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LARGO MEDICAL CENTER 201 14TH ST SW LARGO, FL 33770 Sept. 26, 2013

Based on record review, staff interview and review of policies and procedures it was determined the facility failed to involve the patient and family in care decisions and failed to educate the patient or family on a change in treatment for one (#1)of ten sampled records.

Findings include:

Patient #1 was admitted on [DATE] after a transfer from the acute care hospital. Review of the History and Physical dated 6/13/13 revealed the patient was alert and oriented to self with difficulty following one step commands, disoriented and confused and unable to understand or answer questions appropriately. The patient's spouse signed the conditions of admission and was making the patient's decisions.

Speech Therapy evaluation dated 6/14/13 revealed an evaluation for "Clinical Dysphagia Evaluation". The documentation indicated the patient had overt signs and symptoms of oral and pharyngeal decompensation and a video swallow study was recommended. The report stated "Video swallow study warranted to rule out aspiration. NPO (Nothing By Mouth) recommended except meds with video swallow study on Monday. However, if family or patient refuses, patient appears to handle thin liquids and mechanical soft solids. Patient should be strictly monitored due to poor endurance and fatigue. Suspect Pharyngeal Dysphagia". Under the section for "Teaching and Education" it stated the patient was the " learner" and that barriers to learning were fatigue and cognition.

Physician's order dated 6/14/13 indicated "NPO except for meds, until video swallow evaluation performed. Start IVF ( Intravenous Fluids) to maintain hydration while NPO".

Interview with the Director of the Rehabilitation Unit and the RN Manager on 9/26/13 at 1: 00 p.m. revealed there would be signage that indicated the patient was NPO and the patient would have an orange armband. All water pitchers and anything that would present risk would be removed from the room and there would be education to the patient and the family. The RN Manager stated they would be told due to safety with swallowing that we are not going to give them food or drink until the test is done and they are determined safe.

Review of nursing notes revealed the NPO status and intravenous fluids were initiated on 6/14/13.

Review of physician's note for 6/15/13 at 1:18 p.m. revealed the spouse was upset over the NPO status and IVF. The status was discussed at length with patient and spouse. The documentation noted the patient remains significantly confused and does not demonstrate the ability to make his own medical decisions at this time.

Review of the hospital's policies and procedures revealed Policy No: B.36 "Patient's Rights and Responsibilities" with a review date of 1/13. Review of the policy revealed "Purpose: LMC must protect and promote each patient's rights. Policy: Each patient/representative must be informed of the patient's rights and responsibilities, whenever possible, in advance of providing or discontinuing patient care. Patients and/or the responsible representative have the right to 6. A patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks , and prognosis. 7. A patient has the right to refuse any treatment, except as otherwise provided by law".

Review of the patient's record revealed no documentation the decision to place the patient on NPO status and intravenous fluids was discussed with or explained to the patient's family prior to this being instituted.