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.

LAKELAND REGIONAL MEDICAL CENTER 1324 LAKELAND HILLS BLVD LAKELAND, FL 33805 May 2, 2017
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, the registered nurse failed to supervise and evaluate nursing care related to peritoneal dialysis (PD) for two (#3, #4) of eleven patients sampled and failed to ensure a patient was turned and repositioned for one (#11) of eleven patients sampled.

Finding included:

1. On 05/02/17 at approximately 10:20 a.m. review of Patient #3's physician history and physical (H&P) dated 04/04/17 revealed a past medical history of end stage renal disease (ESRD), PD and hypertension (HTN).

Review of Nephrologist PD orders dated 04/03/17 at 6:12 p.m. revealed orders for PD.

Review of Patient #3's nursing documentation revealed there was no documentation PD was performed on 04/04/17. A nursing note on the same date revealed PD could not be performed because they were waiting on a machine. There was no nursing documentation the physician was made aware PD was not performed on 04/04/17.

2. On 05/02/17 at approximately 2:20 p.m. review of Patient #4's H&P dated 03/28/17 revealed a past medical history of HTN, ESRD and PD.

Review of Nephrologist PD orders dated 03/28/17 at 10:05 p.m. revealed orders for the PD.

Review of Patient #4's nursing documentation revealed there was no documentation PD was performed on 03/29/17. There was no nursing documentation the physician was made aware the PD was not performed on 03/29/17.

On 05/02/17 at approximately 3:00 p.m. an interview conducted with the M6 medical unit RN Team Leader and Quality Manager confirmed the above findings.

3. Review of the medical record for patient #11 revealed the patient was admitted on [DATE]. Review of the nursing assessment dated [DATE] revealed the patient required total care. It noted the patient had multiple extremity contractures and was unable to turn and reposition themselves.

Review of the nursing documentation for turning and repositioning revealed on the following sampled days no evidence the patient was turned and repositioned every 2 hours:

2/6/2017 9:40 a.m. to 8:05 p.m. no documentation of turning and repositioning
2/8/2017 7:00 a.m. to 8:00 p.m. no documentation of turning and repositioning
2/10/2017 3:15 p.m. to 10:45 p.m. no documentation of turning and repositioning
2/10/2017 10:45 p.m. to 2/11/2017 8:00 a.m. no documentation of turning and repositioning
2/11/2017 8:00 a.m. to 12:00 p.m. no documentation of turning and repositioning
2/11/2017 12:00 p.m. to 4:00 p.m. no documentation of turning and repositioning
2/11/2017 4:00 p.m. to 9:00 p.m. no documentation of turning and repositioning
2/12/2017 3:00 a.m. to 10:00 p.m. no documentation of turning and repositioning
2/15/2017 12:45 a.m. to 8:00 a.m. no documentation of turning and repositioning
2/16/2017 12:00 p.m. to 7:20 p.m. no documentation of turning and repositioning

Interview and review of the medical record with the Quality Manager on 5/2/2017 at 4:00 p.m. confirmed the above findings.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record reviews and staff interview it was determined the nursing staff failed to ensure the care plan was current and met the individual needs of the patient for one (#11) of eleven patients sampled.

Findings included:

Review of the medical record for patient #11 revealed the patient was admitted on [DATE]. Review of the nursing assessment dated [DATE] revealed the patient required total care. The patient had multiple extremity contractures and was unable to turn and reposition.

Review of nursing documentation revealed on multiple days the patient was not turned and repositioned due to the patient being in pain. Review of the nursing plan of care for the patient's admission, from 2/3/2017 to 2/27/2017, revealed no evidence nursing developed a plan of care to address the patient's pain.

Review of the patient's plan of care revealed discharge planning was developed for the patient. The plan revealed the patient would be discharged home with home health care services. Review of the medical record revealed the patient's parent was the primary caregiver.

Review of the record revealed the patient had a feeding tube placed during the admission and would be discharged home with the feeding tube with continuous feedings. Review of the nursing documentation revealed no evidence the patient's primary caregiver was educated about the post-hospital needs related to the feeding tube and continuous feedings.

Interview and review of the medical record with the Quality Manager on 5/2/2017 at 4:00 p.m. confirmed the above findings.