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.

ORLANDO HEALTH 52 W UNDERWOOD ST ORLANDO, FL 32806 Jan. 10, 2011
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to ensure that a registered nurse properly supervised the care of a patient with new, self-inflicted injuries through behavioral unit physician notification, wound site assessment in the behavioral unit, or that any staff in the Emergency Department documented an occurrence of self injury in one of six sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted on [DATE] the the behavioral health unit. A nurse's note on 10/19/10 at 9:22 AM read: "Multiple self-induced bite marks to left hand". In addition, nurse's notes on 10/20/10 at 9 AM read, "Multiple self-induced bite marks on hands and arms." In both cases there was no evidence of physician notification during this time frame regarding the patient's successful attempts to bite himself, as evidenced by the marks.

Further review of the record revealed that the patient went to the Emergency Department (ED) of the facility at 10:22 AM on 10/19/10 for staple removal. An entry at this time by a Mental Health Tech read, "While in ED pt continued to scream intermittently. He bit his rt forearm and broke skin. ED MD looked at arm and ED tech cleaned arm." A nurse's note of 10/19/10 at 11:59 AM, following this report of the incident, read, "Pt was brought back to the unit from the ER at this time. Pt had bit his arm per the tech who went with the pt. Per ... the Dr. down there had looked over the area."

There was no evidence in the medical record in Emergency Department documentation of the incident as described above. Furthermore, there was no evidence of the nurse in the behavioral health unit having assessed the site or informing the physician of the injury as reported by the Mental Health tech.

During an interview of the Nursing Operations Manager on 1/10/11 at approximately 4:30 PM, she confirmed the preceding.