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.

WILLOUGH AT NAPLES, THE 9001 TAMIAMI TRAIL EAST NAPLES, FL Sept. 20, 2011
VIOLATION: EMERGENCY SERVICES Tag No: A0093
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Review of Policy and Procedures, the facility failed to have an adequate Policy and Procedure in place that addresses procedures for appraisals or emergencies, initial treatments and referrals when appropriate for patients arriving at unscheduled times.

The findings include:

On 9/19/11, a review of the Policy titled "After Hours Admissions" was reviewed. The Policy number is A-006 with an effective date of 10/1/94 and revised on 10/3/07. The review revealed under POLICY: It is the policy of the Willough at Naples to admit patients 24 hours a day, seven (7) day a week. During the hours of 8:00 a.m. and 6:30 p.m., there will be an assessment and referral counselor in the admissions office Monday through Friday. After hours and on the week-ends the nursing staff will handle all admissions."

During an interview with sampled Patient #16 on 9/18/11 at approximately 8:40 p.m., the patient said that he had been living at a local halfway house since his discharge from the hospital. He said that a male staff member at the halfway house was abusive towards him and he needed to get out. He had been admitted to their Crisis Unit and was discharged on [DATE]. A friend drove him to the hospital at about 11:30 p.m., on Thursday 9/15/11. He rang the bell and a nurse answered and let him into the hospital lobby. The Nursing Supervisor told him he had to leave and would not let him stay there. He said he showed the staff his papers about being admitted on [DATE]. The police were called and they came at about 12:15 a.m. The nurse asked the police how to get him off the property and asked if there was any way they could Baker Act him (involuntary commitment for evaluation at a psychiatric crisis unit). The police said the only way to make him leave was to swear out a warrant for trespassing
The patient said a male staff member then took him to the carwash next door because he didn't want the patient to be arrested for trespassing. The patient spent the night at the carwash. He said the police sat in their car and watched over him and he finally fell asleep at about 1:30 in the morning. He walked back to the hospital around 8:00 a.m., he was then admitted .

The patient's clinical record contains a computer generated form, which is dated 9/14/11. The form shows that Patient #16 has 60 Medicare days left and also says "Unconditional acceptance."
An interview was conducted with the Admissions Coordinator on 9/19/11 at 4:45 p.m. He stated that the patient was supposed to call the hospital and make an appointment for an assessment and the patient didn't call. The other Admission Coordinator had spoken to the Community Mental Health Center about admitting the patient. On 9/16/11, he said that he knew about the patient's potential admission and the patient had been told to call on Friday, there was a waiting list. He said that the hospital does admissions, if the assessment is done, 24 hours a day. He admitted Patient #16 right away, on 9/16/11, because someone (a patient) was leaving that day. He said that he cancelled two other patient admissions to admit Patient #16. He was asked if he told anyone about the patient sleeping at the carwash. He said as soon as he found out, he told the Administrator.
Interview with administrative staff on 9/19/11, showed they were aware of this incident. The hospital C.O.O (Chief Operating Officer) stated that they were going to discuss it in the morning meeting on Monday but due to the survey, the meeting was delayed.
When asked what policy and procedure is followed when a person presents to the hospital for admission after hours, no procedure was available. Administrative staff stated that the nurse on duty had followed the chain of command and called her supervisor. On 9/19/11, the Nursing Supervisor confirmed that the nurse called her and asked what to do. She stated that she told the nurse her gut feeling was to let him stay but "Do what you usually do."
The hospital administrative team was asked about the incident and the hospital's response. At that time, Administrative staff said that Patient #16 was not a patient of the hospital when he (MDS) dated [DATE]. Therefore it was not a case of violating patient rights, he was trespassing.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the facility failed to have in place a grievance process that addressed a written notice, a notice of decision after investigation, a contact person and date of completion for a grievance filed by 1 (Patient #15) of 23 sampled patients.

The findings include:

Patient #15 was admitted on [DATE]. The patient has a diagnosis of Bipolar Disorder and Poly Substance Abuse. The patient is oriented x 4. During an interview with the patient on 9/18/11 at approximately 8:25 p.m., the patient stated that she had made out a complaint about a week ago against a female Mental Health Technician (MT). She said that she was trying to help another patient who didn't feel well and the MT said loudly and in a mean ton, "Miss F-----, you need to take care of yourself!" The patient said it was embarrassing; she was very upset because the MT used her last name. She was asked if the hospital had gotten back to her about the complaint she said no one has talked to her about it. She said the patient's don't use last names here and she doesn't want every one knowing her last name.

Review of the hospital complaint log on 9/19/11 shows that a complaint from this patient was not listed. The patient was interviewed again on 9/20/11 at 9:50 a.m. She was asked what she did with the complaint she had turned in and she said she thought she gave it to the nurse and asked if she should fill out another one. She said that the MT ignored her last night but was giving her dirty looks. The MT had come in her room. She said "Can I help you?" to the MT and the MT started yelling at her so she asked her to leave. She said the MT said "No, I'm not leaving your room." The patient said she told the MT don't talk to me and I won't talk to you.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on patient interview, staff interview and clinical record review the hospital failed to ensure that nursing staff completed appropriate and timely assessments of patient injuries for 2 (Patients #14 and #17) of 12 sampled patients per standards of care. The hospital nursing staff failed to utilize knowledge, skills and appropriate judgment to provide quality nursing care to patients.

The findings include:

Sampled Patient #14 was admitted on [DATE] with a diagnosis of Major Depression and Poly Substance Dependence.

During an interview with the patient on 9/18/11, at approximately 8:30 p.m., he stated that he had fallen and hit his head and neck. He said that the nurses didn't do anything about it. He saw the doctor the next day and got an X-Ray.
Review of the clinical record shows that on 9/13/11 at 0800 (8:00 a.m.) a nurse documented " Pt. told me he fell in the shower last night @ 0530 (5:30 a.m.). He had soaped up both feet + when he tried to rinse off he slipped + fell . He hit his head + there is a swollen area on the occipital area (back of head). He also stated he was dizzy. Dr. L notified + consult ordered." The next nursing progress note is on 9/13/11 at 1200 (noon). The note includes a statement "Pt. also c/o HA (headache), + neck pain medicated with Ibuprophen 400 mg. Tylenol ES two p.o. (by mouth) at 1000 (1:00 p.m.). At 2000 (8:00 p.m.), on 9/13/11, a nurse documented "Pt. c/o light headedness + some nausea, medicated with Phenergan 25 mg. p.o. Dr. was notified."

Per the United States National Institute of Health web site, the symptoms of a head injury include, but are not limited to, headache, confusion, lightheadedness, dizziness, blurred vision, fatigue or lethargy, repeated vomiting or nausea, convulsions, dilation of one or both pupils of the eyes, or slurred speech.

Review of the clinical record shows that the patient's vital signs and neurological status were not assessed after the identification of a head wound. The patient complained of a headache and neck pain and received pain relieving medication without the benefit of an assessment to identify if further interventions were needed. The patient was treated for complaints of nausea on 9/13/11 at 8:00 p.m., however no assessment was completed to show if there was a potential that the nausea was related to the patient's head injury.

Nursing staff completed a consult form on 9/13/11. The form shows the reason for consult is " Pt. fell in shower, has lump on occiput + is c/o (complaining of) dizziness and constipation." The consultant's findings on 9/13/11 at 1730 (5:30 p.m.) show that the plan included a C-Spine Series (X-rays of cervical spine). An order was written 9/13/11 at 1730 for "C-Spine series Next 24 (hours). Please return to medical when results are available; Robaxin 1500 mg. 3 x daily x 3 days and Fleet Enema warmed x 2 30 min. apart tonight followed by Brown Cow x 1 dose." The order was noted by nursing staff on 9/14/11at 0200 (2:00 a.m.).

The clinical record shows that the C-Spine Series was not completed within 24 hours as ordered, it was completed on 9/15/11. The indication for the X-rays was documented as "Pain status post trauma." The patient had a medical follow up on 9/18/11 which showed " C-Spine results not available."

Further interview with the patient was conducted on 9/19/11 at 2:15 p.m. At the time of the interview, the patient was in his bedroom, lying in bed with an ice pack to the back of his head. He said that he continues to have head and neck pain. He was asked when the fall occurred. He stated that he had fallen in the evening after dinner. He said that he told the nurse at the nurse's station and they didn't do anything, they didn't touch his head, or take his blood pressure. They sent him back to bed and he had a headache that night. He said that he mentioned going to the ER (emergency room ), they said if you go to the ER they won't give you anything (meaning pain medication).

On 9/19/11 at approximately 11:55 a.m., the Registered Nurse (RN) on the patient's unit was asked if the hospital had a protocol for following up on head injuries, such as neuro-checks. The nurse said they don't have a protocol for neuro-checks, if a patient falls and hits their head we send them out (to the ER). The nurses said that she was not on duty when the patient fell and could not say why he did not go out to the hospital.

At 3:55 p.m., the Acting Director of Nurses (ADON) was asked if the hospital had a protocol for nurses to follow after a patient sustained a head injury. She said that there was no protocol and neuro-checks are completed only if ordered by the doctor.