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.

OAK HILL HOSPITAL 11375 CORTEZ BLVD BROOKSVILLE, FL 34613 March 31, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview the facility failed to protect and promote each patient's rights. The facility failed to implement the use of restraints in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy and procedure (A 0167). The facility also failed to report each death known to the hospital that occurs within 1 week after restraint where it is reasonable to assume that use of restraint contributed directly or indirectly to a patient's death(A 0214). As a result of these findings, the facility was found to be deficient under the Condition of Participation for Patient Rights

Findings:

Reference A 0167: Based on record review and interview the facility failed to implement their own policy and procedures related to restraints for 2 of 10 sampled residents (#1 and #6).

Reference A 0214: Based on record review and interview the facility failed to report the death of 1 of 3 patients (#1) reviewed following the use of restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to implement their own policy and procedures related to restraints for 2 of 10 sampled residents (#1 and #6).

Findings:

1.) Record review for patient #1 revealed that the patient was readmitted on [DATE] and that she was having nausea and vomiting. The record show that patient #1 had been discharged from the facility on 8/18/2010 after having surgery related to colon cancer. A note from the emergency department dated 8/21/2010 at 12:00 AM states that the patient has been vomiting for two days and called surgeon who told her to stop taking antibiotics and pain medicine and to take xanax 0.5 milligrams (mg) every 3 hours it also states that patient denies vomiting "just spit up like a baby."

Review of the notation for patient #1 dated 8/21/2010 at 2:47 AM reveals that the patient has a nasogastric tube and included the amount of drainage. Review of the notation for patient #1 dated 8/21/2010 at 05:30 AM revels that restraints were assessed for appropriateness and alternatives and found to be appropriate.

Review of the admission assessment for patient #1 dated 8/21/2010 at 7:54 AM reveals that the nurse notes that gastrointestinal (GI)/Nutrition is within defined parameters. The notation defines parameters as abdomen soft non tender without distention Bowel sounds present in all four quadrants Bowel movements with in own normal pattern, tolerating diet without nausea or vomiting. The assessment also indicates that NEW decline in Patient's ability to transfer, ambulate, feed, bathe, dress self, and communicate has not occurred

Review of the note for patient #1 dated 8/21/2010 at 7:54 AM indicates a goal of "Restraint free and without injury."

Review of the note for patient #1 dated 8/21/2010 at 9:49 AM reveals that the patient had an oral intake of 240 cc, 100% of a solid food breakfast.

Review of the notation for patient #1 dated 8/21/2010 at 10:00 reveals that the criteria for restraint release is not met.

Review of the notation for patient #1 dated 8/21/2010 at 10:31 AM revels an order enter in the electronic record reads "ok to use soft wrist restraints to prevent pulling lines".

Review of the second tier restraint assessment for patient #1 dated 8/21/2010 at 11:41 AM reveals that restraints were assessed as appropriate.

Review of the notation for patient #1 dated 8/21/2010 at 2:00 PM reveals that the criteria for restraint release is not met.

Review of the notation for patient #1 dated 8/21/2010 at 4:00 PM reveals that the criteria for restraint release is not met.

Review of the notation for patient #1 dated 8/21/2010 at 6:00 PM reveals that the criteria for restraint release is not met.

Review of the record reveals that no assessment is completed for restraints from 6:00 PM until after patient is transferred to the surgical intensive care unit.

Review of the notation for patient #1 revealed an entry dated 8/22/2010 at 4:31 AM which indicates that an incident occurred and 4:19 AM. Review of the information recorded, regarding this incident revealed that the incident actually occurred on 8/21/2010 at 9:30 PM. It also indicates that the CNA (Certified Nursing Assistant) enter patient #1's room and noted a change in the patient color and called nurse. Patient #1's oxygen saturation was documented as being 54%.

Review of the notation dated 8/21/2010 at 9:00 PM reveals that the nurse found the patient on arrival with vomit around mouth and with green bile.

Review of the provided documentation does not reveal a date or time that the restraints for patient #1 was discontinued from admission until after transfer to intensive care.

Review of the physicians progress note dated 8/23/2010 at 9:30 AM reveals that patient #1 is status post aspiration.

Review of the notation for patient #1 dated 8/21/2010 at 7:54 AM reveals the intervention head of bead less that 30 degrees unless medically contraindicated.

Review of the bronchoscopy results for patient #1 dated 8/23/2010 reveals that the bronchoscopy is consistent with aspiration pneumonia.

Record review for patient number one reveals that the care plan has aspiration precautions implemented on 8/22/2010.

During interview on 3/31/2011 at 1:20 PM with the Patient Care Assistant (PCA) who was caring for patient #1 on 8/21/2011 from 7:00 PM to 7:00 AM he stated that he seemed to remember that he had entered the room of patient #1 to care for the roommate when he noticed a gurgling, coughing respiration from the area of patient #1, he immediately checked the patient and call for assistance.

During interview on 3/31/2011 at 2:00 PM with the physician who signed the restraint order written for patient #1 on 8/21/2010 at 06:45 AM he stated that he was not involved with the care of patient #1 and that he sign the order when it was presented, but had placed a question mark by his signature as he was not involved.

Review of the discharge summary for patient #1 dated 9/24/2010 reveals that patient #1 had aspiration pneumonitis and passed away on 8/28/10.


2.) Record review of Physicians orders for resident #6 reveals that no physicians order is present for restraints implemented on 8/18/2010.

Review of the nursing note for patient #6 dated 8/19/2010 at 5:16 AM reveals that soft wrist restraints were placed at 8:30 PM on 8/18/2010.

During interview with the Risk Manager on 3/31/2010 at 3:30 PM she stated that she could not find an order for restraints for patient #6.

3.) Review of the facility's Policy and Procedure (P&P) entitled, "Restraint and Seclusion," dated 2/10 revealed on page 14, section 4 entitled "Orders for Restraint". According to this section, "A LIP/physician order is required for restraints. The initial order must be time limited not to exceed twenty-four (24) hours, and must specify clinical justification for the restraint, the date and tome ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release." Further review of this P&P revealed,"For continuation of restraint usage beyond the initial 24 hours, the LIP/physician must see the patient and do a clinical assessment and in collaboration with other clinical staff, determine if continuation of restraint is warranted."

Review of the facility's P&P regarding restraints revealed a section entitled, "Ongoing Assessment While Patient is in Restraints". Review of this section revealed, "Assessment by an RN [a Registered Nurse] will occur immediately upon application of restraint and at least every 2 hours thereafter. The RN 2-hour assessment will include at a minimum that patient safety, readiness of release from restraint and maintenance of patient rights and dignity are addressed."
VIOLATION: PATIENT RIGHTS: SECLUSION OR RESTRAINT Tag No: A0214
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to report the death of 1 of 3 patients (#1) reviewed following the use of restraints.

Findings:

1.) Record review for patient #1 revealed that the patient was readmitted on [DATE] and that she was having nausea and vomiting. The record show that patient #1 had been discharged from the facility on 8/18/2010 after having surgery related to colon cancer. A note from the emergency department dated 8/21/2010 at 12:00 AM states that the patient has been vomiting for two days and called surgeon who told her to stop taking antibiotics and pain medicine and to take xanax 0.5 milligrams (mg) every 3 hours it also states that patient denies vomiting "just spit up like a baby."

Review of the notation for patient #1 dated 8/21/2010 at 2:47 AM reveals that the patient has a nasogastric tube and included the amount of drainage. Review of the notation for patient #1 dated 8/21/2010 at 05:30 AM revels that restraints were assessed for appropriateness and alternatives and found to be appropriate.

Review of the admission assessment for patient #1 dated 8/21/2010 at 7:54 AM reveals that the nurse notes that gastrointestinal (GI)/Nutrition is within defined parameters. The notation defines parameters as abdomen soft non tender without distention Bowel sounds present in all four quadrants Bowel movements with in own normal pattern, tolerating diet without nausea or vomiting. The assessment also indicates that NEW decline in Patient's ability to transfer, ambulate, feed, bathe, dress self, and communicate has not occurred

Review of the note for patient #1 dated 8/21/2010 at 7:54 AM indicates a goal of "Restraint free and without injury."

Review of the note for patient #1 dated 8/21/2010 at 9:49 AM reveals that the patient had an oral intake of 240 cc, 100% of a solid food breakfast.

Review of the notation for patient #1 dated 8/21/2010 at 10:00 reveals that the criteria for restraint release is not met.

Review of the notation for patient #1 dated 8/21/2010 at 10:31 AM revels an order enter in the electronic record reads "ok to use soft wrist restraints to prevent pulling lines".

Review of the second tier restraint assessment for patient #1 dated 8/21/2010 at 11:41 AM reveals that restraints were assessed as appropriate.

Review of the notation for patient #1 dated 8/21/2010 at 2:00 PM reveals that the criteria for restraint release is not met.

Review of the notation for patient #1 dated 8/21/2010 at 4:00 PM reveals that the criteria for restraint release is not met.

Review of the notation for patient #1 dated 8/21/2010 at 6:00 PM reveals that the criteria for restraint release is not met.

Review of the record reveals that no assessment is completed for restraints from 6:00 PM until after patient is transferred to the surgical intensive care unit.

Review of the notation for patient #1 revealed an entry dated 8/22/2010 at 4:31 AM which indicates that an incident occurred and 4:19 AM. Review of the information recorded, regarding this incident revealed that the incident actually occurred on 8/21/2010 at 9:30 PM. It also indicates that the CNA (Certified Nursing Assistant) enter patient #1's room and noted a change in the patient color and called nurse. Patient #1's oxygen saturation was documented as being 54%.

Review of the notation dated 8/21/2010 at 9:00 PM reveals that the nurse found the patient on arrival with vomit around mouth and with green bile.

Review of the provided documentation does not reveal a date or time that the restraints for patient #1 was discontinued from admission until after transfer to intensive care.

Review of the physicians progress note dated 8/23/2010 at 9:30 AM reveals that patient #1 is status post aspiration.

Review of the notation for patient #1 dated 8/21/2010 at 7:54 AM reveals the intervention head of bead less that 30 degrees unless medically contraindicated.

Review of the bronchoscopy results for patient #1 dated 8/23/2010 reveals that the bronchoscopy is consistent with aspiration pneumonia.

Record review for patient number one reveals that the care plan has aspiration precautions implemented on 8/22/2010.

During interview on 3/31/2011 at 1:20 PM with the Patient Care Assistant (PCA) who was caring for patient #1 on 8/21/2011 from 7:00 PM to 7:00 AM he stated that he seemed to remember that he had entered the room of patient #1 to care for the roommate when he noticed a gurgling, coughing respiration from the area of patient #1, he immediately checked the patient and call for assistance.

During interview on 3/31/2011 at 2:00 PM with the physician who signed the restraint order written for patient #1 on 8/21/2010 at 06:45 AM he stated that he was not involved with the care of patient #1 and that he sign the order when it was presented, but had placed a question mark by his signature as he was not involved.

Review of the discharge summary for patient #1 dated 9/24/2010 reveals that patient #1 had aspiration pneumonitis and passed away on 8/28/10.
During interview with the risk manager on 3/30/2010 at 12:30 PM she stated that a report on patient #1 had not been filed because he was not in restraints at the time the resident had a significant decline.


2.) Review of the facility's Policy and Procedures (P&P) entitled, "Restraint and Seclusion," dated 2/10 revealed a section entitled Reporting Requirements". Under this section it states that the facility must report to the Centers for Medicare/Medicaid Services the following deaths, "(a) Each death that occurs while a patient is in restraint or seclusion. (b) Each death that occurs within 23 hours after the patient has been removed from restraint or seclusion. (c) Each death known to the hospital that occurs within 1 week after restraint or placement in seclusion contributed directly or indirectly to a patient's death. 'Reasonable to assume' in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death to chest compression, restriction of breathing or asphyxiation."
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 ensure that the nursing staff kept a current care plan for 1 of 10 (#1) sampled patients who was in restraints.

1.) Record review for patient #1 revealed that the patient was readmitted on [DATE] and that she was having nausea and vomiting. The record show that patient #1 had been discharged from the facility on 8/18/2010 after having surgery related to colon cancer. A note from the emergency department dated 8/21/2010 at 12:00 AM states that the patient has been vomiting for two days and called surgeon who told her to stop taking antibiotics and pain medicine and to take xanax 0.5 milligrams (mg) every 3 hours it also states that patient denies vomiting "just spit up like a baby."

Review of the notation for patient #1 dated 8/21/2010 at 2:47 AM reveals that the patient has a nasogastric tube and included the amount of drainage. Review of the notation for patient #1 dated 8/21/2010 at 05:30 AM revels that restraints were assessed for appropriateness and alternatives and found to be appropriate.

Review of the notation for patient #1 dated 8/21/2010 at 3:07 AM reveals that the nasogastric tube drainage was 2600 CC.

Review of the notation for patient #1 dated 8/21/2010 at 4:08 AM reveals that the patient is on bed rest, nasogastric tube to low intermittent suction, Normal Saline with 20 meq of potassium chloride at 150 cc per hour.

Review of the note for patient #1 dated 8/21/2010 at 6:40 AM reveals a urine output of 100 cc with no out put from the nasogastric tube.

Review of the admission assessment for patient #1 dated 8/21/2010 at 7:54 AM reveals that the nurse notes that gastrointestinal (GI)/Nutrition is within defined parameters. The notation defines parameters as abdomen soft non tender without distention Bowel sounds present in all four quadrants Bowel movements with in own normal pattern, tolerating diet without nausea or vomiting. The assessment also indicates that NEW decline in Patient's ability to transfer, ambulate, feed, bathe, dress self, and communicate has not occurred

Review of the note for patient #1 dated 8/21/2010 at 9:49 AM reveals that the patient had an oral intake of 240 cc, 100% of a solid food breakfast.

Review of the notation for patient #1 dated 8/21/2010 at 10:00 reveals that the criteria for restraint release is not met.

Review of the notation for patient #1 dated 8/21/2010 at 10:31 AM revels an order "ok to use soft wrist restraints to prevent pulling lines.

Review of the second tier restraint assessment for patient #1 dated 8/21/2010 at 11:41 reveals that restraints were assessed as appropriate.

Review of the notation for patient #1 dated 8/21/2010 at 1:00 PM reveals that the Foley output was 800 cc and that no output is noted from the Asiatic tube.

Review of the notation for patient #1 dated 8/21/2010 at 2:00 PM reveals that the criteria for restraint release is not met.

Review of the notation for patient #1 dated 8/21/2010 at 4:00 PM reveals that the criteria for restraint release is not met.

Review of the notation for patient #1 dated 8/21/2010 at 6:00 PM reveals that the criteria for restraint release is not met.

Review of the notation for patient #1 dated 8/21/2010 at 6:19 PM reveals that the Foley output was 800 cc and that no output is noted from the nasogastric tube.

Review of the notation for patient #1 revealed an entry dated 8/22/2010 at 4:31 AM which indicates that an incident occurred and 4:19 AM. Review of the information recorded, regarding this incident revealed that the incident actually occurred on 8/21/2010 at 9:30 PM. It also indicates that the CNA (Certified Nursing Assistant) enter patient #1's room and noted a change in the patient color and called nurse. Patient #1's oxygen saturation was documented as being 54%.

Review of the notation dated 8/21/2010 at 9:00 PM reveals that the nurse found the patient on arrival with vomit around mouth and with green bile.

Review of the provided documentation does not reveal a date or time that the restraints for patient #1 were discontinued from admission until after transfer to intensive care.

Review of the physicians progress note dated 8/23/2010 at 9:30 AM reveals that patient #1 is status post aspiration.

Review of the notation for patient #1 dated 8/21/2010 at 7:54 AM reveals the intervention head of bead less that 30 degrees unless medically contraindicated.

Review of the discharge summary for patient #1 dated 9/24/2010 reveals that patient #1 had aspiration pneumonitis and passed away on 8/28/10.

Review of the bronchoscopy results for patient #1 dated 8/23/2010 reveals that the bronchoscopy is consistent with aspiration pneumonia.

Record review for patient number one reveals that the care plan has aspiration precautions implemented on 8/22/2010, the day after the patient aspirated.

During interview with the Risk Manager on 3/30/2011 at 5:00 PM she stated that it would be appropriate for a patient with vomiting and a naso gastric tube to be on aspiration precautions.