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.
|CENTERS INC, THE||5664 SW 60TH AVE OCALA, FL 34474||Feb. 11, 2015|
|VIOLATION: CONTENT OF RECORD||Tag No: A0449|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, interview, revealed that nursing staff failed to have documentation of hygiene needs of care and services for 2 (#1, and #2) of 4 sample patients.
1.) Medical record review revealed patient #1 was admitted from an Assisted Living Facility under a Baker Act involuntary examination for attacking staff and residents on 12/19/2014. Was discharged from this facility to an Acute Care hospital on [DATE] for decreased responsiveness, refused medications, fluids, foods, decreased blood pressure, continued deterioration and dehydration.
On admission resident #1 was documented that she required assistance in all Activities of Daily Living (ADL) including hygiene, has Hypertension, an overactive bladder, urinary incontinence, and a suspected Urinary Tract Infection. Urinary Analysis (UA) ordered by the physician revealed a UTI ( Urinary tract infection), antibiotics were ordered.
Review of the physicians progress note on 12/21/2014 stated that this patient has been refusing her medications, has a UTI, and will not take her antibiotics.
Review of the Nursing 24 hour Progress Note revealed that for patient #1's hygiene needs, it was not documented on the 7:00 PM to 7:00 AM shift that she was assisted or total care by nursing staff on 12/21, 12/22/, 12/23, 12/24, and 12/25/2014. Review of patient #1's record with the Director of Nursing (DON) revealed that the documentation from the 12/21 to 12/25/2014 was not done.
2.) Medical record review revealed patient #2 was admitted from home under a Baker Act involuntary examination for threatening and attacking family members on 12/18/2014, and discharged from this facility on 12/28/2014.
On admission resident #2 was documented that she has a history of Bipolar and had not been taking her medications. Review of the Nursing 24 hour Progress Note revealed that for patient #1's hygiene needs, it was not documented on the 7:00 PM to 7:00 AM shift that she was assisted or total care by nursing staff on 12/26, and 12/27/2014. Review of patient #1's record with the Director of Nursing (DON) revealed that the documentation of the 12/26 to 12/27/2014 was not done.
During an interview with the Director of nursing, on 02/11/2015 at 10:05 AM, stated if the documentation is not there, then the care is not done for both patient's #1 and #2.