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 June 18, 2014
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on staff interview and facility record review the facility failed to provide reassessments and physician notification of the parameters identified in the care plan for provider notification for three (Patient #1, #2, and #3) of 14 patients reviewed.

Findings include:
An interview with the Nurse Director for the neurosurgery floor was conducted on 06/17/2014 at 11:07 a.m. The Director explained the "provider notification" would be a part of the patient's care and the expectation is the nurse would notify the provider/physician of vital signs, or other diagnostic that do not meet the parameters as outlined in the "Notify" orders.

1. A review of the "Notify" orders for Patient #1 was conducted on 06/17/14. The parameters for the blood pressures (BP) are documented as "If the systolic (the first or top number of the blood pressure) is greater than 200 mmhg (millimeters of mercury- measurement)" the provider is to be notified.
The "Notify" parameter includes: If the systolic blood pressure is less than 100 mmhg" the provider is to be notified.
A review of the medical record for Patient #1 contains the following:
6/14/14 at 7:08 a.m.the BP is documented as 97/61
6/16/14 at 7:35 a.m. the BP is documented as 91 /63
6/15/14 at 7:01 a.m. the BP is documented as 97/62

A review of the record with the Director verified the nurse did not document the notification of the physician by stating "No, according to this the physician was not notified."

2. A chart review with the Director was conducted in the afternoon on 06/18/2014.
A review of the record for Patient #2 reveals the following parameters for the blood pressure are:
If the systolic (the first or top number of the blood pressure) is greater than 160 mmhg (millimeters of mercury- measurement)" the provider is to be notified.
If the systolic blood pressure is less than 90 mmhg" the provider is to be notified.
If the diastolic (the second or bottom number of the blood pressure) is greater than 120 mmhg and/or less than 60 mmhg the provider is to be notified.

A review of the medical record for Patient #2 contains the following:
6/14/2014 at 7:22 a.m. the BP is documented as 167/92
6 14/2014 at 11:28 p.m. the BP is documented as 162/ 94
6/15/14 at 3:05 a.m. the BP is documented as 174/ 101
The Director commented there were no notifications to the provider regarding these parameters.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation, staff interview and facility record review the facility failed to properly store drugs in a locked secure area for one (Patient #1) of the 3 sampled patients.

Findings include:
1. On 06/17/18 at 10:40 a.m. a tracheostomy treatment was observed for Patient #1
The Patient was in an isolation room due to an antibiotic resistant infection. During the treatment, this surveyor observed a medication box on the Patient's table. The medication box had a pharmacy label attached to the box. The medication name observed was "Nystop" with the patient name, the medication name, route and dosage. After the completion of the treatment the nurse was asked about the medication in the patient room and the nurse commented the facility was discussing the appropriate storage options for multi dosage /single user oral (by mouth administration) and topical (on the skin administration) medications for patients in isolation rooms. The medication was observed in the patient room on the bedside table as this surveyor entered the room with the nurse for the tracheostomy treatment and was not secured. The nurse (Staff Nurse #3) commented this medication was in the patient room and not secured. A review of the Medication Administration Record (MAR) revealed this medication was to be administered 2 times daily at 9:00 a.m. and 9:00 p.m. An interview with the Clinical Leader was conducted after leaving the Patient room. The Clinical Leader explained the facility was discussing the storage of these types of medications regarding the patient's in isolation rooms. The nurse was observed exiting the patient room leaving the medication in the room unattended during the interview with the Clinical Leader.

2. On 06/18/14 an interview was conducted with the Chief Nursing Officer (CNO) at approximately 9:30 a.m. The CNO then explained the facility had looked at medication storage for the multi-dose bottles and multi-dose tubes for the single user isolation patient. The CNO commented there are some rooms with locked storage cabinets, but there were concerns with family patient visitors accessing the storage areas as the staff is not in the rooms 24/7. The CNO stated a policy does not exist currently but this will be evaluated and rectified. The CNO commented the observations during the medication pass and treatment administration were troubling and all of these would be addressed as the goal is to be compliant.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Findings include:

1. A medication pass observation was conducted on 06/16/2014 for the 2:00 p.m. medication pass. The nurse (Staff Nurse " A " ) was observed appropriately obtaining the Heparin injectable medication from the drug dispensing system (Omnicell). The nurse using appropriate infection control methods was observed obtaining and preparing the syringe for the subcutaneous injection for Patient # 1. Patient #1 is in a private isolation room. The nurse explained the patient was on precautions due to a Methicillin (antibiotic) resistant Staphylococcus aureus (known as a "super bug").

The facility had PPE (Personal Protective Equipment) including gloves gowns, and hand sanitizer outside the Patient room. The nurse donned the appropriate PPE and entered the room. The nurse attempted to gain access to the computer in the isolation room and was unable to enter the information. The nurse explained she would need to leave the room, obtain a Workstation on Wheels (WOW) in order to complete the medication pass. The nurse was observed removing and discarding the gown and gloves with appropriate technique. The nurse then performed appropriate hand hygiene at the sink. The nurse returned with the WOW (computer station on wheels) and proceeded to perform hand hygiene and enter the isolation patient room after donning appropriate PPE. The nurse then accessed the computer situated on the top shelf of the WOW and entered the patient information for this medication administration. The nurse was observed appropriately administrating the heparin injection. The nurse completed entering additional information regarding the medication pass on the computer. The nurse removed the PPE and performing hand hygiene and removed the WOW from the isolation room.
This surveyor removed the PPE and performed hand hygiene at the sink (approximately 2 minutes) and exited the patient room. The WOW and the nurse were observed at the nursing station. The Clinical Leader explained the nurse used a Super Sani Wipe to clean the WOW, and the nurse was at the nursing station to label the WOW as cleaned.
At 3:30 p.m. an interview was conducted with the Administrative Director for Nursing Quality (ADNQ). The ADNQ explained the facility uses the Super Sani Wipe for cleaning equipment including the WOW between each patient use.
The ADNQ explained the recommendations on the label for the wipes do include a contact time of 2 minutes.

2. On 06/17/2014 an observation of the tracheostomy care for Patient #1 was conducted at 10:40 a.m. for Patient #1. The Staff Nurse ( " B " ) gathered the supplies for the procedure, donned the appropriate PPE after performing hand hygiene, and explained the procedure to the patient.
The nurse removed and disposed the contaminated tracheostomy gauze. After removing the gauze from under the tracheotomy site, the nurse removed the contaminated gloves and donned a new pair of gloves. The nurse did not wash hands per hand hygiene between removing and donning the new gloves. The nurse completed the tracheostomy care. After completing the tracheostomy care the nurse was asked about the "Nystop" observed on the over the bed table in the patient room. The nurse was observed taking the medication in her hand and accidentally dropped the medication on floor.
The medication was retrieved off the floor and returned the medication to the patient ' s table. The nurse explained she was not sure of the policy regarding medications in an isolation room, commenting there was discussion about these types of medications and topical medications used for the isolation patient. The nurse explained to the patient she would return to complete cleaning up the room after she retrieved additional supplies. The nurse removed and disposed the PPE appropriately. The nurse was observed performing hand hygiene at the sink. After leaving the Patient #1 room the nurse was interviewed regarding the tracheostomy care. The nurse stated "I did not wash my hands. " , adding " I should have washed my hands between the glove change. " The Clinical Leader was outside the room and she explained the expectation would be the nurse would have performed hand hygiene between glove changing. The Clinical leader continued to comment the facility had discussed placing the medication in a red bag and returning the medication to the Omnicell system. The Nurse Director commented the facility had locked boxes in some rooms for oral and topical drugs for isolation patients, but that was not available in this room. At 10:58 a.m. the ADNQ commented she had contacted the Pharmacist regarding a policy for oral solutions used in an isolation room. The ADNQ reported the Pharmacist did not have one (policy) and would need to get clarification.

3. On 06/17/14 a medication pass observation was conducted at 5:05 p.m. with Staff Nurse " C " . The nurse was observed using the WOW in the patient room. After the medication pass was completed the nurse was observed using the Super Sani Wipe to sanitize the WOW the nurse wiped off the top and sides of the WOW for approximately 30 seconds. The Nurse Director was notified by this surveyor and the Nurse Director stated "It would be cleaned properly."
4. On 06/18/14 an interview was conducted with the Chief Nursing Officer (CNO) at approximately 9:30 a.m. The CNO explained the hospital was informed of the findings during medication pass. The CNO continue to explain the facility had recognized a problem with hand hygiene back in 2012. The facility Infection Control was actively involved in evaluating the hand hygiene compliance. The CNO commented they have a way to go prior to meeting their goals and would need to implement additional training for the staff regarding hand hygiene and the appropriate cleaning and sanitizing of the equipment especially after using in an isolation room. The CNO then explained the facility had looked at medication storage for the multi dose bottles and tubes for the isolation patient. The CNO commented there are some rooms with locked storage cabinets, but there were concerns with family patient visitors accessing the storage areas as the staff is not in the rooms 24/7. The CNO stated a policy does not exist currently but this will be evaluated and rectified. The CNO commented the observations during the medication pass were troubling and all of these concerns would be addressed.