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.

MARION COMMUNTIY HOSPITAL 1431 SW 1ST AVE OCALA, FL 34478 Sept. 9, 2011
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview the Governing body failed to ensure that Nursing Services provided services to meet the patient's needs related pressure sore prevention and that the facility failed to ensure that Discharge Planning needs of the patients are met in a sate and appropriate manner.

Findings:

1 .Reference A 0385: Based on record review and interview the facility failed to ensure that Nursing Services provide services to identify and prevent the development of pressure sores and to ensure the safe and appropriate Discharge Planning of its patients. This failure resulted in the Condition of Participation for Nursing Services to be found deficient.

2 .Reference A 0799: Based on record review and interview the facility failed to meet the safe and appropriate Discharge Planning need of all patients. This failure resulted in the Condition of Participation for Discharge Planning not to be met.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview the facility failed to ensure that Nursing Services provide services to identify and prevent the development of pressure sores and to ensure the safe and appropriate Discharge Planning of its patients. This failure resulted in the Condition of Participation for Nursing Services to be found deficient.

Findings

1 .Reference A 0396: Based on record review and interview, the facility failed to insure for 2 of 10 patients,(Patients #1 and #2), that they developed, revise and implement a plan of care for the prevention and treatment of pressure sores for patient #1 and a discharge plan to an appropriate facility that could meet the needs of patient #2.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to insure for 2 of 10 patients,(Patients #1 and #2), that they developed, revise and implement a plan of care for the prevention and treatment of pressure sores for patient #1 and a discharge plan to an appropriate facility that could meet the needs of patient #2.

Findings:

1. Review of patient #1's record revealed that the patient was admitted on [DATE] following a fall at home that resulted in a fractured right hip. Further review of the record revealed that the same day as admission the, patient underwent surgery to repair the fractured hip.

Review of the both the emergency room and 4th floor nursing admission assessments revealed that the patient was free of any pressure sores or skin tears. Review of the pre-anesthesia assessment, surgical history and physical and surgical nursing assessments revealed that the patient was free of pressure sores and skin tears. Review of the post-anesthesia and post-surgical evaluations did not reveal any concerns related to pressure sores or skin tears.

Review of the nursing notes and shift assessments/reassessments for the remainder 07/01/2011 and all of 07/02/2011 revealed the skin was free of pressure sores and skin tears.

Review of the shift assessment/reassessment for 07/03/2011 at 7:30 AM revealed Wound Location: Right Buttock, Wound Type: Skin Tear, Wound Condition: Healing, Dressing Type: Zinc Oxide. Review of the medical record revealed the following Plan of Care was put in place--Skin interventions: Manage moisture. Avoid drying the skin, Manage nutrition. Maintain good hydration, Manage friction and shear, No massage of reddened bony prominence, Reposition every 2 hours and as needed (PRN), offer toileting when turning, Pericare PRN, Use moisture barrier: body wash and lotion routinely, Maximal remobilization-up in chair for meals when appropriate, Protect (offload heels), Use turn sheets to reduce friction/shear, head of bed (HOB) greater than 30 degrees unless medically contraindicated, Consider pressure relieving surface (if bed or chair bound), Provide education on pressure ulcers to patient, and Assess nutritional statue, Obtain nutrition consult PRN.

Review of the medical record revealed a physician order dated 07/03/2011 at 12:45 PM "Zinc Oxide - apply topically to Right buttock and coccyx area".

Review of the shift assessment/reassessment for 07/04/2011 at 9:25 AM revealed Wound Location: Right Buttock, Wound Type: Skin Tear, Wound Condition: Healing, Dressing Type: Zinc Oxide and under Ulcer Location: Coccyx, Ulcer Stage: Suspected Tissue Injury, Ulcer Condition: Slough Dressing Type: Zinc.

Review of the shift assessment/reassessment for 07/05/2011 at 12:52 PM revealed Ulcer Location: Mid Buttock Right, Ulcer Stage: II, Ulcer Condition: Moist Slough Dressing Type: Zinc Oxide. The nursing documentation for the shift does not address the second wound.

Review of the medical record revealed a Wound Care Consult from the wound care nurse dated 07/05/2011 at 12:50 PM that stated, "This patient is noted to have a stage II Pressure Ulcer in the mid buttock area that measures 8.5 [centimeter] cm [by] x 5.5 cm x 0.1 cm. Moderate red drainage is noted from the wound. Cleanse the wound with Betasept daily a follow the orders of the patient's family doctor for zinc oxide". Review the Wound and Skin Treatment Orders, (standing orders completed by the wound care nurse), dated 7/5/2011 and Authenticated by the physician on 07/23/2011, (18 days), revealed the above orders and under additional orders, "This patient is incontinent of bowel and bladder. It would be extremely difficult to keep a dressing on the area. Keep positioning him off the area".

Review of the shift assessment/reassessment for 07/05/2011 at 8:00 PM revealed Ulcer Location: Right Buttock R, Wound Type: Skin Tear, Wound Condition: Draining, Dressing Type: OTA and PROSHIELD. The medical record did not reveal that nurse on duty had reviewed either the wound care consult/physician orders or the nursing assessment for earlier that day. Review of the medical record did not reveal a physician order or a consult recommendation for OTA or Proshield. Review of the Plan of Care dated 07/05/2011 at 8:00 PM revealed that the Plan of Care was not updated to reflect the patient's wound care needs.

Review of the shift assessment/reassessment for 07/06/2011 at 7:45 AM revealed 1. Wound Location: Right Buttock, Wound Type: Skin Tear, 2. Wound Location LFA, Wound Type: Skin Tear, Wound Condition: Healing, Dressing Type: TEGADERM, Dressing Condition: Dry and Intact, Dressing Changed: Y, and under Ulcer Location: Coccyx, Ulcer Stage: III, Ulcer Condition: Necrotic Dry, % Necrosis: 50, Ulcer Margins: Intact Dressing Type: Zinc, Dressing Condition: Dry/Intact, Dressing Changed: Y.

Review of the Medical record revealed a Nursing note dated 07/06/2011 at 2:19 PM "Patient incontinent of stools. Patient placed in supine. Assisted CNA with cleaning. Rolling total assist. Patient left in supine. Left with CNA. Call button table phone in reach. Review of the medical record revealed a physician order dated 07/05/2011 that stated " This patient is incontinent of bowel and bladder. It would be extremely difficult to keep a dressing on the area. Keep positioning him off the area".

Review of the shift assessment/reassessment for 07/07/2011 at 9:44 AM revealed 1. Wound Location [left forearm] LFA, Wound Type, Wound Condition: Bruising, Dressing Type: Occlusive, Dressing Condition: Dry and Intact, 2. Wound Location: Bilateral Arms, Wound Type Bruising, Wound Condition: Bruising, and under Ulcer Location: Mid Buttocks, Ulcer Stage: II, Ulcer Condition: Moist Slough Dressing Type: Zinc,

Review of the Medical Record did not reveal evidence that the Plan of Care was evaluated or updated to reflect patient #1's changing skin condition or if the Plan of Care was effective or being followed.

Review of patient #1's medical record did not reveal that the patient was placed in anything other the standard bed which is used by the hospital.

Review of the medical record revealed the patient was transferred to a local Skilled Nursing Facility, (SNF), on 07/07/2011. Review of the Medical Certification for Nursing Facility/Home and Community-based Services Form, (AHCA MEDSERV V ) dated 07/07/2011 revealed under Skin Condition a Stage II decubitus 8 ? cm by 5 ? cm.. The form did not reflect the wound measurements at the time of transfer; instead the facility reported the wound description from 07/05/2011.

Review of patient #1's medical record at the SNF revealed a Admission Nursing Note dated 07/07/2011 at 7:30 PM that states, "Left lateral forearm old skin tear scabbed over approximately 8 cm by 6 cm, ...Right buttocks and mid coccyx open area approximately 6 cm x 5 cm" , depth could not be determined. According to the documentation, the area was "dark in color, left lateral heel area dark intact approximately 5 cm x 4 cm dark in color, Right medial heel dark area approximately 2 cm x 2 cm intact ..."

Review of the, (hospital), medical record did not reveal that the patient had any concerns related to the skin condition of his heels. Review of the medical record did not reveal that any of the Plan of Care Approaches was performed either at all or on a consistent basis.

Interview of a Patient Care Technician, (CNA), on the 4th floor on 09/07/2011 at 12:15 PM revealed when asked how she learned what were the care needs of her patients, the CNA stated that the CNA leaving would tell her about the patients.

Interview with a Registered Nurse on the same floor on 09/07/2011 at 12:30 PM revealed that the CNA was told about the care needs by the nurse.

2. Review of the medical record for patient #2 revealed that the patient was transferred on 05/31/2011 to the facility from a Skilled Nursing Facility for the evaluation of headache and blurred vision, because of the patient's history of cerebrovascular accidents, (CVA). The patient was admitted to the facility to rule out a second CVA or a Transient Ishemic Attack (TIA). Review of the patient's medical history revealed [DIAGNOSES REDACTED]

Review of the Discharge Summary dictated on 06/7/2011 by the patient's attending physician revealed under, "The plan was for him to return to the skilled nursing facility however secondary to sexual offense, no skilled nursing facility, (SNF), was willing to take him. [named SNF] was not willing to take him back and an assisted living facility referral was made and patient is subsequently to an assisted living facility, (ALF) in stable condition".

Interview on 09/07/2011 at 9:00 AM with the Case Manager that provided discharge planning for the patient revealed that the patient was "on the state's sexual predator list" and because of that, there were no skilled nursing homes that would take him.

Review of the Case Management note dated 06/02/2011 at 9:14 AM revealed "Call from neuro [Neurology floor], floor director wants patient transferred today if possible ..." Review of Case Management note date 06/02/2011 at 4:52 PM revealed "D/C [discharge] order for today, no accepting facility".

Review of Case Management note dated 06/02/2011 at 4:53 PM revealed, "Contacted Mary at Good Samaritan ALF for possible placement there. She will come see patient in the morning. [named] patient, who is very, very difficult to understand. He may require more assistance than Mary can provide with regards to dressing and toileting, but she will assess in the AM..."

Review of the Case Management note dated 06/03/2011 at 1:58 PM revealed "Mary here form Samaritan Comfort ALF to assess patient, feels he'll be appropriate and has observed him going to the bathroom, feeding himself, ETC. Mary requested RX's [prescriptions] be faxed to RX Care Pharmacy at [telephone number provided] for delivery to her home and states she is in a program which takes care of patient's copay's. Mary will transport patient".

Review of the current list of ALFs used by the facility for discharge planning did not include, Good Samaritan ALF, Samaritan Comfort ALF or any other ALF that could be understood as the ALF described in the medical record or staff interviews.

Review of State of Florida records revealed that the facility that Mary represents does not have ALF license or any other state license that would allow her to accept residents requiring assistance with medical needs and activities of daily living.

A search of the Florida Department of Business Professional Regulation's website at https://www.myfloridalicense.com/wl11.asp?mode=2&search=Name&SID=&brd=&typ=
failed to reveal that the address listed on patient #1's record is licensed as a, "Rooming House"
Interview with the Case Worker on 09/07/2011 at 9:00 AM revealed that she did not know that Samaritan Comfort was not a licensed ALF and after review the facility's referral list for ALFs stated it was not on the facility's list. The Care Worker stated that she did not remember how she came to know of Mary or were she obtained her telephone number when she called her.

Review of the medical record or staff interview did not reveal that the facility had a record of how it determined that Samaritan Comfort was a ALF or that it would be a safe and appropriate environment to discharge the patient to who the physician felt should have been returned to a SNF or ALF.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on record review and interview the facility failed to meet the safe and appropriate Discharge Planning need of all patients. This failure resulted in the Condition of Participation for Discharge Planning not to be met.

Findings

1. Reference A 808: Based on staff interview and record review the facility failed for 1 of 10 patents, (patient #2), develop a discharge plan, based on the physician's recommendation and the patient's discharged needs.

2 .Reference A 837: Based on record review and interview, the facility failed to ensure that 1 of 10 (#2) patients was discharged to an appropriate facility, as indicated by the patient's physician.
VIOLATION: POST-HOSPITAL SERVICES Tag No: A0808
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and record review the facility failed for 1 of 10 patents, (patient #2), develop a discharge plan, based on the physician's recommendation and the patient's discharged needs.

Findings:

Review of the medical record for patient #2 revealed that the patient was transferred on 05/31/2011 to the facility from a Skilled Nursing Facility for the evaluation of headache and blurred vision, because of the patient's history of cerebrovascular accidents, (CVA). The patient was admitted to the facility to rule out a second CVA or a Transient Ishemic Attack (TIA). Review of the patient's medical history revealed [DIAGNOSES REDACTED]

Review of the Discharge Summary dictated on 06/7/2011 by the patient's attending physician revealed under, "The plan was for him to return to the skilled nursing facility however secondary to sexual offense, no skilled nursing facility, (SNF), was willing to take him. [named SNF] was not willing to take him back and an assisted living facility referral was made and patient is subsequently to an assisted living facility, (ALF) in stable condition".

Interview on 09/07/2011 at 9:00 AM with the Case Manager that provided discharge planning for the patient revealed that the patient was "on the state's sexual predator list" and because of that, there were no skilled nursing homes that would take him.

Review of Case Management note dated 06/02/2011 at 4:53 PM revealed, "Contacted Mary at Good Samaritan ALF for possible placement there. She will come see patient in the morning. [named] patient, who is very, very difficult to understand. He may require more assistance than Mary can provide with regards to dressing and toileting, but she will assess in the AM... "

Review of the Case Management note dated 06/03/2011 at 1:58 PM revealed "Mary here form Samaritan Comfort ALF to assess patient, feels he'll be appropriate and has observed him going to the bathroom, feeding himself, ETC. Mary will transport patient".

Review of the current list of ALFs used by the facility for discharge planning did not include, Good Samaritan ALF, Samaritan Comfort ALF or any other ALF that could be understood as the ALF described in the medical record or staff interviews.

Review of State of Florida records revealed that the facility that Mary represents does not have ALF license or any other state license that would allow her to accept residents requiring assistance with medical needs and activities of daily living.

Interview with the Case Worker on 09/07/2011 at 9:00 AM revealed that she did not know that Samaritan Comfort was not a licensed ALF and after review the facility's referral list for ALFs stated it was not on the facility's list. The Care Worker stated that she did not remember how she came to know of Mary or were she obtained her telephone number when she called her.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure that 1 of 10 (#2) patients was discharged to an appropriate facility, as indicated by the patient's physician.

Findings:

Review of the medical record for patient #2 revealed that the patient was transferred on 05/31/2011 to the facility from a Skilled Nursing Facility for the evaluation of headache and blurred vision, because of the patient's history of cerebrovascular accidents, (CVA). The patient was admitted to the facility to rule out a second CVA or a Transient Ishemic Attack (TIA). Review of the patient's medical history revealed [DIAGNOSES REDACTED]

Review of the Discharge Summary dictated on 06/7/2011 by the patient's attending physician revealed under, "The plan was for him to return to the skilled nursing facility however secondary to sexual offense, no skilled nursing facility, (SNF), was willing to take him. [named SNF] was not willing to take him back and an assisted living facility referral was made and patient is subsequently to an assisted living facility, (ALF) in stable condition".

Interview on 09/07/2011 at 9:00 AM with the Case Manager that provided discharge planning for the patient revealed that the patient was "on the state's sexual predator list" and because of that, there were no skilled nursing homes that would take him.

Review of the Case Management note dated 06/02/2011 at 9:14 AM revealed "Call from neuro [Neurology floor], floor director wants patient transferred today if possible ..." Review of Case Management note date 06/02/2011 at 4:52 PM revealed "D/C [discharge] order for today, no accepting facility".

Review of Case Management note dated 06/02/2011 at 4:53 PM revealed, "Contacted Mary at Good Samaritan ALF for possible placement there. She will come see patient in the morning. [named] patient, who is very, very difficult to understand. He may require more assistance than Mary can provide with regards to dressing and toileting, but she will assess in the AM..."

Review of the Case Management note dated 06/03/2011 at 1:58 PM revealed "Mary here form Samaritan Comfort ALF to assess patient, feels he'll be appropriate and has observed him going to the bathroom, feeding himself, ETC. Mary requested RX's [prescriptions] be faxed to RX Care Pharmacy at [telephone number provided] for delivery to her home and states she is in a program which takes care of patient's copay's. Mary will transport patient".

Review of the current list of ALFs used by the facility for discharge planning did not include, Good Samaritan ALF, Samaritan Comfort ALF or any other ALF that could be understood as the ALF described in the medical record or staff interviews.

Review of State of Florida records revealed that the facility that Mary represents does not have ALF license or any other state license that would allow her to accept residents requiring assistance with medical needs and activities of daily living.

A search of the Florida Department of Business Professional Regulation's website at https://www.myfloridalicense.com/wl11.asp?mode=2&search=Name&SID=&brd=&typ=
failed to reveal that the address listed on patient #1's record is licensed as a, "Rooming House".
Review of the medical record or staff interview did not reveal that the facility had a record of how it determined that Samaritan Comfort was an ALF or that it would be a safe and appropriate environment to discharge the patient to who the physician felt should have been returned to a SNF or ALF.

Interview with the Case Worker on 09/07/2011 at 9:00 AM revealed that she did not know that Samaritan Comfort was not a licensed ALF and after review the facility's referral list for ALFs stated it was not on the facility's list. The Care Worker stated that she did not remember how she came to know of Mary or were she obtained her telephone number when she called her.