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PALM BEACH GARDENS MEDICAL CENTER 3360 BURNS RD PALM BEACH GARDENS, FL 33410 June 5, 2012
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and staff interview, the facility failed to ensure the licensed registered nurses provided or ensured the patient received the care and services as prescribed by physician order for 2 of 10 patients (Patient # 1 and Patient # 9).

The findings include:

1)Review of the clinical record for Patient # 1 discloses the patient presented to the facility's emergency room on [DATE] at 3:30 AM with a chief complaint of Abdominal Pain.

The physician prescribed on 3/15/2012 at 3:45 PM the following orders which include, Small Bowel Series with (GGPT) Gastro Graphic rule out Small Bowel Obstruction and Gastro Graphic enema. Then at 4:46 PM, the order prescribing the Small Bowel series was discontinued.

Further review of the clinical record failed to provide evidence the Gastro Graphic Enema prescribed on 3/15/2012 was performed.

Interview with the Quality Nurse was conducted on 6/4/2012 in the afternoon who confirmed the Gastro Graphic Enema is a procedure performed in Radiology. Additional review of the Radiology Reporting for Patient # 1 for the Gastro Graphic Enema disclosed, the procedure was input to be performed on 3/15/2012 at 5:46 PM. However the nurse canceled the test and the procedure was reentered for rescheduling on 3/15/2012 at 6:15 PM. The procedure was reentered to be performed on 3/16/2012 at 5:00 AM. Furthermore on 3/16/2012 at 9:25 AM, the procedure was again canceled in the computer.

Interview with the Internal Medicine Physician, the primary physician, was conducted on 6/5/2012 at 11:10 AM who confirmed the orders on 3/15/2012 for the patient to receive the Small Bowel Series with the GGPT and the Gastro Graphic Enema were written at his directive. The subsequent cancellation of the Small Bowel Series was based on the fact that he felt it was highly unlikely the patient would be able to swallow the contrast necessary for the small bowel series. The Gastro Graphic Enema was not discontinued and was expected to be performed. He further confirmed the procedure is done by radiology. He stated he writes the order and he feels it is up to the nurse to follow through with his prescribed orders.

Interview with the Director of Radiology was conducted on 6/5/2012 at 11:51 AM who confirmed he was not knowledgeable regarding why the procedure was canceled. Based on the documentation in the computer, it was canceled according to directives given by the nurses. He stated the procedure is input into the computer and once radiology is prepared to perform the test, Radiology contacts the unit and transports the patient to Radiology. Patients in the Intensive Care Unit (ICU) are accompanied by the nurse to the procedure. However this did not occur for Patient # 1 secondary to the test being canceled.

Interview with Registered Nurse who cared for the Patient on 3/15/2012 was conducted on 6/5/2012 at 12:56 PM who confirmed she canceled and rescheduled the procedure. She stated the patient's blood pressure was low; patient was receiving titrated dosing of Levophed and the patient was not stable. (It should be noted the above circumstances were present at the time the physician order was written). She further stated the order was not stat (to be done immediately) and it was the change of shift. She stated she's sure she must have talked with the Nurse Practitioner regarding cancellation, but confirmed there is no evidence to support this. The Director of Intensive Care Units was also present during the interview and stated it was her assumption, the nurse canceled the procedure the second time secondary to the patient coded (cardiopulmonary arrest) during the night. It was confirmed that there is no evidence of a corresponding order or documentation from the physician canceling the procedure.

2) Review of the clinical record for Patient # 9 discloses the patient was admitted to the facility on [DATE] with diagnosis of [DIAGNOSES REDACTED]. Review of the Medication Administration Record on 6/4/2012 at 12:48 PM revealed the 6/4/2012 9 am dose of HCTZ was not given.
Interview with the nurse was conducted on 6/4/2012 at 12:50 PM who confirmed she did not administer the HCTZ because the medication was unavailable this morning. She stated she noted the medication was unavailable and put in to administer the medication the following day (6/5/2012).

An interview was conducted on 6/4/2012 at 2:39 PM with the Pharmacy Director who stated the medication is normally placed in the Pixas in the patient specific bin. If the medication is not there, the nurse is to call pharmacy and pharmacy will deliver within one hour. He confirmed the medication was available in pharmacy and would have been dispensed as two 50 mg tablets.