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.

NORTH FLORIDA REGIONAL MEDICAL CENTER 6500 NEWBERRY RD GAINESVILLE, FL 32605 June 8, 2011
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure that nursing staff with competencies to meet the needs of the patient were assigned for 1 of 5 patients reviewed (#1)

Findings:

Record review for patient #1 reveals that the patient was admitted for an aortic femoral bypass graft and initially did well postoperatively was transferred from intensive care to the fourth floor for continuing care on 4/17/2011 she had a change in condition on 4/17/2011 at approximately 9:00 PM that was identified by the nurse, but not reported to the physician. The record reveals that the patient was diagnosed with a cerebral vascular accident on 4/18/2011 and was transferred back to intensive care where she was treated with conservative medical treatment until she expired the record also reveals that the patient had consented to treatment and that she was assessed by a registered nurse and had a plan of care developed.

Review of the nurses notes for patient #1 dated 4/16/2011 reveals that the patient had ambulated in the hall three times. Further review reveals no notes dated for 4/17/2011. A note dated 4/18/2011 and timed at 6:19 AM states that at 9:00 PM the patient was confused and trying to get out of bed and that as of 6:00 AM the patient is sleeping with no change in condition. A note dated 4/18/2011 and time at 7:35 AM states that the daughter was called at 9:00 PM and that the daughter could not come in the note also indicates that the physician was call at 7:30 AM and told patient is confused. Note dated 4/18/2011 at 08:15 states family expressed concern for mother condition. A note on 4/18/2011 at 11:00 AM reveals family asking for physician and very concerned. A note dated 4/18/2011 at 2:10 PM reveals that the family was still concerned and physician had ordered a scan. A note from the charge nurse dated 4/18/2011 at 4:31 PM indicates that she was informed by the physician at 2:00 PM that patient #1 was not responding correctly and that he ordered a stat scan.

Review of the physicians note date on 4/18/2011 at 1:00 PM reveals that family stated patient became progressively more confused since prior to discharge from intensive care and that the physician was called at 7:00 AM and told patient was confused with no other issues.

Review of the nursing assessment dated [DATE] at 08:00 AM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened spontaneously, that she was confused being disoriented to time and place, the assessment also reveals that the patient follows commands.

Review of the nursing assessment dated [DATE] at 08:00 PM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened spontaneously, that she was confused being disoriented to time and place, the assessment also reveals that the patient follows commands.

Review of the nursing assessment dated [DATE] at 08:00 AM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened never, that she could not be assessed for orientation, the assessment also reveals that the patient follows localizes pain and that her speech is incomprehensible.

During interview with the nurse #3 who was the charge nurse on 6/7/2011 at 10:45 AM she stated that she remembered the situation with patient #1 and that she had been asked on 4/17/2011 to check on the patient's IV and found that it only needed to be repositioned and re-taped. She was asked to look at the patient #1's IV again on 4/18/2011 and stated that she told the nurse that if it remained positional it would have to be restarted. She further stated that at that time she was asked by patient #1 ' s family if the patient had received medication that was making her lethargic. She stated that at that time she went to check the medication administration record and that by the time she had reviewed it that the physician had come in to examine the patient and found her to have severe confusion, right sided weakness, and slurred speech. She also stated the physician ordered a CAT Scan of the head and that patient #1 be transferred to intensive care.

During interview with nurse #4 on 6/7/2011 at 10:50 AM she stated that she had received in-service training on recognizing a stroke and that the signs and symptoms included slurred speech and single sided weakness. She also stated that if her patient had these signs and symptoms that she would call an "STP." When asked what STP is she stated that it is the hospitals code for needing clinical assistance.

During interview with the surgeon caring for patient #1 on 4/18/2011 he stated that he had found the patient very lethargic, with no motor activity on the right side and unintelligible speech. He further stated that he had been called at 7:00 AM on 4/18/2011 and given only information that the patient needed a sitter because she was restless.

During an interview with the Director of Nursing on 6/7/2011 at 2:30 PM she stated that the incident with patient #1 was on the agenda for nursing peer review and that the results would be reported to the Quality Assurance (QA) committee and then to medical executive committee and finally to the governing board. She also stated that agency nurses would have to complete the stroke training prior to the first shift working in the future and that the Clinical Nurse Director for the fourth floor had been demoted and transferred after review of the nursing competencies revealed several nurses on that floor had expired competencies and that a new clinical nurse had been hired.

Review of the training record for the fourth floor reveals that a complete audit of all nurse trainings was conducted and that now all nurses are current. A review of the training record for the entire hospital reveals that all nurses are current and that the fourth floor was the only location with deficiencies prior to 4/18/2011.

Review of the facility provided stroke overview and policy review reveals:
"If you suspect a patient in the hospital is having a stroke, notify the patient's nurse immediately. The nurse should notify the charge nurse of the unit. The charge nurse and the primary nurse should quickly evaluate the patient. If the determination is made that the patient may be experiencing a stroke or TIA the nurse should call the operator and notify of a "STP ALERT" on their unit The Abbreviation "STP" stands for stroke team protocol. The time of symptom onset should be determined and documented.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews the facility failed to ensure that contract nursing staff had competencies to meet the needs of the patient they were assigned for 1 of 5 patients reviewed (#1)

Findings:
Record review for patient #1 reveals that the patient was admitted for an aortic femoral bypass graft and initially did well postoperatively was transferred from intensive care to the fourth floor for continuing care on 4/17/2011 she had a change in condition on 4/17/2011 at approximately 9:00 PM that was identified by the nurse, but not reported to the physician. The record reveals that the patient was diagnosed with a cerebral vascular accident on 4/18/2011 and was transferred back to intensive care where she was treated with conservative medical treatment until she expired the record also reveals that the patient had consented to treatment and that she was assessed by a registered nurse and had a plan of care developed.

Review of the nurses notes for patient #1 dated 4/16/2011 reveals that the patient had ambulated in the hall three times. Further review reveals no notes dated for 4/17/2011. A note dated 4/18/2011 and timed at 6:19 AM states that at 9:00 PM the patient was confused and trying to get out of bed and that as of 6:00 AM the patient is sleeping with no change in condition. A note dated 4/18/2011 and time at 7:35 AM states that the daughter was called at 9:00 PM and that the daughter could not come in the note also indicates that the physician was call at 7:30 AM and told patient is confused. Note dated 4/18/2011 at 08:15 states family expressed concern for mother condition. A note on 4/18/2011 at 11:00 AM reveals family asking for physician and very concerned. A note dated 4/18/2011 at 2:10 PM reveals that the family was still concerned and physician had ordered a scan. A note from the charge nurse dated 4/18/2011 at 4:31 PM indicates that she was informed by the physician at 2:00 PM that patient #1 was not responding correctly and that he ordered a stat scan. Review of this patient's record revealed that nurse #1 and #2 took care of this patient prior to the physician determining that the patient had suffered a stroke.

Review of the physicians note date on 4/18/2011 at 1:00 PM reveals that family stated patient became progressively more confused since prior to discharge from intensive care and that the physician was called at 7:00 AM and told patient was confused with no other issues.

Review of the nursing assessment dated [DATE] at 08:00 AM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened spontaneously, that she was confused being disoriented to time and place, the assessment also reveals that the patient follows commands.

Review of the nursing assessment dated [DATE] at 08:00 PM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened spontaneously, that she was confused being disoriented to time and place, the assessment also reveals that the patient follows commands.

Review of the nursing assessment dated [DATE] at 08:00 AM reveals that patient #1 had a nursing assessment that revealed that the patient's eye opened never, that she could not be assessed for orientation, the assessment also reveals that the patient follows localizes pain and that her speech is incomprehensible.

During interview with the surgeon caring for patient #1 on 4/18/2011 he stated that he had found the patient very lethargic, with no motor activity on the right side and unintelligible speech. He further stated that he had been called at 7:00 AM on 4/18/2011 and given only information that the patient needed a sitter because she was restless.

During an interview with the Director of Nursing on 6/7/2011 at 0930 AM she stated nurse #2 was an agency nurse and that she was no longer used by the facility. When asked if this was the facilities decision or the nurses she stated that it was the facilities decision.

During interview with the nurse #3 who was the charge nurse on 6/7/2011 at 10:45 AM she stated that she remembered the situation with patient #1 and that she had been asked on 4/17/2011 to check on the patient's IV and found that it only needed to be repositioned and re-taped. She was asked to look at the patient #1's IV again on 4/18/2011 and stated that she told the nurse that if it remained positional it would have to be restarted. She further stated that at that time she was asked by patient #1 ' s family if the patient had received medication that was making her lethargic. She stated that at that time she went to check the medication administration record and that by the time she had reviewed it that the physician had come in to examine the patient and found her to have severe confusion, right sided weakness, and slurred speech. She also stated the physician ordered a CAT Scan of the head and that patient #1 be transferred to intensive care.

During an interview with the Director of Nursing on 6/7/2011 at 2:30 PM she stated that the incident with patient #1 was on the agenda for nursing peer review and that the results would be reported to the QA committee and then to medical executive committee and finally to the governing board. She also stated that agency nurses would have to complete the stroke training prior to the first shift working in the future and that the Clinical Nurse Director for the fourth floor had been demoted and transferred after review of the nursing competencies revealed several nurses on that floor had expired competencies and that a new clinical nurse had been hired.

Review of the training record for the fourth floor reveals that a complete audit of all nurse trainings was conducted and that now all nurses are current. A review of the training record for the hospital reveals that all nurses are current and that the fourth floor was the only location with deficiencies prior to 4/18/2011.

Review of the facility provided stroke overview and policy review reveals:
"If you suspect a patient in the hospital is having a stroke, notify the patient's nurse immediately. The nurse should notify the charge nurse of the unit. The charge nurse and the primary nurse should quickly evaluate the patient. If the determination is made that the patient may be experiencing a stroke or TIA the nurse should call the operator and notify of a "STP ALERT" on their unit The Abbreviation "STP" stands for stroke team protocol. The time of symptom onset should be determined and documented.