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.

CORAL GABLES HOSPITAL 3100 DOUGLAS RD CORAL GABLES, FL 33134 Feb. 7, 2012
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to ensure medical records reflecting respiratory care and treatments were complete for 1 (#2) out of 10 sampled patients (SP).

The findings include:

Clinical record review of SP#2 records reflects that the patient was admitted to the facility on [DATE] after an elective surgery to his back. The patient was subsequently admitted to the hospital and physician orders were written for respiratory therapy. The order for respiratory treatments, dated 11/11/2011 reads: Advair 250/50 milligrams inhalation twice a day.

Clinical record review reveals that on 11/14/2011 the SP#2 was not administered any respiratory treatments this entire day. There was no documentation reflecting the reason for the missed medication(s); nor was there any documentation reflecting that the patient's nurse or physician was notified of this missed respiratory treatment(s).

On 11/15/2011, review of the respiratory treatment form reflects that SP#2 did not receive 1 of the ordered Advair doses. There was no documentation reflecting the reason for the missed medication, nor was there any documentation reflecting that the patient's nurse or physician was notified of the missed respiratory treatment(s).

On 11/16/2011, review of the respiratory treatment form reflects that SP#2 did not receive 1 of the ordered Advair doses. There was no documentation reflecting the reason for the missed medication, nor was there any documentation reflecting that the patient's nurse or physician was notified of the missed respiratory treatment(s).

On 2/10/2012 at 11:43am, interview with the Director of Pulmonary Services reveal that the Medical Doctor (MD) order(s) for respiratory treatments were: Advair 250/50 milligrams; inhalation two times daily. He confirms that SP#2 did not receive the Advair doses on the above dates and that the respiratory therapist should have informed the nursing staff.
VIOLATION: RESPIRATORY SERVICES Tag No: A1164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure that physician orders for respiratory care services and treatment orders were administered for 1 (#2) out of 10 sampled patients (SP).

The findings include:

Clinical record review of SP#2 records reflects that the patient was admitted to the facility on [DATE] after an elective surgery to his back. The patient was subsequently admitted to the hospital and physician orders were written for respiratory therapy. The order for respiratory treatments, dated 11/11/2011 reads: Advair 250/50 milligrams inhalation twice a day.

Clinical record review reveals that on 11/14/2011 the SP#2 was not administered any respiratory treatments this entire day. There was no documentation reflecting the reason for the missed medication(s); nor was there any documentation reflecting that the patient's nurse or physician was notified of this missed respiratory treatment(s).

On 11/15/2011, review of the respiratory treatment form reflects that SP#2 did not receive 1 of the ordered Advair doses. There was no documentation reflecting the reason for the missed medication, nor was there any documentation reflecting that the patient's nurse or physician was notified of the missed respiratory treatment(s).

On 11/16/2011, review of the respiratory treatment form reflects that SP#2 did not receive 1 of the ordered Advair doses. There was no documentation reflecting the reason for the missed medication, nor was there any documentation reflecting that the patient's nurse or physician was notified of the missed respiratory treatment(s).

On 2/10/2012 at 11:43am, interview with the Director of Pulmonary Services reveal that the Medical Doctor (MD) order(s) for respiratory treatments were: Advair 250/50 milligrams; inhalation two times daily. He confirms that SP#2 did not receive the Advair doses on the above dates and that the respiratory therapist should have informed the nursing staff.