints/grievances and managing customer services in his/her areas of accountability. These activities include but are not limited to: (See Patient Compliant/Grievance Process attached) ... 4) Providing within 7 days or when practical written feedback to the person initiating grievance" and on page 5 of 12, "Response to a Grievance Resolution: Additional tools may be used to resolve a grievance, such as meeting with the patient and his family, or other effective methods. However, in all cases a written notice is to be provided (response) to each patient's grievance(s). In its resolution of the grievance, the patient or representative must be provided with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."

The hospital's policy and procedure related to patient grievance process was not consistently implemented by the hospital staff and Patients #61, #62, #63, #64 and #65 were not provided a written resolution of their grievances.

Based on patient interview, staff interview and record review, the facility failed to ensure the patients right to be free from abuse/neglect by failing to provide services necessary to avoid physical harm, mental anguish, or mental illness for 1 (Patient #13) of 60 patients surveyed.

The findings include:
During the initial tour of the facility on 9/12/11 at 9:45 a.m., Patient #13 reported she was admitted to the 7th floor in the Waldemere Tower from the Emergency Care Center (ECC) at 6:30 a.m. (9/12/11). The resident stated she has been experiencing pain, nausea and vomiting since her arrival on the nursing unit but has not received any pain or nausea medication and is not receiving any fluids. The resident stated she has made many requests for the medication and the nursing staff is well aware of her pain. The resident stated she was told the nurses do not have any physician orders for her care or medications.

In an interview on 9/12/11 at 10:00 a.m., the nursing unit charge nurse stated the care nurse had made attempts to contact the physician for orders without success. The charge nurse stated she had tried to contact the physician but had not received a response. At 10:12 a.m., after surveyor inquiry, the charge nurse reported the physician was contacted and orders received.

On 9/14/11 a review of the medical record for Patient #13 was conducted with the nursing unit manager, the division nursing administrator and the hospital CEO. The record reveals the patient was admitted to the ECC on 9/11/11 at 10:58 p.m. with abdominal pain. The ECC record states the resident was given Dilaudid 0.5 mg IV for pain at 11:55 p.m., 12:54 a.m.(9/12/11), and 1:04 a.m. The medical record documents the ECC physician recommended the patient be admitted into the hospital on a medical/surgical floor at 3:30 a.m. The 'attending physician's' service was called and forwarded to the surgeon covering. The covering physician accepted the patient to the service of the designated attending physician at 4:16 a.m. The ECC physician wrote bridge orders at 3:30 a.m. as follows: "Admit per ICM Protocol as discussed with Admitting Physician; (fluids) Sodium Chloride 0.9% 1000 ml @ 150 ml/hr REDUCED TO 15 ML/HR WHEN PATIENT TRANSFERRED TO FLOOR; NPO (nothing by mouth); Dilaudid 0.5 mg IV QH PRN SEVERE PAIN; Zofran ODT 4 mg PO Q6H; Nasogastric Tube.

The medical record states the patient was transferred to the hospital nursing unit at 6:10 a.m. on 9/12/11 admitted to the nursing unit at 6:12 a.m. The patient was assessed by nursing at 6:30 a.m. as having a pain level of 3 on a 0 to 10 scale. The unit manager stated the pain management protocol is initiated when the pain level reaches 4.

At 6:31 a.m. the bridge orders for pain medication Dilaudid and fluids Sodium Chloride 0.9% timed out; that is, were discontinued by pharmacy and not available to the nurse. The Zaofran had timed out at 3:35 a.m. and was discontinued by the pharmacy. The patient was admitted to the nursing unit without admission orders from the attending physician. The nurse placed a call to the physician at 7:00 a.m. No response was received. The medical record documents the nurse assessed the patient at 8:00 a.m. finding: "Patient awake in bed, tearful, just vomited approx 50 ml of brownish fluid. Pain level of 5* - standard: VAS under 4 or experiencing chronic pain that is effectively managed: NOT MET; - intervention: comfort measures given, will call MD."

The medical record dated 9/12/11 documents: "Physician Update - at 8:20 a.m. call placed to attending physician's office regarding orders for medications. Prior to calling office, overhead paged and surgery called to see if physician in surgery. Placed an additional call at 8:45 a.m. to physician's office to obtain orders." There was no response from the physician and no documentation of follow-up until surveyor intervention at 10:00 a.m.

The unit manger stated the hospital protocol for requesting physician orders requires the nurse to make 3 calls to the physician at 15 minute intervals. If no response the nurse is to hand off to the chain of command for administrative assistance to contact the physician or obtain orders. The administrators acknowledged a patient was admitted to the nursing unit without physician's orders for care, the protocol for obtaining physician orders was not followed, there was insufficient follow-up or administrative action when the next level of management was involved, and the patient's needs were not met resulting in unnecessary pain and suffering.

At 10:00 a.m. the nurse assessed the patient and found the patient experiencing a pain level of 7. The physician was again called for orders. The medical record documents the physician called back at 10:10 a.m. placed verbal orders for Dilaudid, Phenergan and IV fluids. The orders were confirmed by read-back and entered into the electronic ordering system. The medications are stored on the nursing unit but are not available to the nurse for administration until released by the pharmacy. The medical record reveals that by 10:45 a.m. the medications had not been released by the pharmacy. The pharmacy was called and "Asked to please verify meds so they can be given to patient." The medication was administered at 10:55 a.m. the patient's pain was assessed at this at the time of administration at a level of 8 (severe pain).

The patient stated she had waited 41/2 hours to receive pain and nausea medication. The resident waited an additional 43 minutes from the time the order was received until administration with pain increasing from a level of 7 to 8.

Nursing management was asked if the pharmacy system could be overridden to give the patient immediate relief. The Nurse Administrator stated there are certain medications that can be immediately retrieved from the medication dispensing system and that Dilaudid is one of the available medications. When asked why the pain medication was not administered at 10:12 a.m. when the order was received, the Nurse Administrator stated is was an error in critical thinking. All agreed that they would not like to wait another 43 minutes when experiencing severe pain. The Administrators acknowledged the patient's suffering and stated: "We did not take care of this patient."

Based on patient interview, staff interview and record review the facility failed to ensure an RN provided care for each patient in accordance with accepted standards of nursing practice and hospital policy for 1 (Patient #13) of 60 patients reviewed.

The findings include:

During the initial tour of the facility on 9/12/11 at 9:45 a.m., Patient #13 reported she was admitted to the 7th floor in the Waldemere Tower from the Emergency Care Center (ECC) at 6:30 a.m. (9/12/11). The resident stated she has been experiencing pain, nausea and vomiting since her arrival on the nursing unit but has not received any pain or nausea medication and is not receiving any fluids. The resident stated she has made many requests for the medication and the nursing staff is well aware of her pain. The resident stated she was told the nurses do not have any physician orders for her care or medications.

In an interview on 9/12/11 at 10:00 a.m., the nursing unit charge nurse stated the care nurse had made attempts to contact the physician for orders without success. The charge nurse stated she had tried to contact the physician but had not received a response. At 10:12 a.m., after surveyor inquiry, the charge nurse reported the physician was contacted and orders received.

On 9/14/11 a review of the medical record for Patient #13 was conducted with the nursing unit manager, the division nursing Administrator and the hospital CEO. The record reveals the patient was admitted to the ECC on 9/11/11 at 10:58 p.m. with abdominal pain. The medical record documents the ECC physician recommended the patient be admitted into the hospital on a medical/surgical floor at 3:30 a.m. The 'attending physician's' service was called and forwarded to the surgeon covering. The covering physician accepted the patient to the service of the designated attending physician at 4:16 a.m.

The medical record states the patient was transferred from the ECC at 6:10 a.m. on 9/12/11, admitted to the nursing unit at 6:12 a.m. The patient was assessed by nursing at 6:30 a.m. as having a pain level of 3 on a 0 to 10 scale. The unit manager stated the pain management protocol is initiated when the pain level reaches 4. The unit manager stated that any orders written for the patient by the ECC physician are automatically discontinued when the patient is admitted to an observation unit or inpatient unit of the hospital. The medical record reveals at 6:31 a.m. the bridge orders from the ECC physician for pain medication, Dilaudid, and fluids, Sodium Chloride 0.9%, timed out; that is, were discontinued by pharmacy and not available to the nurse.

The patient was admitted to the nursing unit without admission orders from the attending physician. The nurse placed a call to the physician at 7:00 a.m. No response was received. The medical record documents the nurse assessed the patient at 8:00 a.m. finding: "Patient awake in bed, tearful, just vomited approx 50 ml of brownish fluid. Pain level of 5* - standard: VAS under 4 or experiencing chronic pain that is effectively managed: NOT MET; - intervention: comfort measures given, will call MD."

The medical record dated 9/12/11 documents: "Physician Update - at 8:20 a.m. call placed to attending physician's office regarding orders for medications. Prior to calling office, overhead paged and surgery called to see if physician in surgery. Placed an additional call at 8:45 a.m. to physician's office to obtain orders." There was no response from the physician and no documentation of follow-up until surveyor intervention at 10:00 a.m.

The unit manger stated the hospital protocol for requesting physician orders requires the nurse to make 3 calls to the physician at 15 minute intervals. If no response the nurse is to hand off to the chain of command for administrative assistance to contact the physician or obtain orders. The administrators acknowledged a patient was admitted to the nursing unit without physician's orders for care, the protocol for obtaining physician orders was not followed, there was insufficient follow-up or administrative action when the next level of management was involved, and the patient's needs were not met resulting in unnecessary pain and suffering.

At 10:00 a.m. the nurse assessed the patient and found the patient experiencing a pain level of 7. The physician was again called for orders. The medical record documents the physician called back at 10:10 a.m. placed verbal orders for Dilaudid, Phenergan and IV fluids. The orders were confirmed by read-back and entered into the electronic ordering system. The medications are stored on the nursing unit but are not available to the nurse for administration until released by the pharmacy. The medical record reveals that by 10:45 a.m. the medications had not been released by the pharmacy. The pharmacy was called and "Asked to please verify meds so they can be given to patient." The medication was administered at 10:55 a.m. the patient's pain was assessed at this at the time of administration at a level of 8 (severe pain).

The patient stated she had waited 41/2 hours to receive pain and nausea medication. The resident waited an additional 43 minutes from the time the order was received until administration with pain increasing from a level of 7 to 8.

Nursing management was asked if the pharmacy system could be overridden to give the patient immediate relief. The Nurse Administrator stated there are certain medications that can be immediately retrieved from the medication dispensing system and that Dilaudid is one of the available medications. When asked why the pain medication was not administered at 10:12 a.m. when the order was received, the Nurse Administrator stated is was an error in critical thinking. All agreed that they would not like to wait another 43 minutes when experiencing severe pain. The Administrators acknowledged the patient's suffering and stated: "We did not take care of this patient."

Based on review of closed records and staff interview, the hospital failed to provide complete medical records, including being date and times for 3 (Patients #21, #23 and #55) of 8 closed patients record reviewed.

The findings included:

1. During record review of Patient #21, on 9/13/11, the pronouncement form failed to document the time the Consultant was notified and document the name of the Supervisor notified at 1310 on 11/03/11. The hospital documented that the Life Link/Lion's Eye Bank was contacted, but failed to document the outcome to the contact.

2. During the record review of Patient #23, on 9/13/11, the Medical Certification for Nursing Facility/Home and Community Based Services Form (MCNF/HCBS) was blank in the following areas:
Section A: Facility Information To, Discharge Date
Section B: Will you care for individual in NF?; If no, refer to; Secondary Diagnosis; Discharge Diagnosis; Surgery Performed & Date; Allergy/Drug Sensitivity; Medication and Treatment Orders.
Section C
Section D
Section E
Section F
Section G
Section H
Section I
Section J, except for the Physician's Signature and Date Required.

Patient #23 did not date and time their signature on the "An Important Message From Medicare About Your Rights" form.

3. The Discharge Summary for Patient #55 is not in the record. Patient #55 was admitted on 5/11/11 to Sarasota Memorial Hospital and discharged on 5/12/11.

During an interview on 9/14/11, at 2: 48 p.m., with the Director of Health Information Management (HIM), she stated, "There has not been a discharge summary completed to date. The doctor has been called and requested to complete the discharge summary and he has not to date." She stated he was out of compliance with the hospital's timeframe and policy and procedure on the completion of patient's discharge summary.

Based on observation and interview with the Nutritional Services Director and Plant Operations Manager, the facility failed to ensure the cafeteria kitchen hood, char-grill, deep fryers and radiant lighting protectors on the steam table were in safe operating condition. In addition, they failed to ensure flammable material in the cafeteria was stored in a safe manner. This failure increases the potential risk of the development of a fire and places all patients, staff and visitors at risk for harm.
The findings include:
1. Observation on 9/12/11 at 12:20 p.m., of the kitchen cafeteria in the presence of the NSD (Nutritional Services Director) and cafeteria manager revealed thick dark brown greasy residue oozing down the bottom of the kitchen hood and onto the tile behind the grill and deep fryer. The grill itself had an extensive amount of hardened black greasy residue lining the top and bottom of the grates and a large amount of hardened dried food particles, hardened black grease, dirt and grime were observed on the bottom of the grill. The amount of black charcoal ladened on each of the grill slats barely made the bottom of the grill visible.
Observation of the area behind the deep fryer was lined with an accumulation of old grease and residue. The cafeteria floor under the cooking stations was lined with old hardened French fries, an extensive amount of hardened grease, black dirt and grime. Four pannini presses were observed inside a box next to the cooking area. These items were covered with black dirt, crumbs, grime and grease.
Further observations revealed the metal protectors surrounding the radiant heating devices above the "Soups and more" station presented an extensive amount of hardened grease and grime. In addition, 9 canisters of butane lighting fluid were observed laying on the inside of the metal cabinet in the kitchen.
Interview with the cafeteria manager during this observation revealed his staff is assigned to clean the areas free of the grease and grime at least once a week. He could not explain the extensive amount of grease and grime build up on the equipment.
Interview with the cafeteria manager on 9/12/11 at approximately 2:30 p.m., in the presence of the plant operations manager and fire life safety inspector revealed he used the butane to fuel an omelet cooking station. He confirmed the butane was supposed to be stored elsewhere in the hospital in a hazardous material storage room. He confirmed he did not use the cook station near the kitchen hood and was unaware of the unsafe use of the lighting fluid. As to the lack of proper and safe maintenance of the cafeteria kitchen equipment, he stated, "You can only do what you can do with the amount of staff that you have."