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.
|OSCEOLA REGIONAL MEDICAL CENTER||700 WEST OAK STREET KISSIMMEE, FL 34741||Feb. 7, 2012|
|VIOLATION: ORGANIZATION OF NURSING SERVICES||Tag No: A0386|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure compliance with the delineated responsibilities for patient care, as stated in policy, for 1 of 10 sampled patients who required a full assessment prior to discharge (#1).
A review of the medical record of patient #1 was performed. The patient was admitted on [DATE]. A nurse's note of 12/20/11 at 7:31 AM mentioned the presence of a pressure ulcer on the left buttock which was being treated with Mediplex. A nursing note of 12/24/11 indicated the presence of a pressure ulcer on the right buttock and that a dressing was in use.
A final nursing assessment was performed at 8 AM on 12/28/11. However, this did not include the two pressure sores, as mentioned above. The medical record had not indicated that the pressure sores had resolved by discharge. Thus, the assessment, which was a patient care responsibility, was not complete. The lack of a complete assessment was not in compliance with policy (see below).
A Case Management note of 12/28/11 at 10:33 AM read, "Call received from ... at Consulate (a skilled nursing facility) that bed is available today. Arrangements made for pt to be transported to (room number)." The patient was discharged at 11:48 AM.
A review of facility policy "2011 Plan for Assessment/Reassessment" revealed the following: "Patients in the Medical Surgical Units are reassessed, at a minimum, every 12 hours, with change in patient condition and prior to transfer or discharge."
The preceding was confirmed during an interview of the Quality Manager at approximately 4 PM.