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Based on staff interviews and facility record review the facility failed to ensure that one of one Advanced Registered Nurse Practitioner/Certified Registered Nurse Anesthetist was to work under the supervision of a specifically identified physician with in written practice protocols.

Findings:

1. Review of the credentialing file for Registered Nurse Practitioner/Certified Registered Nurse Anesthetist,(CRNA) revealed that the file did not contain either a supervising physician or an approved practice protocol.

2. Interview with the Medical Staff Credentialing Coordinator on 11/04/2014 at 2:00 PM revealed that when she questioned the CRNA he stated that Florida was an Opt-Out under a 2001 CMS rule that allows states to op-out of the federal supervision requirement of CRNA's. The Credentialing Coordinator stated that the CRNA stated that he is part of an anesthesia group that has a contract with an Ocala Hospital to independently perform anesthesia services without the supervision of a physician. The Credentialing Coordinator stated that the CRNA told her that his lawyer told him that under the Opt-out provision that the group did not need or have a supervision or worked within a practice protocol. The Credentialing Coordinator stated that two additional CRNAs in the group have applied for privileges at the facility.

3. Review of the credentialing file for the CRNA revealed a document for the American Association of nurse Anesthetists, titled Fact Sheet Concerning State Opt-Outs and November 13, 2001 CMS rule. The document stated that as of April 2012, 17 states have elected the Opt-out option. A list of the 17 states was included in the documents but did not list Florida.

4. Review of the License Verification for the CRNA revealed under Practitioner Profile, subcategory ARNP Protocols 64B9-4.010 Standards of Protocols revealed "An Advanced Registered Nurse Practitioner shall only performed medical act of diagnosis. treatment, and operation pursuant to a protocol between the ARNP and a Florida-licensed medical doctor, osteopathic physician or dentist. The degree and method of supervision, determined by the ARNP and the physician or dentist, shall be specifically identified in the written protocol and shall be appropriate for prudent health care providers under similar circumstances.

Based on observation, interview and record review the facility failed to ensure medications were administered by the facility's established standard of practice for Gastrostomy Tube (G-Tube) for 1 ( patient # 16) of 2 sampled patients.

Findings:

An observation conducted on 11/04/2014 at 9:30 AM of the ICU (Intensive Care Unit) RN #2 (Registered Nurse) during medication pass for Patient #16 showed the RN crushed ten medication in their single dose containers, and placed the closed containers into a plastic cup. A crushed medication was put into a plastic cup with 30 cc of water and was administered by G-Tube, and this was repeated 9 additional times. The RN did not flush in between each medication as it was administered.

An interview was conducted on 11/04/2014 at 10:29 AM with ICU RN #2 and she stated she did not flush in between medications., " I should have, that was my mistake " .

Record review of the Policy and Procedure entitled, " Gastrostomy Tube Care, Maintenance, and Medication Administration " with an effective date of 12/13 showed flush after each medication with 15-30 mL of water.

Based on interview and record review the facility failed to ensure initial nursing admission assessments were dated for 30 of 30 sampled patients, Patients #1 - 30. The facility further failed to ensure initial nursing admission assessments were signed by the completing nurse for 2( patient's #19 and # 22) of 30 sampled patients.

Findings:

Record review of the initial nursing admission assessments for Patients #1 - 30 showed the assessment was not dated or timed. There was no area on the assessment that allowed for a date and time of the completion of the assessment.

Record review of the initial nursing admission assessments for Patients #19 and #22 showed the assessments were not signed by the completing nurse.

An interview was conducted on 11/03/2014 at 11:27 AM with the Risk Manager and she stated she will get some clarification regarding the initial nursing assessment not showing a date. I will have to discuss this with our corporate office. I never noticed there was no place to date and time the completion of the assessment.

An interview was conducted on 11/04/2014 at 3:58 PM with the Risk Manager and she verified the initial nursing admission assessments were not signed by the completing nurse for Patients #19, and #22.

Based on interview and record review the facility failed to ensure a history and physical was complete for 1( patient # 11) of 30 sampled patients.

Findings:

Record review of Patient #11's medical chart showed the patient was admitted into the facility on 10/10/2014, and did not have a history and physical in his medical chart.

An interview was conducted on 11/03/2014 at 3:53 PM with the Risk Manager and she stated there was a problem during the dictation process, and it stated the physician's dictation ended. We apparently have a problem with the system, and it is something we will have to look into. We have a call into the physician now regarding the H & P. The Risk Manager further stated it would seem that the H & P not being done would have been noticed before now.

Based on observation, interview and record review the facility failed to ensure the feeding solution was labeled and dated per the facility's established policy and procedures for 1 ( Patient# 16) of 2 sampled patients.

An observation conducted on 11/04/2014 at 9:44 AM of Patient #16 showed Patient #16 was receiving tube feeding and the bag containing the tube feeding was observed not to be labeled or dated.

An interview was conducted on 11/04/2014 at 10:24 AM with ICU (Intensive Care Unit) RN (Registered Nurse) #2 and she stated she didn ' t know why the tube feeding bag was not labeled and dated. " This is the first time that has ever happened. The night shift always labels and dates the bags " .

Record review of the Policy and Procedure entitled, " Feeding Tubes, Care of the Patient with; with an effective date of 05/11 under 1. "Label feeding tube with date and time when hung".