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.

MEDICAL CENTER OF TRINITY 9330 SR 54, STE 401 TRINITY, FL 34655 Feb. 15, 2011
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined that the facility failed to ensure the nursing staff complied with the plan of care for one (#3) of five patients selected for review.


Findings include:

Patient #3 was admitted to the facility on [DATE] with the chief complaint of severe back pain. The physician noted, in the History and Physical, that the patient had thoracic spinal fractures with neuralgia. Review of the physician's orders revealed that nursing staff were to perform neurological assessments twice every shift at the time of admission. Review of the medical record on 2/15/11 revealed that the neurological assessments were performed once per shift.

Interview with a staff nurse on 2/15/11 at approximately 10:00 a.m. confirmed the assessments were being performed only once each shift.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, it was determined that the facility failed to administer medication as ordered for one (#5) of five sampled patients. This practice may result in failure to achieve therapeutic goals.



Findings include:

Patient #5 was admitted to the facility on [DATE] with the chief complaint of chest pain and shortness of breath. The physician documented, in the History and Physical, the patient had a history of hypertension and [DIAGNOSES REDACTED]. Review of the physician orders revealed the physician wrote an order for Coreg 3.125 twice daily on 11/11/10. Review of the Medication Administration Record revealed no evidence that the medication had been administered and no explanation as to why.

During an interview on 2/15/11 at approximately 9:30 a.m., the Director of Nursing confirmed there was no evidence that the medication had been administered.