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ADVENTHEALTH ORLANDO 601 E ROLLINS ST ORLANDO, FL 32803 Dec. 13, 2016
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on interview and record review, the facility failed to ensure an accurate history and physical for 1 of 10 sampled patients (#1).

Findings:

Patient #1's medical record revealed the patient had been taken to the emergency room (ER) on 10/28/16 and admitted to the hospital. A nurse's note (NN) of 10/29/16 at 5:28 AM read, "Send wireless page to (physician A) with the updated pt's condition as pt is still tachycardic...." NN of 10/29/16 at 5:53 AM read, "Called to see pt regarding respiratory distress and tachycardia HR (heart rate) 150's. As I arrived in room pt projectile vomited, ? aspiration. Respiratory arrest Code Blue initiated...." NN of 10/229/16 at 5:54 AM read, "Pt (patient) was unresponsive and....covered in vomit, no pulse felt. Called code blue and started CPR (cardio pulmonary resuscitation)."

NN of 10/29/16 at 6:11 AM read, "Called (physician A) and notified that pt was found unresponsive and doing resuscitation." NN of 10/29/16 at 7 AM read, "Pt....intubated with copious amounts of coffee ground emesis, pt on two pressors, BP continuing to drop - (physician B) at bedside to assess, pupils fixed and nonreactive."

"CODE/Critical Care Note FH (Florida Hospital)" of 10/29/16 at 6:48 AM by a physician's assistant read, "Code called at 5:54 AM (see above text). Pt was talking w/staff moments before, then vomited. It appears she aspirated.... Physical Examination....Cardiovascular: currently sinus tach; Gastrointestinal: soft, obese, non-distended....Neurologic: obtunded. Psychiatric: obtunded."

NN at 7:01 AM on 10/29/16 read, "Intubated at 6:20 AM with 8.0 ETT (endo-tracheal tube) secured...." At approximately 7:01 AM, the patient was moved to the Intensive Care Unit (ICU).

An admission History & Physical, performed by physician A on 10/29/16 at 7:43 AM, read, "This is a...years old....with past medical history of autism (and) seizure disorder....brought to the emergency room at Florida Hospital East Orlando because she has fallen at home.... Patient was found to be dehydrated she is tachycardic and given some IV (intravenous) fluids in the emergency room and admitted to the PCU (Progressive Care Unit). In the middle of the night patient was started having some vomiting again and she aspirated and short of breath and cardiopulmonary resuscitation was started and intubated. Patient was transferred to the ICU. Currently on ventilator pressor support was started. Code was done by the ICU team it was difficult intubation and 40 minutes was spent for code....Assessment and Plan....#7 Status post aspiration after vigorous vomiting and coded; #8 Acute hypoxic respiratory failure status post VDRF (ventilation dependent respiratory failure) on vent."

There was nothing in the entry which contradicted prior documentation in the medical record. However, the note continued with documentation for a physical examination which contradicted the findings as indicated by others. It read, "Physical examination.... Cardiovascular: Normal rate, regular rhythm, no murmur.... Neurologic: Alert, oriented, normal sensory, normal sensory, normal motor function, no focal deficits. Psychiatric: Cooperative, appropriate mood & effect."

NN at 8:30 AM on 10/29/16 read, "Pt critically ill and continuing to decompensate despite being maxed out on pressors and ventilator."

On 12/13/16 at 12:10 AM, physician A stated that he was called into the case with the patient's second code. He stated that all of the above mentioned entries indicating a normal physical assessment status had actually been automatically populated by the computer. He stated that due to the nature of events at the time, he did not have time to actually perform an overall assessment. He confirmed that the patient's physical condition, as documented above (showing no problems in the mentioned areas, via computer automatic documentation), did not accurately describe the patient's overall condition. Thus, the entry as signed by physician A as shown above was inaccurate with respect to the patient's physical assessment.

On 12/16/16 at 12 PM, the Risk Manager confirmed the findings.