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Based on record review and staff interview, it was determined that the facility failed to conduct a thorough review following the death of 1 (#1) of 16 sampled patients within 24 hours of transfer from the facility.
This practice does not ensure identification of problems related to patient care.


Findings include:

Patient #1's Certification and Consent to Transfer dated 4/26/11 revealed the 14 year old child was transferred via basic life transport to a skilled nursing facility approximately 5 hours away on 4/26/11.
Interview with the Risk manager on 9/16/11 at approximately 11:00 a.m. revealed the facility had been notified on 4/27/11 that the patient had a cardiac arrest and expired earlier that day. The Risk Manager stated that the attending pediatrician and the Pediatric Nurse Manager had reviewed the record and found no concerns related to physician or nursing care. The interview revealed there was no evidence of an investigation having been initiated.

Based on clinical record reviews and staff interviews it was determined that the Registered Nurse failed to ensure
a medically complex 14 year old pediatric patient was assessed for hydration and medication needs prior to transfer for one (#1) of sixteen sampled patients. This practice did not ensure hydration and medication needs were met for an approximately five hour transport.

Findings include:

1. Patient #1's History and Physical dated 3/29/11 revealed the a fourteen year old child was admitted to the facility due to concern for medical neglect. The history included cerebral palsy, significant global developmental delay, and seizure disorder. The child also suffered from constipation and chronic sinus infections. Review of the nursing admission data base, dated 3/29/11, noted the child had been hospitalized two weeks prior for pneumonia.

Review of physician admission orders, dated 3/29/11, at 9:00 p.m. instructed for a pureed diet with assistance and vital signs every four hours. The medications included Neurontin 300 milligrams (mg) three times a day at 9A-3P-9P and Tegretol 220 mg three times a day at the same time. Both of the above medications are anti- seizure medications. Other medications included Diastat per rectum as needed for seizure activity and Albuterol as needed for cough or wheeze. Physician orders, dated 4/4/11 at 3:00 p.m., instructed to push oral fluids. Physician orders, dated 4/23/11, at 7:30 a.m. instructed for the patient to receive a minimum of 2000 ml every day-example 400 ml per meal/snack 5 times per day. A Physician order, dated 4/24/11, no time, instructed for a weight to be obtained on 4/25/11 as the last weight before discharge.

Physician orders, dated 4/26/11 at 8:00 a.m., instructed for the patient to be transferred to a Skilled Nursing Facility (SNF) which was on the East coast of Florida. Review of the Physician Medication Discharge Order form, signed and dated 4/26/11 at 9:00 a.m., ordered to continue the same medication, which included the Neurontin and Tegretol. Review of the Patient Discharge Teaching form revealed the child was on a pureed diet and fall precautions. The teaching form lacked that the child was on seizure precaution.

The Nursing Medication Discharge Teaching form revealed the Tegretol administration time was 9A-3P-9P. The Neurontin was listed as every eight hours, however, the time due was listed as 9A-3P-9P. This was in conflict with the physician's order of three times a day. There was a line drawn through the entire list and "error" was written and initialed.

Review of nursing documentation, dated 4/23/11, revealed vital signs were done every four hours and the intake was 2160 milli liters (ml). Review of nursing documentation, dated 4/24/11, noted the vital signs were done every four hours and the intake was 1410 ml. Review of nursing documentation from 4/25/11 revealed the child was not weighed, as ordered, as the last weight prior to discharge, vitals sign were performed every four hours as ordered, and intake was 1880 ml for the twenty four hour period. The last oral fluid intake was 200 ml documented at midnight on 4/26/11.

Review of nursing documentation, dated 4/26/11 for the 7:00 a.m. to 3:00 p.m. shift, revealed the child was fed 75% of her breakfast but no fluid intake was documented. The documentation noted the child had one diaper change. Review of vital signs documentation, dated 4/26/11, showed the vital signs were obtained at 8:45 a.m. with a heart rate of 135 and the child was crying. The child's usual heart rate was 70 to 110. The vital signs were to be reassessed at approximately noon, but were not done.

Documentation at 12:00 p.m. noted the patient was transferred with no distress with the ambulance transport. The patient had no documented fluid intake from midnight until the time of transport at approximately noon.

Interview with the Registered Nurse (RN) who cared for the child on the day of discharge on 9/16/11 at approximately 9:55 a.m. revealed no recollection of telling the ambulance personnel about the two seizure medications that were due at 3:00 and 4:00 p.m. during transport. The RN did not remember if the child had lunch, a snack, or fluids before she was transported. She stated vital signs and a reassessment (to determine if the child was stable and hydrated for the five hour trip) were not done prior to discharge.


The interview and review of documentation revealed the Registered Nurse did not supervise and evaluate care for fluid therapy and discharge needs of a medically complex child with specific needs.

Based on record review and staff interview, it was determined that the nursing staff did not administer medications as ordered by the physician for one (#1) of sixteen records reviewed. This practice does not ensure safe and effective medication therapy.

Findings include:

1. Patient #1's Medication Administration Record (MAR), dated
4/26/11, revealed that Cod Liver Oil was not given at 8:00 a.m. There was no documentation as to why the medication was not given.

Review of the MAR, dated 4/14/11, revealed the 10:00 p.m. dose of Neurontin was not administered as ordered. On 4/17/11, the 10:00 p.m. dose of Neurontin was not administered as ordered. There ws no documentation as to why the medication was not given.

Interview with the Risk Manager on 9/15/11 at 3:45 p.m. confirmed the medication was not documented as given or why it was not given.

Based on record review, policy review and staff interview, it was determined that the facility failed to assess and ensure that a safe, effective, and appropriate discharge plan was provided to a 14 year old medically complex child.

1. A medically complex pediatric patient was transferred to a Skilled Nursing Facility (SNF) approximately five hours away via Basic Life Support (BLS) on 4/26/11. The child's diagnosis included cerebral palsy and seizures. The child was on a pureed diet, unable to communicate, and was total care.

The staff interview and review of the clinical record revealed a safe discharge was not implemented. The type of transportation was not ordered by the physician or the interdisciplinary team to reflect the type of transportation that would be required for a child with seizure precautions, who could quickly dehydrate, and required medications that were scheduled to be given during the transport hours. Record review showed the medically complex pediatric patient did not receive fluid since midnight prior to discharge (12 hrs total) and was on a daily fluid minimum. There was no documentation if the child was to have nothing by mouth during transportation or according to the discharge instruction of a pureed diet. There was no planning for the Diastat or Albuterol that was ordered for seizures or wheezing/coughing. There was no clarification with the physician or planning with the receiving facility about two seizure medications that were due during transportation. Cod Liver Oil (used for constipation) was sent with the child without a physician order or documentation of the medication being sent. The Certification and Consent for Transfer was not signed by the physician prior to transfer as per facility policy and procedure. (Refer to A817).

2. The facility failed to initiate a timely discharge plan for one (#9) of sixteen patients in a timely manner. (Refer to A810)

3. The facility failed to ensure appropriate preparation for discharge for two (#1, #3) of sixteen patients. (Refer to A837).

4. The facility failed to provide ongoing assessment and reassessment of the discharge planning process for a medically complex child requiring medications and hydration during transportation. (Refer to A843).

Due to the cumulative effect of these systemic problems, it was determined that the Condition of Participation for Discharge Planning was out of compliance and Immediate Jeopardy was present and on going.

Based on clinical record review and staff interview it was determined that the facility failed to ensure post hospital needs were initiated in a timely manner for 1 (#5) of sixteen records sampled. This practice may delay a discharge.

Findings include:

1. Patient #5 was interviewed in the patient's room at 11:40 a.m. on 9/16/11. The patient was to be discharged from the orthopedic surgery unit later that day.

ON 9/16/11 at approximately 11:15 a.m. and interview was conducted with the patient's nurse and they stated the patient was to be discharged with physical therapy rehabilitation at home.

The patient confirmed that he was being discharged that day and the patient knew he was to receive physical therapy services at home. The patient did not know what agency would be providing the physical therapy services or when the services were scheduled to begin.
A review of patient #5 ' s physician ' s order confirmed the patient was discharged home with physical therapy. Further review of the patient ' s chart failed to note what physical therapy providers were offered to the patient. There was no documentation to indicate exactly when physical therapy would begin only that the social worker was to coordinate physical therapy services.

Interview with the Risk Manager on 9/16/11 at approximately 5:30 p.m. confirmed no documentation of when home physical therapy would begin.

Based on review of clinical records, policy, and procedure and staff interviews it was determined that the
facility failed to ensure a medically complex pediatric patient was assessed for hydration and medication needs prior to transfer and the transfer met the needs of the pediatric patient for two (#1, #13) of sixteen sampled patients. This practice does not ensure the safety and that the needs of the medically complex pediatric patient en route to another facility are met. This practice may have contributed to potential harm for the child who expired within eighteen hours of being transferred. The clinical record was reviewed by the attending physician and pediatric nurse manager who indicted no concerns were noted with the care provided for discharge planning by the physician or nursing. Staff were not aware of the policy and procedure requiring a physician or a qualified medical personnel involvement in determining the type of transport that would be needed. This places all pediatric patients requiring transportation for transfer at risk for harm or death, therefore, Immediate Jeopardy is present and on going for discharge planning.

Findings include:

1. Patient #1's History and Physical, dated 3/29/11, revealed the 14 year old child was admitted to the hospital due to concern for medical neglect. The history included cerebral palsy, significant global developmental delay, and seizure disorder. The child also suffered from constipation and chronic sinus infections. Review of the nursing admission data base, dated 3/29/11, noted the child had been hospitalized two weeks prior for pneumonia.

Physician admission orders, dated 3/29/11 at 9:00 p.m., called for a pureed diet with assistance, vital signs every four hours, and seizure precautions. The medications included Neurontin 300 milligrams (mg) three times a day at 9A-3P-9P and Tegretol 220 mg three times a day at the same time. Both of the above medications are anti- seizure medications. Other medications included Diastat per rectum as needed for seizure activity and Albuterol as needed for cough or wheeze. The orders included Cod Liver Oil 5 milliliters (ml) every day. Physician orders, dated 4/4/11 at 3:00 p.m., stated to push oral fluids. A Physician order, dated 4/21/11 at 1:45 p.m., instructed for the patient to be placed on continuous pulse oximetry (oxygen monitoring) at night. Physician orders, dated 4/23/11 at 7:30 a.m., instructed for the patient to receive a minimum of 2000 ml every day-example 400 ml per meal/snack 5 times per day. A Physician order, dated 4/24/11, no time, instructed for a weight to be obtained on 4/25/11 as the last weight before discharge.

Physician orders, dated 4/26/11 at 8:00 a.m., called for the patient to be transferred to a Skilled Nursing Facility (SNF) after the child was seen by the attending, soft pureed diet with assistance, home nursing care daily from midnight to 7:00 a.m., and medications per the medication reconciliation form. Review of the Physician Medication Discharge Order form, signed and dated 4/26/11 at 9:00 a.m., ordered to continue the same medication, which included the Neurontin and Tegretol. Review of the Patient Discharge Teaching form revealed the form was signed by Emergency Medical Technician B on 4/26/11, no time, showed the child was on a pureed diet, fall precautions, and was to receive home nursing care from midnight to 7:00 a.m. The teaching form did not include that the child was on seizure precautions and would require medications, The Nursing Discharge Medication Teaching Sheet, signed by the same person, had the medication listed. The Tegretol was due at 9A-3P-9P. The Neurontin was listed as every eight hours, however the time due was listed as 9A-3P-9P, which was in conflict with the original physician order. There was a line drawn through the entire list and "error" was written and initialed. This did not provide clear information regarding medications for the transport personnel.

Review of nursing documentation, dated 4/23/11, revealed vital signs were done every four hours and the intake was 2160 ml. Review of nursing documentation, dated 4/24/11, noted the vital signs were done every four hours and the intake was 1410 ml, a deficit of 590 ml. Review of nursing documentation from 4/25/11 revealed the child was not weighed as ordered as the last weight prior to discharge, vitals sign were performed every four hours as ordered, and intake was 1880 ml, a deficit of 120 ml, for the twenty four hour period. The last oral fluid intake was 200 ml documented at midnight on 4/26/11. The child already had a deficit of 710 ml. There was no further documentation of the child receiving fluid hydration prior to transport.

Review of nursing documentation, dated 4/26/11 for the 7:00 a.m. to 3:00 p.m., shift revealed the child was fed 75% of her breakfast but no fluid intake was documented. The documentation noted the child had one diaper change prior to transport. Review of vital signs documentation, dated 4/26/11, showed the vital signs were obtained at 8:45 a.m. with a heart rate of 135 and the child was crying. The child's normal heart was 70-110. There ws no evidence of the vital signs being reassessed by the nursing staff as ordered and indicated by clinical symptoms. Nursing documentation at 12:00 p.m. noted the patient was transferred with no distress with the ambulance transport.

Review of physician progress note, dated 4/24/11, showed the increased fluid intake was started secondary to low urine output that was improving with the increased fluids. Review of physician orders and physician progress notes from 4/14/11, the day medically cleared to 4/26/11, the date of transfer, revealed no evidence of documentation of the type of transportation the child would require for the approximately five hour drive to the East Coast of Florida. Review of the physician progress notes revealed a note dated 4/26/11 at 7:30 a.m., and the attending note was signed at 8:45 a.m.

Interview with the child's attending pediatrician on 9/16/11 at approximately 6:35 p.m. revealed she was aware of the BLS transport and had no concerns with the BLS transport. However, there was no documentation as such. The interview revealed the child would "quickly dehydrate" but when questioned on that statement she stated that can happen when the child has a temperature. When questioned about the length of time it would take the child to dehydrate, she was unable to answer the question with a timeframe.

Review of the Medication Administration Record (MAR) revealed the Neurontin was given at 10:00 a.m. and the Tegretol was given at 9:00 a.m. on 4/26/11, the day of discharge. The MAR indicated the Cod Liver Oil was not given at 8:00 a.m. The next dose of Neurontin was due at 4:00 p.m. and the Tegretol was due at 3:00 p.m. There was no plan from the physician or nursing to provide the medication during the transport placing the child a potential risk for seizures.

Review of Case Management (CM) note, dated 4/22/11, noted the transport at discharge was a private vehicle, a SNF that had accepted the patient, and the SNF was in agreement with the child arriving at approximately 3:00 p.m. The documentation noted the consent for transfer was in the chart. CM note, dated 4/26/11, revealed the child transportation was private vehicle. There was no documentation of the rationale for the private vehicle. The ambulance company was called on 4/26/11 and told transportation was needed ASAP and would be scheduled for 11:00 a.m. that day. The documentation did not show the rationale for the type of transportation selected to ensure the medically complex child's needs could be met.

Review of the ambulance Physician Certification Statement, dated 4/22/11, revealed the child was a fall risk. No other information regarding feedings, medication, or seizure precautions was noted. The form was signed by the case manager.

Review of the Certification and Consent to Transfer form indicated the child would be transferred via Basic Life Support (BLS) and the diagnosis was cerebral palsy and medical neglect. The form was signed by the resident physician at 4:00 p.m. on 4/26/11, approximately four hours after the child had been transferred. There was no evidence that the physician had reviewed the form including the mode of transportation prior to the child's transport.

Review of receiving facility documentation revealed the child arrived at 5:30 p.m. The documentation noted the child was screaming and thrashing about. The child's temperature on 4/26/11, no time, (on the admission nursing history and skin condition form) was 99.7 degrees Farenheit axillary. Review of SNF documentation revealed only a bottle of Cod Liver Oil arrived with the child.

Review of the receiving facility's nursing documentation dated 4/27/11 at 5:40 a.m. revealed the child began to experience respiratory distress. At 5:45 a.m., the child was unresponsive and Cardiopulmonary Resuscitation (CPR) was started. 911 was called, the child was transported to an acute care facility and pronounced expired in the Emergency Room.

Review of the transferring facility documentation and interview with the Pediatric Nurse who cared for the patient on the day of discharge on 9/16/11 at approximately 9:55 a.m. revealed no evidence of the medication being sent with the child or a physician's order to send the medication with the child. The Cod Liver Oil was sent with the child without a physician's order, however, the Neurontin, Tegretol, that were due at 3:00 p.m. and 4:00 p.m. were not sent or addressed by the Registered Nurse or physician. The as needed medications Diastat (for seizures) and Albuterol (for coughing and wheezing)were not sent or addressed by the Registered Nurse or physician.

Review of the ambulance run report, dated 4/26/11, revealed no evidence of planning for seizure precautions and listed the medications as Miralax, Cod Liver Oil, and Neurontin. There was no documentation of planning if the child was thirsty or hungry or the type of diet the child was allowed. There was no documentation of planning for emergency medications of Diastat or Albuterol.

Review of policy and procedure, "Patient Transfers In & Out of TGH" #CC-19 last revised 8/10 revealed on page 11, #9 indicated the physician and Qualified Medical Personnel (QMP)/Transport nurse will determine the appropriate level of transport, personnel and equipment. They will review and sign the Certification and Consent to transfer form. Review of the clinical record showed there was no physician or QMP order for the mode of transportation and the Certification and Consent form was signed approximately four hours after the child left the facility

Interview with the ambulance company's Transportation Coordinator on 9/15/11 at approximately 5:35 p.m. revealed BLS personnel cannot give any oral medications. The interview revealed the service arrived at the transferring facility at 12:08 p.m. on 4/26/11 and at the receiving facility at 5:08 p.m. The interview revealed an envelope was given to the receiving facility from the transferring facility. The crew consisted of the driver and one EMT. The interview revealed the type of transport final decision is with the physician if Advanced Life Support is needed.

Interview with the social worker manager on 9/15/11 at 4:35 p.m. revealed the Certification and Consent to Transfer form shows the physician ' s authorization. He confirmed that there was no order for the type of transportation or the decision regarding the oral seizure medications that were due during transportation in the child's clinical records. He confirmed there was no documentation of the CM discussing the type of transportation with the physician or the interdisciplinary team. He stated there was no policy and procedure on how to determine the type of transportation to be used. He indicated the ambulance company graph is used.

Interview with the Pediatric Nurse Manager on 9/15/11 at approximately 6:00 p.m. and the Risk Manager on 4/26/11 at approximately 3:45 p.m. confirmed there was no physician order for the type of transportation or what was to be done about the seizure medications. The Pediatric Nurse Manager stated there is no policy or procedure for nursing related to transportation or discharge assessment.

Interview with the Registered Nurse (RN) who cared for the child on the day of discharge on 9/16/11 at approximately 9:55 a.m. revealed no recollection of telling the ambulance personnel about the two seizure medications that were due at 3:00 and 4:00 p.m. The RN did not remember if the child had lunch, a snack, or fluids before she was transported. She stated vital signs and a reassessment (to determine if the child was stable and hydrated for the five hour trip) were not done prior to discharge.

Review of the receiving facility's documentation on the admission revealed the child had an axillary temperature of 99.7 degrees and had not had any fluid since midnight, approximately seventeen hours.

Interview with the Risk Manager, Vice President of Pediatrics, Director of Risk Management, and the Pediatric Nurse Manager on 9/16/11 at approximately 10:20 a.m. revealed the clinical record was reviewed by the attending physician and pediatric nurse manager who indicted no concerns were noted with the care provided for discharge planning by the physician or nursing.

Review of the Physician Discharge orders, dated 4/26/11, and the Nurses Discharge Teaching form, dated 4/26/11, showed the child was being transferred to a SNF and was to receive home nursing care from midnight until 7 a.m. This order should have been clarified, as home nursing care is not provided in a SNF setting.

The interviews and review of documentation revealed a safe discharge to meet the needs of a medically complex child was not implemented. The type of transportation was not ordered or acknowledged by the physician or the interdisciplinary team. There was no evidence of the physician being involved in the transportation plan for a child with seizure precautions and medications needs, the child being unable to communicate, and the child not receiving fluid since midnight prior to discharge who was on a fluid minimum. There was no documentation if the child was to have nothing by mouth during transportation or according to the discharge instruction of a pureed diet. There was no planning for the Diastat or Albuterol that was ordered for seizures or wheezing/coughing on a as needed basis or if the medications would be available during transport. There was no clarification with the physician or planning with the receiving facility about two seizure medications that were due during transportation. The Certification and Consent for Transfer was not signed by the physician prior to transfer as per facility policy and procedure. This practice and lack of acknowledgement of concerns for this practice by facility staff placed this child in danger and future patients in danger while being transported.

2. Patient #13 an infant was admitted to the pediatric unit on 08/16/11 with a diagnoses of a metabolic disorder, abnormal blood clotting with deep vein thrombosis and stroke. The infant had a gastrotomy tube feeding tube and seizures. Case Management note, dated 9/14/11, noted the child was transferred to another hospital closer to home on 9/15/11. Physician's order, dated 9/15/11 at 9:00 a.m., included an order to transfer the child to the other hospital. A review of the clinical record revealed there was no Certification and Consent to Transfer present in the record. On 9/16/11 at 6:00 p.m., the Pediatric Nurse Manager reviewed the clinical record and confirmed that the Certification and Consent to Transfer was not present in the medical record. The attending physician was interviewed via telephone on 9/16/11 at 6:35 p.m. She stated she remembered reviewing and signing the form, however, she did not know what happened to the form afterwards.

Based on staff interview and review of clinical records it was determined that the facility failed to ensure the transporting service and the receiving facility was aware of medication needs and the hydration status of a pediatric patient prior to transfer for two (#1, #3) of sixteen records reviewed. This practice may cause adverse effects during transportation.

Findings include:

1. Patient #1 was transferred to a Skilled Nursing Facility (SNF) on 4/26/11 via Basic Life Support services (BLS). Review of the physician orders and the Mediation Administration Record (MAR) from admission to discharge revealed the physician ordered and the patient received Neurontin three times a day 9A-3P-9P and Tegretol at 10A-4P-109P. The child was to receive Diastat for seizure activity and Albuterol for coughing/wheezing on an as needed basis. Review of the ambulance run report, dated 4/26/11, revealed no evidence of planning for seizure precautions and listed the medications as Miralax, Cod Liver Oil, and Neurontin. There was no documentation of planning if the child was thirsty or hungry or the type of diet the child was allowed. There was no documentation of planning for emergency medications of Diastat or Albuterol. There was no documentation of planning for the two seizure medications that were due doing transport.

The Nursing Discharge Medication Teaching Sheet signed by Emergency Medical Technician B had all the child's medication listed. The Tegretol stated the time of the medication was 9A-3P-9P. The Neurontin was listed as every eight hours, however the time due was listed as 9A-3P-9P. There was a line drawn through the entire list and "error" was written and initialed. This made the medication list appear as if the medications had been listed in error to the personnel receiving the instructions.

Interview with the Registered Nurse (RN) who cared for the child on the day of discharge on 9/16/11 at approximately 9:55 a.m., revealed no recollection of telling the ambulance personnel about the two seizure medications that were due at 3:00 and 4:00 p.m. The RN did not remember if the child had lunch, a snack, or fluids before she was transported. She stated vital signs or reassessment (to determine if the child was stable and hydrated for the five hour trip) were not done prior to discharge.

There was no evidence the transportation personnel or the receiving facility had accurate and consistent information related to hydration and medication needs.

2. Patient #3 was admitted to the pediatric unit 4/9/11 and discharged on 4/22/11. Review of the Physician Medication Discharge Order form signed and dated, no time, by the physician indicated three new medications. Review of the Nursing Discharge Medication Teaching Sheet date and time non legible revealed the three new medications. The first medication Prednisolone box that indicated to continue the medication at home or not was not checked. The section to insert the time the next dose was due was blank. The second medication Iron Sulfate box showed the not to continue at home box was circled. The section to insert the time the next dose was due was blank. The third medication Amlodipine box that indicated to continue the medication at home or not was not checked. The section to insert the time the next dose was due was blank. The form was not complete and parts were not eligible which had the potential for the infant to receive the medications at the wrong time or not at all.

Based on review of clinical records, policy, and procedure and staff interviews it was determined that the facility did not reassess a child's transfer needs prior to transfer for one (#1) of sixteen records sampled. This practice may cause potential harm or possible readmittance to the acute care setting.

Findings include:

Patient #1's History and Physical, dated 3/29/11, revealed the child was admitted due to concern for medical neglect. The history included cerebral palsy, significant global developmental delay, and seizure disorder.

Review of physician admission orders, dated 3/29/11 at 9:00 p.m., instructed for a pureed diet with assistance, vital signs every four hours, and seizure precautions. The medications included Neurontin 300 milligrams (mg) three times a day at 9A-3P-9P and Tegretol 220 mg three times a day at the same time. Both of the above medications are anti- seizure medications. Other medications included Diastat per rectum as needed for seizure activity and Albuterol as needed for cough or wheeze.

Physician orders, dated 4/4/11 at 3:00 p.m., instructed to push oral fluids. A Physician order, dated 4/21/11 at 1:45 p.m., called for the patient to be placed on continuous pulse oximetry (oxygen monitoring) at night. Physician orders, dated 4/23/11 at 7:30 a.m., instructed for the patient to receive a minimum of 2000 ml every day-example 400 ml per meal/snack 5 times per day.

Physician orders, dated 4/26/11 at 8:00 a.m., stated for the patient to be transferred to a Skilled Nursing Facility (SNF) with soft pureed diet with assistance, home nursing care daily from midnight to 7:00 a.m., and medications per the medication reconciliation form. Review of the Physician Medication Discharge Order form, signed and dated 4/26/11 at 9:00 a.m., ordered to continue the same medication, which included the Neurontin and Tegretol. Review of the Patient Discharge Teaching form revealed the child was on a pureed diet, fall precautions, and was to receive home nursing care from midnight to 7:00 a.m. The Nursing Discharge Medication Teaching Sheet, signed by the same person, had the medication listed. The Tegretol was due at 9A-3P-9P. The Neurontin was listed as every eight hours, however, the time due was listed as 9A-3P-9P. There was a line drawn through the entire list and "error" was written and initialed. This did not provide clear information regarding medications for the transport personnel.

Review of nursing documentation, dated 4/25/11, revealed the child was not weighed as ordered as the last weight prior to discharge. Nursing documentation, dated 4/28/11, noted the last oral fluid intake was 200 ml documented at midnight. The child already had a deficit of 710 ml over the prior two day period. There was no further documentation of the child receiving fluid hydration prior to transport. Review of nursing documentation, dated 4/26/11, for the 7:00 a.m. to 3:00 p.m. shift revealed the child was fed 75% of her breakfast but no fluid intake was documented. The documentation noted the child had one diaper change prior to transport. Review of vital signs documentation, dated 4/26/11, showed the vital signs were obtained at 8:45 a.m. with a heart rate of 135. Documentation at 12:00 p.m. noted the patient was transferred with no distress with the ambulance transport. Vital signs were not reassessed.

Review of a physician progress note, dated 4/24/11, showed the increased fluid intake was started secondary to low urine output that was improving with the increased fluids. Review of physician orders and physician progress notes from 4/14/11, the day medically cleared to 4/26/11, the date of transfer revealed no evidence of documentation of the type of transportation the child would require for the approximately five hour drive. Review of the physician progress notes revealed a note, dated 4/26/11 at 7:30 a.m., and the attending note was signed at 8:45 a.m.

Review of the Medication Administration Record (MAR) revealed the Neurontin was given at 10:00 a.m. and the Tegretol was given at 9:00 a.m. on 4/26/11, the day of discharge.

Review of a Case Management (CM) note, dated 4/14/11, revealed a plan to transfer the child to a SNF or group home. A CM note, dated 4/15/11, indicated the social work manager was involved as well as outside agencies working on placement. A CM note, dated 4/18/11, revealed the patient was still pending placement. A note, dated 4/20/11, indicated the outside agencies were aware of the difficulty placing the child. A CM note, dated 4/21/11, noted the same information. A CM note, dated 4/22/11, noted the transport at discharge was private vehicle, a SNF that had accepted the patient, and the SNF was in agreement with the child arriving at approximately 3:00 p.m. The documentation noted the consent for transfer was in the chart. A CM note, dated 4/26/11, revealed the child's transportation was private vehicle. There was no documentation of the rationale for the private vehicle. An addendum note stated the transfer was delayed on 4/22/11 due to a legal issue for transporting out of the county for placement. The ambulance company was called on 4/26/11 and told transportation was needed ASAP and would be scheduled for 11:00 a.m. that day. The documentation did not show the rationale for the type of transportation selected to ensure the medically complex 14 year old child's needs could be met.

Review of the ambulance Physician Certification Statement, dated 4/22/11, revealed the child was a fall risk. No other information regarding feedings, medication, or seizure precautions was noted. The form was signed by the case manager.

Review of the Certification and Consent to Transfer form indicated the child would be transferred via Basic Life Support (BLS) and the diagnosis was cerebral palsy and medical neglect. The form was signed by the resident physician at 4:00 p.m. on 4/26/11, approximately four hours after the child had been transferred. There was no evidence that the physician had reviewed the form including the mode of transportation prior to the child's transport.

Interview with the ambulance company's Transportation Coordinator on 9/15/11 at approximately 5:35 p.m. revealed BLS personnel cannot give any oral medications. The interview revealed the service arrived at the transferring facility at 12:08 p.m. on 4/26/11 and at the receiving facility at 5:08 p.m. The interview revealed an envelope was given to the receiving facility from the transferring facility. The crew consisted of the driver and one EMT. The interview revealed the type of transport final decision is with the physician if Advanced Life Support is needed.

Interview with the social worker manager on 9/15/11 at 4:35 p.m. revealed the Certification and Consent to Transfer form showed the physician's authorization. He confirmed that there was no order for the type of transportation or the decision regarding the oral seizure medications that were due during transportation in the child's clinical records. He confirmed there was no documentation of the CM discussing the type of transportation with the physician or the interdisciplinary team. He stated there was no policy and procedure on how to determine the type of transportation to be used. He indicated the ambulance company graph is used.

Interview with the Pediatric Nurse Manager on 9/15/11 at approximately 6:00 p.m. and the Risk Manager on 4/26/11 at approximately 3:45 p.m. confirmed there was no physician order for the type of transportation or what was to be done about the seizure medications. The Pediatric Nurse Manager stated there is no policy or procedure for nursing related to transportation or discharge assessment.

Interview with the Registered Nurse (RN) who cared for the child on the day of discharge on 9/16/11 at approximately 9:55 a.m. revealed no recollection of telling the ambulance personnel about the two seizure medications that were due at 3:00 and 4:00 p.m. The RN did not remember if the child had lunch, a snack, or fluids before she was transported. She stated vital signs and a reassessment (to determine if the child was stable and hydrated for the five hour trip) were not done prior to discharge.

Interview with the child's attending pediatrician on 9/16/11 at approximately 6:35 p.m. revealed she was aware of the BLS transport and had no concerns with the BLS transport. However, there was no documentation to as such. The interview revealed the child would "quickly dehydrate" but when questioned on that statement she stated that can happen when the child has a temperature. When questioned about the length of time it would take the child to dehydrate, she was unable to answer the question with a timeframe. Review of the receiving facility's documentation on the admission revealed the child had an axillary temperature of 99.7 degrees and had not had any fluids since midnight, approximately seventeen hours.

Interview with the Risk Manager, Vice President of Pediatrics, Director of Risk Management, and the Pediatric Nurse Manager on 9/16/11 at approximately 10:20 a.m. revealed the clinical record was reviewed by the attending physician and pediatric nurse manager who indicted no concerns were noted with the care provided for discharge planning by the physician or nursing.

Review of the Physician Discharge orders, dated 4/26/11, and the Nurses Discharge Teaching form, dated 4/26/11, showed the child was being transferred to a SNF and was to receive home nursing care from midnight until 7 a.m. This order should have been clarified, as home nursing care is not provided in SNF setting.

The interviews and record review did not show evidence of the the discharge plan including the transportation plan to be reassessed to ensure the medically complex child's needs for hydration, medications, and emergency medication were addressed and met.