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.

UF HEALTH LEESBURG HOSPITAL 600 E DIXIE AVE LEESBURG, FL 34748 March 1, 2011
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review and interview the facility failed to provide care as needed to prevent falls for 1 of 6 patients (#5) reviewed.

Findings:

Review of the nurse's notes dated 1/5/11 for patient #5 revealed the patient was assessed as being at high risk falls. According to the patient's record, the interventions of call bell being accessible, 2 side rails, fall precautions, and bed in low position were identified.

The nurse's note dated 1/6/11 at 02:00 AM indicates that patient #5 was confused, getting in and out of bed, pulling at her intravenous lines, and picking. A vest restraint was placed. Further review of the nursing notes dated 1/6/2010 reveal that the patient had a sitter.

Review of staffing records for 1/6/2011 reveal that patient #5 had a sitter from 7:00 AM to 7:00 PM.

During an interview with patient #5's adult child on 3/2/2011 at 4:00 PM revealed that he/she had informed the facility of the patient's confusion and wandering and requested that a vest restraint be used.

Review of the nursing notes indicates that patient #5 had neither a vest restraint nor sitter after 7:00 PM on 1/6/2011.

Review of the nursing notes for patient #5 dated 1/6/2011 reveals that the patient had a fall in her room on 1/6/2011 at 8:25 PM and had a laceration and bruising of her face. Further documentation reveals that the patient was placed in a vest restraint after the fall.

Review of the nurses notes dated 2/2/2011 reveal that patient #5 did not have a vest restraint or sitter on 2/2/2011 at 7:32 PM when the patient was found on the floor with no apparent injury. Notes further indicate that after the patient was found on the floor a vest restraint was placed.

Correction Date: 4/1/2011