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.

ST CLOUD REGIONAL MEDICAL CENTER 2906 17TH STREET SAINT CLOUD, FL 34769 June 22, 2012
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 that the nursing staff develops and keeps current a nursing care plan for each patient for 2 of 10 sampled patient records (#6 & 10).

Findings:

1. Review of records reflected patient #6's record, an [AGE] year old with documented impaired skin integrity, failed to reflect a documented plan of care addressing the actual or potential impaired skin integrity.

2. Patient #10's record, a [AGE] year old intensive care unit patient bedridden with impaired skin integrity, failed to reflect a documented plan of care addressing the actual or potential impaired skin integrity.

Interview on 6/22/12 at 4:30 p.m. with the nursing director of ICU confirmed the findings and lacked plans of care addressing the patients' potential or impaired skin integrity.
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to insure a medical history and physical (H&P) examination was completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 1 of 10 sampled patients (#8).

Findings:

Patient #8's record reflected the patient was admitted on [DATE] at 10:16 p.m. The H&P was not available on 6/22/12 at 11:45 a.m., when the record was being reviewed.

Interview on 6/22/12 at 11:45 a.m. with the director of Risk Management confirmed the H&P was not on the chart, and that when she called the physician he confirmed it was not dictated.

The facility Medical Staff rules and regulations stated that H&Ps shall be completed within 24 hour of the admission.