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 SHANDS HOSPITAL 1600 SW ARCHER RD GAINESVILLE, FL 32610 Oct. 3, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the facility failed to ensure enough nursing personnel, during an emergency, to ensure 1 of 10 (#1) patients's right to be cared for in a safe setting. This failure resulted in the Condition of Participation for Patient Rights not to be met.

Findings:Reference A 0144: Based on interview and record review the hospital failed to provide emergency medical care in a safe setting for 1 (#1) of 10 patients reviewed.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview and record review the hospital failed to provide emergency medical care in a safe setting for 1 (#1) of 10 patients reviewed.

Findings:

During record review for Patient #1 it was revealed that the patient was admitted to the hospital's emergency department on 9/16/11 at 10:43 AM. The patient was transported by Emergency Medical Services (EMS) from a skilled nursing facility. EMS reported that the patient was short of breath and had altered mental status. After testing in the emergency department it was discovered that the patient had an elevated troponin level of 18.80 (normal limits = less than 0.10). The physicians determined that she was not a candidate for a cardiac catheterization procedure. The physician's note revealed that the patient was to be admitted to the cardiac unit for a cardiac work-up. Review of the nurse's notes revealed that report was called to the cardiac unit on 9/16/11 at 4 PM. The nurse noted that patient was awaiting transport to the cardiac unit. The last recorded vital signs documented at 4 PM (prior to CPR) were as follows: blood pressure= 66/54, heart rate= 114, oxygen saturation= 91%, respirations= 34 and pulse=121. At 4:59 PM the critical care technician noted that the patient appeared to have difficulty breathing and there was no pulse. The nurse was alerted and cardiac resuscitation began. At 5:17 PM the patient was pronounced dead.

Interview with the Chief Nursing Officer on 10/3/11 at 3:30 PM revealed that on 9/16/11 at 7 PM the staff was questioned concerning the cardiac event involving Patient #1. None of the staff members recalled hearing an asystole alarm. The Emergency Department was busy and the staff were preparing for a trauma patient to arrive. She stated that one nurse was left to monitor the patients in that area of the emergency department. The other nurses were preparing for the trauma patient. On 9/20/11 the hospital's biomedical department preformed testing on the monitor. The results of the testing revealed that there were no monitor malfunctions. On 9/23/11 the company that manufactures the monitor performed testing on the monitor. The testing results revealed that on 9/16/11 at 4:08 PM, Patient #1's monitor alarm sounded for asystole (no cardiac rhythm). At 4:13 PM the monitor asystole alarm was silenced at the central monitor. The report concluded that the monitor was physically silenced at the central station. All staff denied silencing the alarm. She stated that the last patient assessment was completed for Patient #1 at 4 PM. The next assessment was at 4:59 PM when cardiac resuscitation began.

Review of the hospital policy titled, "Patient Assessment and Reassessment # ED-AM-018 (revised December 2009, next review date of December 2011) revealed that documentation of reassessments will be done every 1-2 hours.

Review of staffing for the ED core area on 9/16/11 at 4 PM (that cared for Patient #1) revealed that there were 2 Registered Nurses (RN's) and 1 critical care technicians for 4 patients. The trauma patient arrived at 4:22 PM. A stat nurse arrived at 5 PM to help with the trauma.

Review of the staffing revealed that the patient nurse ratio is 4 patients to 2 nurses. In the event of an emergency (trauma) the department is to call for additional staff.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on record review and interview, the facility failed to have adequate staffing, in the event of an emergency, to provide emergency services to one of ten (#1) patients. This failure resulted in the Condition of Participation under Emergency Services to be not met.

Findings:
Reference A 1112: Based on record review and interview the hospital failed to provide adequately staffing to meet the needs of 1 (#1) of 10 patients reviewed for a change in medical status (no cardiac rhythm for 45 minutes) when there is a trauma patient being admitted to the emergency department.
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
Based on record review and interview the hospital failed to provide adequately staffing to meet the needs of 1 (#1) of 10 patients reviewed for a change in medical status (no cardiac rhythm for 45 minutes) when there is a trauma patient being admitted to the emergency department.

Findings:

During record review for Patient #1 it was revealed that the patient was admitted to the hospital's emergency department on 9/16/11 at 10:43 AM. The patient was transported by Emergency Medical Services (EMS) from a skilled nursing facility. EMS reported that the patient was short of breath and had altered mental status. After testing in the emergency department it was discovered that the patient had an elevated troponin level of 18.80 (normal limits = less than 0.10). The physicians determined that she was not a candidate for a cardiac catheterization procedure. The physician's note revealed that the patient was to be admitted to the cardiac unit for a cardiac work-up. Review of the nurse's notes revealed that report was called to the cardiac unit on 9/16/11 at 4 PM. The nurse noted that patient was awaiting transport to the cardiac unit. The last recorded vital signs documented at 4 PM (prior to CPR) were as follows: blood pressure= 66/54, heart rate= 114, oxygen saturation= 91%, respirations= 34 and pulse=121. At 4:59 PM the critical care technician noted that the patient appeared to have difficulty breathing and there was no pulse. The nurse was alerted and cardiac resuscitation began. At 5:17 PM the patient was pronounced dead.

Interview with the Chief Nursing Officer on 10/3/11 at 3:30 PM revealed that on 9/16/11 at 7 PM the staff was questioned concerning the cardiac event involving Patient #1. None of the staff members recalled hearing an asystole alarm. The Emergency Department was busy and the staff were preparing for a trauma patient to arrive. She stated that one nurse was left to monitor the patients in that area of the emergency department. The other nurses were preparing for the trauma patient. On 9/20/11 the hospital's biomedical department preformed testing on the monitor. The results of the testing revealed that there were no monitor malfunctions. On 9/23/11 the company that manufactures the monitor performed testing on the monitor. The testing results revealed that on 9/16/11 at 4:08 PM, Patient #1's monitor alarm sounded for asystole (no cardiac rhythm). At 4:13 PM the monitor asystole alarm was silenced at the central monitor. The report concluded that the monitor was physically silenced at the central station. All staff denied silencing the alarm. She stated that the last patient assessment was completed for Patient #1 at 4 PM. The next assessment was at 4:59 PM when cardiac resuscitation began.

Review of staffing for the ED core area on 9/16/11 at 4 PM (that cared for Patient #1) revealed that there were 2 Registered Nurses (RN's) and 1 critical care technicians for 4 patients. The trauma patient arrived at 4:22 PM. A stat nurse arrived at 5 PM to help with the trauma, prior to this nurse arrival, there was just one nurse caring for 4 patients while the other nurse attended to the trauma patient.

Review of the staffing revealed that the patient nurse ratio is 4 patients to 2 nurses. In the event of an emergency (trauma) the department is to call for additional staff.