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.

TAMPA COMMUNITY HOSPITAL 6001 WEBB RD TAMPA, FL 33615 March 28, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and staff interview it was determined the facility failed to provide evidence that patients received written notice of decision regarding their grievance. This practice does not ensure patients' right to grievance resolution is maintained.

Findings include:

Review of the facility's policy "Customer Grievance/Complaint Procedure" #RM1204, last reviewed 12/10, revealed the requirement that a written response regarding the results of the facility's investigation of patient's grievance be provided.

The Risk Manager was asked to provide the grievance log for the prior two months. She provided a redacted log that failed to provide enough information to substantiate the facility was in compliance with federal regulations and their own policy. She indicated this was the only information she was permitted to provide.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**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 comply with the patient's advance directive regarding discharge planning for one (#10) of 12 sampled patients. This practice does not protect patient rights.

Findings include:

Patient #10 was admitted to the facility on [DATE] with diagnoses that included altered mental status, insulin dependent diabetes and history of alcohol abuse. Review of case management notes revealed that the case manager spoke with a case worker from an adult protective agency on 2/8/11. The case worker told the case manager that the patient was living with a neighbor and expressed concerns about the living conditions. The case worker also provided the facility's case manager with the name and phone number of a stepson who had Power of Attorney (POA). The advance directive was contained in the medical record. The facility's case manager noted on 2/10./11 that she had spoken with the stepson (POA). There was no documentation that the discharge plan was discussed with the stepson. There was no other documentation regarding contact with the POA until 2/15/11, the day of discharge. The medical record revealed the patient was discharged to return to the neighbor's home without evidence the plan had been discussed with the POA.
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During interview on 3/28/11 at approximately 3:00 p.m., the Director of Case Management confirmed the findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0173
Based on record review, policy review and staff interview it was determined that the facility failed to ensure appropriate physician orders were obtained for three (#10, #11, #12) of 12 sampled patients. This practice does not ensure appropriate physician involvement with restraint usage.

Findings include:

The facility's policy "Restraint and Seclusion" #PC 336 required that verbal and phone orders be authenticated within 24 hours.

1. Patient #10's medical record revealed that the patient had been in restraints. Review of the physician orders revealed a verbal order for soft restraints had been written on 2/8/11 at 5:30 p.m. The order had not been authenticated at the time of the record review on 3/28/11.

2. Review of patient #11's medical record on 3/28/11 revealed a verbal order written on 3/12/11 had not been authenticated. The order for the restraint was written on 3/22/11 at 8:00 a.m. The order indicated the order was valid for 24 hours. The order was not renewed until 1:30 p.m. on 3/23/11. Review of the nursing documentation on restraint revealed the patient was restrained from 8:00 a.m. on 3/22/11 to 1:30 on 3/23/11.

3. Observation of patient #12 showed the patient was restrained on 3/28/11 at approximately 1:00 p.m. . Review of physician orders revealed a verbal order to restrain the patient on 3/26/11 at 8:00 a.m. The order was renewed on 3/27/11 at 6:00 a.m. The verbal order had not been authenticated as of 3/28/11 at approximately 1:00 p.m. Review of the progress notes written on 3/27/11 and on 3/28/11 revealed no documentation by the physician regarding the need for continued restraint.


The Nurse Manager from the Intensive Care Unit was present during the record reviews of the three patients and confirmed the findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on record review, policy review and staff interview it was determined that the facility failed to ensure appropriate monitoring of patients in restraints for three (#10, #11, #12) of twelve sampled patients. This practice does not ensure patient safety.

Findings include:

The facility's policy "Restraint and Seclusion" #PC 336 required that the nursing staff monitor the patient every two hours and document circulation, range of motion, nutrition needs, hydration needs, elimination needs, level of distress/agitation, psychological status, cognitive functioning, comfort, readiness for discontinuation and skin integrity.

1. Review of the nursing documentation regarding monitoring of patient #10 while in restraints revealed no documentation of the required monitoring on 2/5/11 from 6:10 a.m. until 8:00 p.m., on 2/7/11 from 6:00 p.m. until 11:00 p.m., on 2/8/11 from 5:30 p.m. until 8:10 p.m., and on 2/14/11 from 7:30 p.m. until 11:30 p.m.

2. Review of the nursing documentation for restraints for patient #11 revealed no documentation of the required monitoring on 3/8/11 at 10:00 p.m. to midnight, on 3/21/11 from 4:00 a.m. until 8:36 a.m., from 11:59 a.m. until 2:41 p.m. and from 2:41 p.m. until 6:17 p.m., on 3/23/11 from 2:00 a.m. until 5:44 a.m. and from 5:20 p.m. until 8:15 p.m. On 3/24/11 the last documented monitoring was noted at 8:33 a.m. There was no documentation of discontinuation of the restraint or that the patient was assessed as readiness for restraint release.

3. Review of the nursing documentation for patient #12 revealed no documentation of the required monitoring while in restraints on 3/27/11 from 5:30 a.m. until 8:00 a.m. and on 3/28/11 from 5:30 a.m. until 8:00 a.m. The monitoring documentation on 3/28/11 at 9:00 a.m. and again at 10:00 a.m. did not include all required information.

The manager of the Intensive Care Unit was present during the record reviews on 3/28/11 and confirmed the findings.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on record review, policy review and staff interview it was determined that the facility failed to monitor and ensure a safe, effective. and appropriate discharge plan was provided.

1. The facility failed to ensure a complete discharge plan for seven (#3, #5, #6, #7, #8, #9, #10) of twelve sampled patients that included the safety of a discharge plan, physician orders for transfer, and providing PASRR screening for discharges to a Skilled Nursing Facility (Refer to A817).

2. The facility failed to initiate a discharge plan for one (#9) of twelve patients (Refer to A820)

3. The facility failed to ensure appropriate preparation for discharge for one (#10) of twelve patients (Refer to A822).

4. The facility failed to ensure patient's right to choice regarding post hospital placement for five (#5, #6, #7, #8, #9) of 12 patients (Refer to A828).

5. The facility failed to provide ongoing assessment and reassessment of the discharge planning process (Refer to A843).

Due to the cumulative effect of these systemic problems, it was determined that the Condition of Participation for Discharge Planning was out of compliance.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and staff interview the facility failed to arrange for the initial implementation of the discharge plan for one (#9) of 12 sampled patients. This practice does not ensure a timely discharge.

Findings include:

Patient #9 was admitted to the facility on [DATE] and discharged on [DATE] at approximately 3:12 p.m.. The patient had been assessed by nursing upon admission and was referred to case management for a consult for discharge planning. Record review revealed that no consultation from case management had been performed.

The findings were confirmed by the Director of Case Management on 3/28/11 at approximately 3:00 p.m.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on record review and staff interview it was determined that the facility failed to provide appropriate education regarding post discharge care for one (#10) of 12 sampled patients. This practice does not ensure patient safety after discharge.

Findings include:

Review of the discharge instructions revealed patient #10 was to be on a mechanical soft diet with nectar thick liquids. Review of the medical record revealed that Speech therapy had performed a swallow study and determined that the patient required the special diet. Review of the patient/family education revealed that the diet was explained to the patient on 2/15/11 before discharge. The patient was assessed to be oriented to person only at 8:00 a.m. that morning. There was no documentation that education was provided regarding the diet to the caregiver who would be caring for the patient post discharge.

The Manager of the Intensive Care Unit confirmed the findings during the record review on 3/28/11 at approximately 3:00 p.m.
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record and policy review and staff interview it was determined that the facility failed to inform five (#5, #6, #7, #8, #9) of 12 sampled records of the option in selecting a provider of their choice for post discharge skilled nursing care.

Findings include:

On 3/28/11 record review was conducted with the Director of Case Management.

1. Patient #5 was discharged on [DATE] to a Skilled Nursing Facility (SNF) and had not been provided with the option of selecting a facility. The patient was discharged to the provider's own SNF.

2. Patient#6 was discharged on [DATE], patient #7 was discharged on [DATE], patient #8 was discharged on [DATE] and patient #9 was discharged on [DATE]. Patient #6, #7, #8, and #9 were not provided with a choice of SNF's.

The findings were confirmed by the Director of Case Management who verified that all patients were to be informed of their options as to their post discharge choice in selecting a SNF provider.

A review of the facilities policy "Patient Choice/Discharge Options" from the Department Case Management (CM #421 last revised 4/10) revealed the Case Management department will ensure that patients are informed of their options and have a free choice in selecting their post discharge provider/agency, and have been informed of any financial interest that the hospital has with the extended care provider agencies. Patients will be informed of their options and have the ultimate choice in selecting the Provider/Service.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on staff interview it was determined that the facility failed to ensure the discharge planning process was assessed for effectiveness. This practice does not ensure that patients' discharge needs are being met.

Findings include:

During interview on 3/28/11 at approximately 5:00 p.m. the Risk Manager stated that the Case Management department does not do any monitoring of discharge planning. She stated that as part of the Utilization Review monitoring, returns to the hospital were tracked. She could not provide any evidence that the discharge process was being evaluated on an ongoing basis.