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 Nov. 21, 2012
VIOLATION: SCOPE OF RADIOLOGIC SERVICES Tag No: A0529
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record reviews, the facility failed to ensure radiology services were available to meet the needs of 1 of 10 patients.( patient # 11)

Findings:

A review of the medical record revealed patient #11 was admitted on [DATE] after a high speed motor vehicle collision. Diagnosis included left frontal intraparenchymal hemorrhage, scalp avulsion, bilateral carotid dissection, left clavicle fracture, left pneumothorax with recurrence left 3rd finger traumatic amputation, C3-C7 right articular pillar fracture, C6-7 vertebral body fracture.

The records also revealed Patient # 11 developed a thoracic epidural abscess with resulting urinary incontinence and decreased motor functions in the bilateral lower extremities. By the date of discharge the patient was still unable to ambulate and a Foley catheter was in place for incontinence.

On 10/20/2012 at 0947 the Resident noted: Patient walking laps in unit with encouragement
On 10/20/2012 at 1900 the patient reported a sudden onset of lower extremity weakness. Also at about 8 PM patient had a tingling/weakness in bilateral lower extremities.

On 10/21/2012 at 0230 the nursing note revealed the patient was unable to void. Bladder scan showed 941 ml, in and out cath done pulled out 950 ml urine, the patient was also complaining of numbness and weakness on both lower extremities.

On 10/21/2012 at 0300 the trauma team assessed the patient. Examination showed sensation intact diffusely. Sensation: able to distinguish soft from sharp all diffusely. Motor function is diminished in the lower extremities. Unable to flex/extend lower extremities, trouble wiggling toes and unable to dorsiflexion/ plantar flexion. Deep tendon reflexes appear increased. Will continue to monitor the patient, and discussed the case with the trauma team. Neurosurgery called for input, MRI ordered.

On 10/21/2012 at 0329 neurosurgery called with the MRI order.

On 10/21 at 0725 the nursing note: patient to MRI, became anxious, unable to tolerate. Returned to floor.

On 10/21 at 0854 the nursing note: Patient back to MRI with anxiolytic (Ativan 2 mg IV).
On 10/21 at 0956 the nursing notes: We have attempted to have radiology call the MRI tech multiple times overnight without results.

10/21 at 1124 time noted on MRI sheet as doing the MRI. At 1305 the Radiology report stated " Epidural hematoma extending from the level of T3 to T9 with obliteration of the surrounding CSF space. There is no abnormal cord signal. Results called to trauma.

On 10/21 at 1803 the patient went to the operating room for laminectomy.

On 10/21/2012 an interview with the neurosurgeon revealed the patient had a large thoracic abscess due to the epidural catheter. She wanted an urgent MRI but the patient did not have it done because of the difficulty with getting an MRI tech. She stated any compressions needs to be relieved as soon as possible. She instructed the resident to contact an MRI tech. She tried to get the MRI early in the morning but was told the MRI tech had left the hospital.

On 11/20/2012 an interview at 10:00 AM with the Technical Director, Radiology and the Administrative Director Radiology revealed:
MRI ' s were available 6 AM to midnight on Saturday and Sunday. An MRI tech is on call from 12AM until 6 AM. On Monday through Friday, an MRI tech is available 24 hours a day. The technical director stated the MRI tech left on 10/21 at 4:28 AM, and there were no pending orders at that time. The MRI order came in at 4:32 AM. An MRI tech came in at 6 AM.

On 11/20/2012 an interview at 11:20 AM with the Radiology resident revealed the MRI tech receives the order, prepares protocol sheet then presents the information to radiology. The Radiologist reviews what has been ordered after receiving the fax from the tech. He stated there is no radiology tech at night on the weekend for MRI ' s. The ordering clinician knows to call the radiologist about the order on weekends. No one would fax at that time of day. Saturday and Sunday nights. The Radiologist calls the MRI tech (who is on call) in to do the MRI study.

The resident further stated he was called by neurosurgery about patient #11 needing an urgent MRI. He stated he was unable to contact the MRI tech. He paged him twice. The tech did not call back. The first page was about 5 AM, then 10 minutes later. When the MRI tech came in at 6:00 AM the resident called the techs and told them the study was urgent and needed to be done immediately.

An interview on 10/20/2012 at 10:35 AM the MRI technician revealed he called the radiologist before he left and notified him he had completed a procedure on another patient.

Continued interview with the MRI tech revealed MRI is open 24 hours a day Monday-Friday. On Saturday and Sunday there is no MRI tech working from 12 midnight until 6 AM. The pager numbers are posted in radiology reading room. The home/personal number is called if there is no response to a page.

He said he was on call the night of 10/20/12 until 6 AM on 10/21/2012 but he did not receive a page or phone call for a STAT MRI. He then checked the log-in book for patients done, and stated he finished the last patient at 4:05 AM and called radiologist and told him the images were there. The radiologist said there were no more pending MRI ' s. He then clocked out. He stated he did not get a page or call after he clocked out.
VIOLATION: ADEQUATE RESPIRATORY CARE STAFFING Tag No: A1154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to ensure adequate respiratory staff to administer respiratory treatments prescribed for 3 of 10 patients (#3, #4, #7).

Findings:
Resident # 3 was admitted on [DATE] with diagnosis of slurred speech, TIA, Hypertension
Review of patient # 3 physicians ' order sheets (POS) dated 11/17/2012 revealed the following orders:
1. Pulse Oximetry, Oxygen 2 liters/min.
2. Duoneb every 4 hours scheduled.

Medication administration report of patient # 3 revealed:
1. On 11/18/2012 Duoneb administered at 16:24. Midnight dose was not given; reason indicated is " workload " .
2. On 11/19/2012 Duoneb administered at 0425 then again at 10:00, 2 hours late as ordered. Not given 2000- " workload "
3. On 11/20/2012 Duoneb not administered at 0115 AM and 0400 for the same reason " workload " .

Patient # 4 was admitted on [DATE] at midnight with diagnosis of chest pain, cough, and shortness of breath.
Record review of patient # 4 physician order sheets (POS) revealed the following orders dated 11/18/2012:
1. Combivent inhaler 2 puffs inhalation every 6 hours PRN for wheezing.
2. Duoneb ordered on [DATE] 0.5-2.5 3 ml nebulizer every 4 hours scheduled. - discontinued on 11/20/2012
3. Duoneb ordered on [DATE] - 0.5-2.5 3 ml every 6 hours scheduled.

Review of medication administration report (MAR) for patient # 4 revealed the following;
1. Duoneb was administered on 11/18/2012 at 0900
2. Duoneb was administered on 11/19/2012 at 0822, 1221, 1645, 2215 (2 hours late) then given at 0100.
3. Duoneb not given on 11/20/2012 at 0800, patient not in room- meds discontinued at 1100
4. Duoneb was administered on 11/20/2012 at 1358, 2008 - 3 hours late. Not given at 0200- no explanation
5. Duoneb was administered on 11/21/2012 at 0844 ( 2 hours late)
6. Duoneb not given at 0200 0n 11/21/2012 as ordered.
7. MAR shows 2 different orders for Duoneb. One for every 4 hours and the other for every 6 hours. Staff # 3 called floor nurse to clarify orders with the physician.

Patient # 7 admitted on [DATE] with the following orders from 11/16/2012: Diagnosis - COPD Exacerbation
1. Proventil 2.5 mg/3 ml nebulizer x 3 doses back to back in emergency room
2. Proventil 2.5 mg nebulizer q 4 hours PRN shortness of breath and wheezing
3. Oxygen 2 liters / nasal cannula continuous and attempt to wean.
4. Advair diskus 1 puff in BID
5. Spiriva 18 mcg. Inhalation daily

Patient # 7 MAR from 11/16/2012 revealed:
1. Proventil 3 ml given on 1546, 2000 , third dose not administered
2. Proventil PRN dose given on 11/17/2012 at 1950 and on 11/18/2012 at 0905, 1415 and 1955 and on 11/19/2012 at 1600
3. Oxygen saturations were done daily ranging from 90%-99% at 2-3 liters of Oxygen
4. Spiriva given daily as ordered.



On 11/21/2012 at 10:00 AM an interview with the Clinical Coordinator of Respiratory Services revealed:
The Clinical Documentation Policy is covered in staff orientation. The Respiratory Care Services Code no.4.3.5 Documentation of Respiratory Care Services Review Date: 10/17/2011 was reviewed with the Clinical Coordinator of Respiratory Services.
He described the process: If the respiratory treatment is not given, the therapist puts a signature or initials by the treatment. The options in the Epic (computer) program are: patient refused, patient sleeping, patient receiving other care, patient not in room, other (the tech has to document a reason). He stated workload is not an option. The tech would need to contact a supervisor if there is not enough staff and the treatments cannot be given.

He further stated the Policy for guiding staff for critical staffing 10/01/2012 is a guide for prioritizing and does not direct them to notify supervisor. The policy also does not show to miss a treatment, but can delay treatment if the tech listens to breath sounds and then puts the treatments in priority order. The staffing was reviewed with the Respiratory Care Coordinator and the following was found:

Critical staffing on 11/17 - 11-19.
11-17 critical staffing 7 PM - 11 PM
11-18 critical staffing 7 PM - 11 PM
11-19 critical staffing 7 PM - 11 PM

An interview with the Associate VP of Operations revealed the department had 5 positions to fill and the positions were posted

All medications that were not administered were reviewed by Staff # 3 with this Surveyor and Staff # 3 concurred that they were not administered on 3 of 10 patients. ( #3, #4, #7 )