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 Nov. 9, 2012
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interview and record review the hospital failed to ensure that the plan of care was updated for 1 (#1) of 10 patients sampled to include patient complaints of constipation. The hospital failed to ensure peg tube feedings/supplements were documented/kept current as ordered for 1 (#1) of 10 patients sampled.

Findings:

Interview with Patient #1 on 11/9/12 at 11 AM revealed that he has been in the hospital since 10/16/12. He stated that the nurses were not assisting him with bowel movements. He stated that due to his diagnosis of Multiple Sclerosis he sometimes needs assistance with bowel movements. He stated that he is not able to use his hands.

Review of physician's orders revealed the following:

10/17/12 at 10 AM Dilaudid 2 mg IVP every 4 hours as needed.
10/18/12 at 8:14 PM chocolate Boost 8 oz. by mouth every 8 hrs. If tolerated.
10/20/12 at 1:30 PM change boost to 8 oz by mouth every 6 hours.
10/24/12 at 8:15 PM Dilaudid 1 mg IV every 4 hours as needed for pain when patient is NPO (nothing by mouth).
10/28/12 at 6 PM docusate sodium (Colace) 100 mg by mouth as needed at bedtime for constipation.
10/30/12 at 11:14 AM discontinue oxycodone, change Percocet 2 tablets by mouth 5/325 mg by mouth every 4 hours as needed.
10/31/12 at 1:49 AM increase Percocet 10/325 mg 1-2 tablets by mouth every 4 hours as needed for pain, increase Dilaudid 1 mg IV every 2 hours as needed for breakthrough pain.
10/31/12 at 3:15 PM D/C plan on Saturday if possible.
10/31/12 at 3:35 PM the dietitian ordered "if patient consumes less than 50% of entree then bolus with 1 can of Two cal. HN 2 hours after meal, provide bolus of 1 can Two cal HN at night and follow with 200 ml of water."
11/2/12 3:15 PM adjust G-tube feeding per "nutritician" (dietitian) guide for now one can every 6 hours.

Review of nursing notes from 10/16/12 to 10/28/12 it is documented that the patient reported that he had not had a bowel movement since the day before his admission (10/15/12). It is also noted that there were no bowel movements documented from 10/31/12 to 11/4/12. There is no documentation that the physician was notified or if any additional orders were requested. It is noted that the patient is on scheduled pain medication that can cause constipation.

Review of the timeline of meal consumption and peg tube feeding from 10/31/12 to 11/9/12 revealed the following:

On 10/31/12 there was no documentation of meal consumption for the dinner meal or the evening peg tube bolus.
On 11/1/12 at 10 AM it is documented that Patient #1 consumed 100% of his meal.
On 11/1/12 at 12 noon it is documented that Patient #1 refused his meal. There is no documentation of the dinner meal. There is no documentation of peg tube supplementation for the lunch, dinner meals or the night time supplement.
On 11/2/12 at 10 AM it is documented that the patient is NPO (nothing by mouth).
On 11/2/12 at 9 PM it is documented that 200 ml of water was given by peg tube with tube feeding.
On 11/3/12 at 8 AM it is documented that 50 ml of water was used to irrigate the peg tube,
On 11/3/12 at 11:06 AM it is documented that 75 ml of Two cal HN was given with 50 ml of residual noted.
On 11/3/12 at 10:25 PM it is documented that Patient #1 refused the 2 cal but requested apple juice to be used instead.
On 11/4/12 at 6 PM it is documented that Patient #1 had ice cream. There are no other meal consumption amounts documented for that day. There is no documentation of the bolus feedings for all three meals and night time supplement.
On 11/5/12 at 6 AM, 8 AM and 12:30 PM it is documented that Patient #1 received bolus feedings. No specific amount of the feeding was documented.
On 11/6/12 there is no documentation of meal consumption amounts or bolus feedings.
On 11/7/12 at 6 AM it is documented that there was a 60 ml residual and the peg tube was irrigated with 50 ml of water. There is no other documentation concerning meal consumption percentages or peg tube supplementation.
On 11/8/12 at 5:21 PM it documented that Patient #1 received bolus irrigation per peg tube of 200 ml of water. There is no other documentation of meal percentages or peg tube supplementation.

Interview with the charge nurse on 11/9/12 at 9 AM she confirmed the missing documentation for Patient #1 regarding no documentation for bowel movements from 10/16/12 to 10/28/12 and 10/31/12 to 11/4/12. She also confirmed that there was missing documentation for supplements and peg tube feedings.

Review of the facility policy titled "Daily patient assessment, intervention and reassessment" effective 9/21/11 page 2 revealed that the gastrointestinal assessment may include bowel sounds, stool continence/incontinence and GI complaints. A more extensive assessment is to be done as warranted for each patient condition including tube feeding."