The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LAKE CITY MEDICAL CENTER SUWANNEE CAMPUS 1100 SW 11TH ST LIVE OAK, FL 32060 Dec. 12, 2011
VIOLATION: PROVISION OF SERVICES Tag No: C1004
Based on observation, record review and interview, the facility failed to care plan for patients' needs and provide care and services for 7 (#1, #2, #3, #4, #5, #8, and #9) of 10 sampled patients reviewed. This resulted in the Condition of Participation for Provision of Services not to be met.

Findings:

Reference C 0294: Based on record review, observation, and interview revealed that the hospital failed to ensure nursing care and services were completed for 5 of 10 (#1, #3, #5, #8, and #9) patient records sampled.

Reference C 0298: Based on observation, interview and record review, the hospital failed to ensure current, complete and accurate care plans were written for 5 of 10 (#2, #3, #4, #5 and #9) patient records sampled.
VIOLATION: NURSING SERVICES Tag No: C1046
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observation, and interviewthe hospital failed to ensure nursing care and services were completed for 5 of 10 (#1, #3, #5, #8, and #9) patient records sampled.

Findings:

1. . Review of the medical record for patient #1 revealed the patient was admitted on [DATE] with a diagnosis of facial cellulitis from an insect bite. Record review of the Patient Care Flow Sheet for patient #1 revealed that the Certified Nursing Assistant (CNA) failed to document and initial Patient Care Assistant (PCA) rounds for repositioning, ambulatory and fluid intake and output on 12/09/2011, from 7:00 PM to 7:00 AM.

2. Review of the medical record for patient #3 revealed the patient was admitted on [DATE] with a complaint of abdominal pain, and admitted with diagnosis of acute enteritis.
A review of the care plan for patient #3 revealed a diagnosis of acute gastroenteritis and abdominal pain. The co-morbidities included hypertension and obesity. The areas of Safety and Functional mobility/Activity level on the care plan were not addressed. Review of the medical record for patient #3 revealed the patient was admitted on [DATE] with a complaint of abdominal pain, and admitted with diagnosis of acute enteritis. Record review of the Patient Care Flow Sheet for patient #3 revealed that the CNA failed to document and initial PCA rounds for repositioning, and ambulation on 12/10/2011, from 7:00 PM to 7:00 AM

3. On 12/12/2011 at 9:10 AM the Chief Nursing Officer took the surveyors to patient # 5's room where an observation was made of 4 side rails in the up position and a yellow sign posted for Fall Risk at the door.

On 12/12/2011 at 9:15 AM an interview was conducted with the RN assigned to the patient. She stated the functional mobility/activity level on the care plan should have been addressed. She also stated she did not know why the 4 side rails were up, the CNA on nights left them up. The bed alarm was on.

During an interview at 9:20 AM an interview with the CNA #3, she stated patient # 5 was heavy and sticks his legs over the side of the bed. She stated she would rather be caught with the 4 side rails up than to let him fall. She further stated the patient was very combative.

Interview on 12/12/2011 at 2:15 PM with the Staff Education Coordinator revealed that all staff members are trained annually in a Hospital Education Continuing Education titled Safety Storm: Gamma 2011, which includes training in use of restraints. During this interview with the Staffing Coordinator she stated, "I am aware that many employees are deficient in their training titled Safety Storm: Gamma 2011, which includes training in restraints." She further stated that she has e-mailed staff, posted notification of the training, verbally and e-mailed department heads, and told the Chief Nursing Officer (CNO) that these staff members are deficient in their training and they still have not completed it.

An observation made at 4:40 PM on 12/12/2011 revealed the call light for the patient was draped over the side rail and hanging down towards the floor. The side rails were up.

On 12/12/2011 at 4:45 PM an interview was conducted with the RN taking care of patient # 5. She stated the nurse ' s call light on the patient ' s beds, don't always work, so she gives the patient the hand held call light button. She stated the patient does not understand and is combative.

Review of the facility's Fall Prevention Protocol revealed the following;
Policy Statements:
1. All patients are assessed on admission and each shift thereafter, for risk factors associated with falls
2. For patients assessed to be at moderate to high risk, specific measures (fall precautions) will be initiated to decrease the patients ' risk.
CONTENT STATEMENTS: N OTE: All 4 side rails in the up position can cause more injury to the patient trying to get out of bed.

Review of the medical record for patient #5 revealed the patient was admitted from a Skilled Nursing Facility (SNF) on 12/09/2011 with a diagnosis of chest pain and admitted for evaluation on Telemetry on the Medical Surgical unit. Review of the physician orders revealed a physician order for patient #5 to receive Pepcid 20 mg Intravenous (IV) every 12 hours. Review of the Patient Care Flow Sheet revealed that the registered nurse who was providing care and services to patient #5 failed to document on 12/10/2011 during the day shift 7:00 AM, to 7:00 PM, and 7:00 PM till 7:00 AM observation and care to patient #5 ' s IV site. Also the CNA failed to document and initial PCA rounds for repositioning, and ambulation on 12/10/2011, from 7:00 PM to 7:00 AM.
Review of the Patient Care Flow Sheet revealed that the registered nurse providing care and services to patient #5 failed to document on 12/11/2011 during the day shift 8:00 AM, to 9:00 AM, and 11:00 AM till 7:00 PM observation and care to patient #5 IV site. Also on 12/11/2011 the registered nurse failed to document on during the evening shift 7:00 PM till 8:00 PM observation and care to patient #5 IV site. Further review of the nurse ' s notes on 12/11/2011 at 11:30 PM revealed that patient #5's IV site had infiltrated and had to be restarted.
Record review of the Patient Care Flow Sheet for patient #5 revealed that CNA failed to document and initial PCA rounds for repositioning, and ambulation on 12/11/2011, from 7:00 PM to 7:00 AM.


4. Medical record review for patient #8 revealed that she presented to the Emergency Department (ED) on 08/22/2011 at 4:48 PM, and admitted on [DATE] at 8:55 PM, with an admitting diagnosis of altered mental status and possible sepsis with multiple other co-morbidities.
Review of the care plan for patient #8 indicated the care plan initiated by the night shift nurse. Education, pain, cardiovascular were identified and addressed, but falls was not identified on the care plan under Safety or Functional mobility/Activity level. On the Morse Fall Scale he was identified as a 85 which indicates high risk for fall, and indicates the action to be taken as Implement fall prevention interventions. Fall precautions were in place, although they were not followed. Patient #8's nurse documented that she made rounds on 08/23/2011 during the evening shift of 7:00 PM to 7:00 AM, but the events that occurred and review of the documentation, revealed that this rounding was not done. Review of the nurse's notes documented on 08/23/2011 at 9:15 AM revealed that all four side rails were up and bed alarm was in place. Four side rails in their up position is considered a restraint and according to the facility policy titled "Fall Precautions" states that if "all 4 side rails in the up position can cause more injury to the patient trying to get out of bed."
Record review revealed that on 08/23/2011 at 8:45 PM a patient notified nursing staff that patient #8 was lying on the floor. Review of the nurse's notes on 08/23/2011 at 8:45 PM revealed that patient #8 was found on the floor exiting the bathroom. Patient #8 was crying, complaining of pain to her right shoulder and her right hip, and apologizing for getting out of bed. Per the nurse's notes, the physician was not notified of the fall until 45 minutes later at 9:30 PM, and orders were received for X-ray. She did not document at any time that patient #8 needed to go to the bathroom or that toileting was offered. When patient #8 got out of bed to use the bathroom on 08/23/2011 at 8:45 PM, she fell . And patient #8's nurse did not chart that she went back into patient #8's room to reassess her pain after medicating her on 08/23/2011 at 9:45 PM. Continued review of the nurse's notes revealed that at 11:00 PM X-Rays were completed and patient #8 was medicated for pain. Review of the Medication Administration Record (MAR) revealed and confirmed that Morphine 1 mg was signed out and administered at 9:45 PM. The nurse had documented in her nurse's notes that she administered this pain medication at 11:00 PM. There was not an assessment of pain documented in the nurse's notes for patient #8 from the time of the fall with injury on 08/23/2011 at 8:45 PM until 08/24/2011 at 3:00 AM, when she charted only that this patient had no signs and symptoms of pain. There was not any documentation of staff instituting further safety precautions for her. Further documentation in the nurse's notes on 08/24/2011 at 3:00 AM revealed a notation that a large hematoma was noted to patient #8's right forehead, but did not note that the physician was notified of this finding, nor did the nurse document monitoring of patient #8's neurological
Further record review of the Patient Care Flow Sheet for patient #8 revealed that CNA#1 (AT) failed to document and initial PCA rounds for repositioning, ambulatory and fluid intake and output on 08/23/2011, from 7:00 PM to 7:00 AM.

Interview on 12/12/2011 at 11:00 AM with the Director of Resource Management/Risk revealed that the facility has cameras ' in the hallways of the Medical Surgical unit, which has a good clear view of the hallway that lead to the room of patient #8. The facility determined after reviewing the film from the camera from 08/23/2011 to 08/24/2011, that the registered nurse (SP) was assigned for the care and services for patient #8; that this nurse had not made her rounds for this time frame, which she documented as doing so. She documented that she had been in patient #8 ' s room 7:45 PM to 8:00 PM and offered to assist the patient to the bathroom. Review of the film from the hallway cameras revealed that she had not. Registered Nurse (SP) visit to patient #8 ' s room on 08/24/2011 was at 12:46 AM, and did not go into patient #8 ' s room for approximately 5 ? hours, but documented that she did. She had stated to the Director of Resource /Risk Management that she was going on what other staff members had told her, signed off that she had gone into patient #8 ' s room every hour, and according to cameras viewing that hallway, she had not. Registered Nurse (SP) had documented that she had assessed patient #8 on 08/24/2011, but she had actually had not gone into her room. The nurse (SP) wrote that patient #8 ' s health was declining at 3:00 AM, but the hospital video showed that she did not go in to further assess patient #8.

Interview on 12/12/2011 at 2:00 PM with Certified Nursing Assistant #1 (CNA) that was working on the night shift on 08/23/2011 with the Registered Nurse (SP). CNA#1 was asked if she observed Registered Nurse (SP) making rounds on patient #8, she state "No sir". Continued interview on 12/12/2011 at 2:00 PM with CNA#1 (AT) revealed she stated "when I was trained, I wasn't told that I was to document that I repositioned the patient. And I was told just to tell the nurse of all my findings and what I've done. This is the first time I've been told that I need to document on the rounds charting for turning and repositioning. I did not document the evening from 7:00 PM to 7:00 AM on 08/23/2011 for patient #8. And I did not observe her fall or find her after her fall."

Interview on 12/12/2011 at 3:00 PM with CNA#2 that was working on the night shift on 08/23/2011 with the Registered Nurse (SP). CNA#2 was asked about documenting Patient Care Flow Sheet, she stated "it was my first night working in this facility, and I was being trained by CNA #1, and I was not instructed that it was my duty to document these findings.

6. A review of the medical record for patient #9 revealed an admission date of [DATE] with blood pressure problems and admission diagnosis of cardiac dysrhythmia, dehydration and dizziness. The nurse's notes stated the patient received a fall on 11/01/2011. The care plan did not address the Safety and Functional Mobility/Activity level. Record review of the Patient Care Flow Sheet for patient #9 revealed that Certified Nursing Assistant (CNA) failed to document and initial PCA rounds for repositioning and ambulatory on 10/29/2011, from 10:00 PM to 7:00 AM.
VIOLATION: NURSING SERVICES Tag No: C1050
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the hospital failed to ensure current, complete and accurate care plans were written for 5 of 10 (#2, #3, #4, #5 and #9) patient records sampled.

FINDINGS:

On 12/12/2011 at 8:45 AM yellow signs were observed at the doorways to patient #2, #3, #4 and #5 identifying them as a Fall Risk.

1. On 12/12/2011 at 8:50 AM an interview with the Registered Nurse assigned to patients #2, #3, and #4 was conducted. She stated a Fall Risk sign posted outside of the rooms means the patient was identified as a fall risk or had a history of falls. She further stated the nursing flow sheet would show the patient was identified as a fall risk. If falls are triggered, safety and functional mobility are care planned, and a yellow bracelet is put on the patient to identify them as a fall risk.

2. A review of the medical records for patient #2 revealed the patient was admitted on [DATE] with a diagnosis of chest pain and a chief complaint of difficulty breathing. The review of the care plan for patient #2 indicated the assessment was completed and care plan initiated by the night shift nurse. Education, pain, cardiovascular were identified and addressed, but falls was not identified on the care plan under Safety or Functional mobility/Activity level. On the Morse Fall Scale he was identified as a 45 which indicates low risk for fall, and indicates the action to be taken as Implement standard fall prevention interventions.

At 1:22 PM on 12/12/2011 an interview with the physician revealed patient #2 was a fall risk.

3. On 12/12/2011 at 8:50 AM an interview with the RN assigned to patient # 3 revealed the patient was admitted on [DATE] and identified as a fall risk with a yellow Fall Risk sign outside the door. She acknowledged the care plan did not address the patient as a fall risk.

A review of the care plan for patient #3 revealed a diagnosis of acute gastroenteritis and abdominal pain. The co-morbidities included hypertension and obesity. The areas of Safety and Functional mobility/Activity level on the care plan were not addressed.

4. On 12/12/2011 at 8:45 AM an observation was made of the yellow Fall Risk sign posted at the door to patient # 4's room.

The review of the medical record revealed patient # 4 was admitted with a chief complaint of high blood sugar. The admitting diagnosis on 12/11/2011 was uncontrolled diabetes mellitus and cellulitis of the face. The care plan listed diabetes and obesity as co-morbidities. The areas of Safety and Functional Mobility/Activity Level were not addressed on the care plan.

5. On 12/12/2011 at 9:10 AM the Chief Nursing Officer took the surveyors to patient # 5's room where an observation was made of 4 side rails in the up position and a yellow sign posted for Fall Risk at the door.

On 12/12/2011 at 9:15 AM an interview was conducted with the RN assigned to the patient. She stated the functional mobility/activity level on the care plan should have been addressed. She also stated she did not know why the 4 side rails were up, the CNA on nights left them up. The bed alarm was on.

During an interview at 9:20 AM an interview with the CNA #3, she stated patient # 5 was heavy and sticks his legs over the side of the bed. She stated she would rather be caught with the 4 side rails up than to let him fall. She further stated the patient was very combative.

Interview on 12/12/2011 at 2:15 PM with the Staff Education Coordinator revealed that all staff members are trained annually in a Hospital Education Continuing Education titled Safety Storm: Gamma 2011, which includes training in use of restraints. During this interview with the Staffing Coordinator she stated, "I am aware that many employees are deficient in their training titled Safety Storm: Gamma 2011, which includes training in restraints." She further stated that she has e-mailed staff, posted notification of the training, verbally and e-mailed department heads, and told the Chief Nursing Officer (CNO) that these staff members are deficient in their training and they still have not completed it.

An observation made at 4:40 PM on 12/12/2011 revealed the call light for the patient was draped over the side rail and hanging down towards the floor. The side rails were up.

On 12/12/2011 at 4:45 PM an interview was conducted with the RN taking care of patient # 5. She stated the nurse ' s call light on the patient ' s beds, don't always work, so she gives the patient the hand held call light button. She stated the patient does not understand and is combative.

Review of the facility's Fall Prevention Protocol revealed the following;
Policy Statements:
1. All patients are assessed on admission and each shift thereafter, for risk factors associated with falls
2. For patients assessed to be at moderate to high risk, specific measures (fall precautions) will be initiated to decrease the patients ' risk.
CONTENT STATEMENTS: N OTE: All 4 side rails in the up position can cause more injury to the patient trying to get out of bed.

6. A review of the medical record for patient #9 revealed an admission date of [DATE] with blood pressure problems and admission diagnosis of cardiac dysrhythmia, dehydration and dizziness. The nurse's notes stated the patient received a fall on 11/01/2011. The care plan did not address the Safety and Functional Mobility/Activity level.
VIOLATION: FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION Tag No: C1612
Based on observation, record review, and interview for 1 of 10 patients (#5), the hospital failed to ensure that the patient was free from restraints. Failure to free patients from restraints may cause physical and psychological harm.

Findings:

On 12/12/2011 at 9:10 AM the Chief Nursing Officer took the surveyors to patient # 5's room where an observation was made of 4 side rails in the up position and a yellow sign posted for Fall Risk at the door.

On 12/12/2011 at 9:15 AM an interview was conducted with the RN assigned to the patient. She stated the functional mobility/activity level on the care plan should have been addressed. She also stated she did not know why the 4 side rails were up, the CNA on nights left them up. The bed alarm was on.

During an interview at 9:20 AM an interview with the CNA #3, she stated patient # 5 was heavy and sticks his legs over the side of the bed. She stated she would rather be caught with the 4 side rails up than to let him fall. She further stated the patient was very combative.

Interview on 12/12/2011 at 2:15 PM with the Staff Education Coordinator revealed that all staff members are trained annually in a Hospital Education Continuing Education titled Safety Storm: Gamma 2011, which includes training in use of restraints. During this interview with the Staffing Coordinator she stated, "I am aware that many employees are deficient in their training titled Safety Storm: Gamma 2011, which includes training in restraints." She further stated that she has e-mailed staff, posted notification of the training, verbally and e-mailed department heads, and told the Chief Nursing Officer (CNO) that these staff members are deficient in their training and they still have not completed it.

An observation made at 4:40 PM on 12/12/2011 revealed the call light for the patient was draped over the side rail and hanging down towards the floor. The side rails were up.

On 12/12/2011 at 4:45 PM an interview was conducted with the RN taking care of patient # 5. She stated the nurse ' s call light on the patient ' s beds, don't always work, so she gives the patient the hand held call light button. She stated the patient does not understand and is combative.

Review of the facility's Fall Prevention Protocol revealed the following;
Policy Statements:
1. All patients are assessed on admission and each shift thereafter, for risk factors associated with falls
2. For patients assessed to be at moderate to high risk, specific measures (fall precautions) will be initiated to decrease the patients ' risk.
CONTENT STATEMENTS: N OTE: All 4 side rails in the up position can cause more injury to the patient trying to get out of bed.

After record review and review of the facility's Policy and Procedures it was determined that the facility did not assess or have a physician's order for restraint use, and therefore continued to provide four (4) side rails up for patient #5.