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.

LEHIGH REGIONAL MEDICAL CENTER 1500 LEE BLVD LEHIGH ACRES, FL 33936 May 9, 2011
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
Based on interview and record review the facility failed to provide appropriate discharge planning / instructions in 2 (Patients #1 and #3) of 5 patient discharged records reviewed.

The findings included:

Record review on 5/9/11 at 2:00 p.m. of Patient #1's medical record revealed physician orders dated 4/15/11 at 1410 (2:10 p.m.) ordering BMP in a.m. Further review revealed this order was not transcribed on the 3008 (transfer H&P to a Skilled Nursing Facility) used for discharge planning purposes. The 3008 allows the receiving facility to obtain information and/or orders regarding the patient. The receiving facility was unable to meet the needs of the patient due to this lack of information.

On 5/9/11 at 2:00 p.m., the Chief Nursing Officer (CNO) was interviewed and stated, "yes, I see where the BMP was ordered and no it is not on the 3008."

Record review on 5/9/11 at 2:00 p.m., of Patient #3's medical record revealed a physician order on 3/2/11 at 1630 (4:30 p.m.) ordering: ok to dc (discharge) to L H&R (Lehigh Health & Rehab). If patient does not void overnight bladder scan and place Foley. Patient #3's 3008 form used for discharge instructions was reviewed and revealed this order was not included and the portion of the form addressing bladder / urinary issues was left blank.

On 5/9/11 at 2:00 p.m., the CNO was interviewed and stated, "I see where the physician ordered "ok to dc to L H&R if pt. does not void overnight bladder scan and place Foley and no it is not on the 3008."

On the 3008 there is a section for 'new orders.' This section for Patients #1 and #3 were left blank. Again, the receiving facility was unable to meet the needs of the patient due to the lack of this information.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on interview and record review the facility failed to provide appropriate discharge planning / instructions in 2 (Patients #1 and #3) of 5 patient discharged records reviewed.

The findings included:

Record review on 5/9/11 at 2:00 p.m., of Patient #1's medical record revealed physician orders dated 4/15/11 at 1410 (2:10 p.m.) ordering BMP in a.m. Further review revealed this order was not transcribed on the 3008 (transfer H&P to a Skilled Nursing Facility) used for discharge planning purposes. The 3008 allows the receiving facility to obtain information and/or orders regarding the patient. The receiving facility was unable to meet the needs of the patient due to this lack of information.

On 5/9/11 at 2:00 p.m., the Chief Nursing Officer (CNO) was interviewed and stated, "yes, I see where the BMP was ordered and no it is not on the 3008."

Record review on 5/9/11 at 2:00 p.m., of Patient #3's medical record revealed a physician order on 3/2/11 at 1630 (4:30 p.m.) ordering: ok to dc (discharge) to L H&R (Lehigh Health & Rehab). If patient does not void overnight bladder scan and place Foley. Patient #3's 3008 form used for discharge instructions was reviewed and revealed this order was not included and the portion of the form addressing bladder/urinary issues was left blank.

On 5/9/11 at 2:00 p.m., the CNO was interviewed and stated, "I see where the physician ordered "ok to dc to L H&R if pt. does not void overnight bladder scan and place Foley and no it is not on the 3008."

On the 3008 there is a section for 'new orders.' This section for Patients #1 and #3 were left blank.

The clinical records failed to contain evidence of communications to the Skilled Nursing Facilities for these new physician orders prior to transfer.