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.

NORTHEAST FLORIDA STATE HOSPITAL 7487 S STATE RD 121 MACCLENNY, FL 32063 Aug. 23, 2011
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on resident record review, interview with staff and family, the facility failed to ensure that a patient received care in a safe setting for one of three patients reviewed (#3).

The findings include:

An interview with the father of Patient #3 on August 22, 2011, revealed that the patient has had three surgeries from April 1, 2011 through June 29, 2011. He noted that the patient was a high fall risk.

A review of facility's records revealed that the care plan was currently one on one care while at the facility. Despite this, the patient has been unable to avoid injuring her hip which was first broken in a fall on March 29, 2011. A second surgery was required due to the facility's inability to contain the random movements of the patient using one on one care and that the first surgery was used to attempt a repair that would provide the least trauma to the patient. The second surgery was a complete hip replacement and even with one on one care the facility failed to avoid the patient's second fall. The hip was repaired again on June 29, 2011. and the patient has returned to Baptist hospital on August 19 due to swelling in the hip area.

Interview with the Director of Nursing, Chief Medical Officer and the Administrator on August 22, 2011, revealed that although the patient was on one to one care, the patient continued to reinjure her broken hip. The medical officer was working with Baptist Hospital and the surgeon to determine a better method to avoid injuries to the patient.