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.

WINTER HAVEN HOSPITAL 200 AVE F NE WINTER HAVEN, FL 33881 Aug. 7, 2013
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on interview, review of facility policy and record review it was determined the facility failed to obtain a physician order for non-violent restraint for 1 (#3) of 4 patients with restraints of 10 sampled patient records.

Findings include:

Patient #3 was observed to be in restraints on 08/07/2013 at approximately 10:21 a.m. A review of the patient's medical record revealed a restraint order received on 08/07/2013 at 9:48 a.m.

A review of the nursing flow sheet revealed documentation beginning at approximately 2:45 p.m. on 08/06/2013 of the restraints. There was no evidence of the original restraint order for 08/06/2013.

An interview with the patient's primary nurse at 10:45 a.m. on 8/7/13 revealed she noticed the patient was in restraints and checked chart for an order, when she found no order she called the physician and obtained an order.

A review of facility policy Restraint-Non Behavioral/Non-Violent (Adult) # CBE 1070 Effective 08/2011 revised 10/2012 page 3 States "a physician order for the initial use of the restraint must be obtained by written, telephone or verbal order as soon as possible after the initiation of the restraint. The order must be timed, and dated by the physician within 24 hours of the initiation of the restraint."

An interview with the director of regulatory compliance confirmed the above findings on 08/07/2013 at 10:40 a.m.