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 23, 2011
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to ensure that a patient's family was informed of his health status specific to a fall at the facility prior to discharge for 1 (#1) of 6 records reviewed.

Findings:

Review of Patient #1 skilled nursing facility record revealed that on 12/16/10 at 4:45 PM the patient was admitted to the skilled nursing facility from the hospital. On the nurse's admission assessment it is noted that the patient complained of right hip pain. Review of the skilled nursing facility nurse's notes revealed that on 12/16/10 the nurse received report from the hospital nurse of the fall occurring prior to discharge. On 12/16/10 at 6:20 PM a stat x-ray of the lumbar spine and hip was ordered by the patient's skilled nursing facility physician. On 12/17/10 the results of the x-ray was "probable right femoral neck fracture ." The skilled nursing facility physician ordered "send patient to ER for evaluation and treatment."

Telephone interview with transport driver on 3/22/11 at 3:30 PM confirmed that he transported Patient #1 to the skilled nursing facility on December 16, 2010. He stated he was on the patient's unit at the hospital when he saw 2 staff members assisting the patient back to his room. The patient fell before the staff could get him back to his room. He stated that he was 20 yards away. The patient was assisted back to bed and assessed by the nurse. The patient complained of back pain, but stated he was not injured. He stated that no x-rays were done by the hospital. He stated that the patient was discharged to him to be transported to the skilled nursing facility.

On 3/21/11 at 2:50 PM interview with Patient #1's spouse revealed that the patient had a fall that resulted in a fracture of the patient's hip. The skilled nursing facility told the spouse it happened in the hospital prior to admission to the facility. Patient #1's spouse requested the chart from the hospital, but it did not document any falls. Patient #1's spouse is unsure where the fall took place. According to Patient #1's spouse on 12/16/10 she called the skilled nursing facility after 5 PM to check on him and was told by the nurse that the patient was complaining of hip pain and an x-ray was ordered. The nurse stated that the patient stated he fell at the hospital. The x-ray results revealed a hip fracture.

During facility record review for Patient #1 it was revealed that the patient was admitted to the facility on [DATE] for cardiac medical issues and discharge to a skilled nursing facility on 12/16/10. The patient returned to the facility on [DATE] for a fractured right hip repair. The nursing documentation revealed that the patient is "alert and confused."

Interview with the Risk Manager on 3/23/11 at 1 PM stated that the incident was reviewed and the investigation determined that the nurse did not document that the patient had 2 falls on 12/16/10 which was also the day of his discharge from the facility. The surveyor also noted that there was no documentation that the patient's physician or family was notified of the fall. The Risk Manager obtained a statement from the patient's physician concerning the incident and he stated that the nurse informed him of the 2 falls. After the first fall a "CT" scan of the head was ordered and the results were no injury. The physician stated that he did not order any tests after the second fall because the nurse reported to him that the patient had no complaints of pain. He also stated that he did not examine the patient prior to discharge based on the nurse's assessment. The Risk Manager also stated that the facility's Safety Committee identified in their January 26, 2011 meeting that the nursing staff were not documenting falls and not implementing interventions after a fall. The staff was re-educated on the facility's fall policy and the unit managers are auditing all charts for patients with falls. She also stated that the staff would not notify family of a fall if the patient was alert and oriented.

The facility's "Safety and Fall Prevention Policy" page 3 states "if a fall occurs: assess immediately for injury; attend to immediate needs and treatment; notify physician, charge nurse and family as appropriate; evaluate patient's current medications; and document details of fall."
VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS Tag No: A0406
Based on record review and interview the facility failed to ensure that verbal orders for medications were authenticated by the physician, as per the facility's policy and procedure, for 1 (#1) of 6 records reviewed.

Findings:

During medical record review for Patient #1 it was revealed that on 12/3/10 at 12:12 PM the physician called verbal orders for medications as follows: "aspirin 325 mg [milligrams] once a day, neurotin 300 mg every 8 hours, plavix 75 mg once a day, zantac 150 mg two times a day, lasix 40 mg two times a day, sodium chloride flush 10 ml [milliliter] every shift, insulin sliding scale every 6 hours, propofol 1,00 mg/100 ml IV as directed, dopamine in D5W 800 mg/250 ml IV, morphine 1 mg/0.5 ml every 2 hours as needed, morphine 2 mg/0.5 ml as needed, Tylenol 650 mg elixir every 4 hours as needed and insta-glucose 31 GM as needed."

On 12/9/10 at 2 PM the physician called verbal orders for Patient #1 as follows: "lopressor 25 mg every 12 hours, zestril 5 mg once a day, bumex 1 mg two times a day, aspirin 325 mg once a day, plavix 75 mg once a day, neurotin 300 mg every 8 hours, mag-oxide 400 mg three times a day, k-dur 10 meq two times a day, zantac 150 mg two times a day, sodium chloride flush 10 ml every shift, insulin sliding scale every 6 hours, morphine 1 mg/0.5 ml every 2 hours as needed, morphine 2 mg/0.5 ml as needed, dextrose 50% in water 25 GM/50 ml IV, insta-glucose 31 GM as needed."

Interview with the RM on 3/23/11 at 4:45 PM confirmed that the verbal orders were not signed by the physician.

The policy provided by the facility titled, "Physician Orders-Phone/Verbal/Written" states that physician orders may be received verbally, by telephone or written by any licensed professional including nurses, registered dieticians, medical social workers and pharmacists. The policy also states that "a physician must sign, date and time these orders within 48 hours."