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.

PALMETTO GENERAL HOSPITAL 2001 W 68TH ST HIALEAH, FL 33016 April 9, 2015
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
Based upon record reviews and interviews, the facility failed to ensure that justification for an emergency treatment order of Ativan was documented in the medical record, per the facility's policy, for one of ten sampled patients. (SP #1)


The findings included:



Review of the facility's policy, "Emergency Treatment Order, "(not dated) revealed that the need for ETOs (emergency treatment orders) must be documented in the progress notes and in the section used for physician orders. Documentation must describe the specific behavior which constitutes a danger to self or others and/or the nature of the extent of the danger posed.

Review of SP#1's medical record revealed that the patient was admitted as an involuntary patient on 02/05/15 at 1:00AM. Review of the Medication Administration Record showed that the patient received Ativan 1mg (one milligram) intra-muscular (IM) on 02/05/15 at 4:17AM, as an emergency treatment order (ETO), for anxiety. The ETO was ordered by the psychiatrist. The medical record did not show any documentation of why the patient required an ETO. Also, the medical record did not show other interventions to control the patient's behavior prior to giving the ETO.


On 04/09/15 at 11:05AM, Staff A, a Registered Nurse (RN), stated that ETOs are ordered when a patient is violent or a danger to self and others and all resources have been exhausted.

On 04/09/15 at 4:00PM, Staff B, a RN, stated that when an ETO is given the nurse documents the patient ' s behavior in the medical record.
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
Based upon interviews and record reviews, the facility failed to involve patients representatives in care planning and treatment for one of ten sampled patients. (SP #1)

The findings included:

Review of the facility ' s " Patient Rights and Responsibilities (Bill of Rights), " revised 09/12, showed that the patient has the right to participate in the development and implementation of his or her plan of care. The patient also has the right to be informed about treatment and services.


On 02/03/15 at 3:35PM, SP #1 patient was admitted to the telemetry unit, accompanied by family. Advance directive form showed the patient ' s daughter was the healthcare surrogate. The neurologist note on 02/03/15 stated that the patient was alert and oriented times one (to person), with significant drowsiness and aggressive behavior from time to time. The note stated that the patient ' s change in mental status appears to be related to an encephalopathic process from drug overdose. The note also stated, "we will recommend to avoid benzodiazepines on her." Neurology progress note on 02/04/15 at 7:57PM stated that the patient was doing better this afternoon, was more awake, cooperative and following commands. The neurologist plan was to continue avoiding benzodiazepines on this patient. However, the medication administration record (MAR) showed that on 02/04/15 at 8:59PM, nursing staff administered Ativan 0.5 milligram Intravenous to SP #1. (Ativan is a benzodiazepine). The patient's medical record did not show that the patient's representative was informed that the patient received Ativan.

On 04/09/15 at 3:17PM during interview, the psychiatrist stated that the patient received Ativan for agitation. He stated that he knew that the neurologist had recommended to avoid benzodiazepines.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based upon interviews and record reviews, the facility failed to involve the patients representatives in care planning and treatment for one of ten sampled patients. (SP #1)

The findings included:

Review of the facility ' s " Patient Rights and Responsibilities (Bill of Rights), " revised 09/12, showed that the patient has the right to participate in the development and implementation of his or her plan of care. The patient also has the right to be informed about treatment and services.


On 02/03/15 at 3:35PM, SP #1 patient was admitted to the telemetry unit, accompanied by family. The advance directive form showed that patient ' s daughter was the healthcare surrogate. The neurologist note on 02/03/15 stated, the patient was alert and oriented times one (to person), with significant drowsiness and aggressive behavior from time to time. The note stated that the patient ' s change in mental status appears to be related to an encephalopathic process from drug overdose. The note also stated, "we will recommend to avoid benzodiazepines on her." The Neurology progress note on 02/04/15 at 7:57PM stated, the patient was doing better this afternoon, was more awake, cooperative and following commands. The neurologist plan was to continue avoiding benzodiazepines on this patient. However, the medication administration record (MAR) showed that on 02/04/15 at 8:59PM, the patient received Ativan 0.5milligram Intravenous. (Ativan is a benzodiazepine). The patient's medical record did not show that the patient's representative was informed that the patient received Ativan.

On 04/09/15 at 3:17PM, the psychiatrist stated that the patient received Ativan for agitation. He stated that he knew that the neurologist had recommended to avoid benzodiazepines for SP#1.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
Based upon record reviews and interviews, the facility failed to ensure the use of a chemical restraint was the least restrictive intervention to protect the patient and others. The facility failed to to ensure that justification for an emergency treatment order for Ativan was documented in the medical record, per the facility's policy, for one of ten sampled patients. (SP #1)


The findings included:

Review of the facility's policy, "Emergency Treatment Order, "(not dated) revealed that the need for ETOs (emergency treatment orders) must be documented in the progress notes and in the section used for physician orders. Documentation must describe the specific behavior which constitutes a danger to self or others and/or the nature of the extent of the danger posed.

Review of SP#1's medical record revealed that the patient was admitted as an involuntary patient on 02/05/15 at 1:00AM. Review of the Medication Administration Record showed that the patient received Ativan 1mg (one milligram) intra-muscular (IM) on 02/05/15 at 4:17AM, as an emergency treatment order (ETO), for anxiety. The ETO was ordered by the psychiatrist. The medical record did not show any documentation of why the patient required an ETO. Also, the medical record did not show other interventions to control the patient's behavior prior to giving the ETO.


On 04/09/15 at 11:05AM, Staff A, a Registered Nurse (RN), stated that ETOs are ordered when a patient is violent or a danger to self and others and all resources have been exhausted.

On 04/09/15 at 4:00PM, Staff B, a RN, stated that when an ETO is given the nurse documents the patient ' s behavior in the medical record.