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.

THE VINES HOSPITAL 3130 SW 27TH AVE OCALA, FL Dec. 5, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
Based on staff interviews, facility document review and patient record review the facility failed to have an effective governing body to ensure that the medical staff practiced within the facility by-laws and State of Florida requirements, facility failed to meet the requirements for Patient Rights and Nursing Services. For this reasons, the Condition of Governing Body was found to be out of compliance

Findings:

1. Reference A0115: Based on record review and staff interviews the facility failed for 5 of 6 sampled residents (residents #1, #2, #3, #5, #6) to promote and protect the patient's rights.

2. Reference A0385: Based on staff interviews and record review the facility failed for 3 of 5, (patient #1, patient #2 and patient #3), patients, to ensure the nursing department develops, implements and updates patient care plans.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and staff interviews the facility failed for 5 of 6 sampled residents (residents #1, #2, #3, #5, #6) to promote and protect the patient's rights.

Findings:

Reference A0144: Based on interview. observation, and record review the facility failed to ensure that 5 of 6 sampled residents (residents #1, #2, #3, #5, #6) received care in an environment that protects patient physical safety and emotional health.

Reference A0145: Based on interview, observation, and record review the facility failed for 1 of 6 (residents #2) to have a system in place to protect residents from abuse and/or neglect
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview. observation, and record review the facility failed to ensure that 5 of 6 sampled residents (residents #1, #2, #3, #5) received care in an environment that protects patient physical safety and emotional health.

Findings:

Interview with the CEO, DON, and Risk Manager on 12/4/12 at 10:20 AM revealed they stated:
DON:
1.)" He (resident #1) was so psychotic, fighting a war in his mind"
2.) "Camera recording were reviewed and revealed that the door to the room (resident #1 and #2" room 402) was not opened and residents were not visualized"
3.) "On the day of the event, he (resident #1) had been uncontrollable, he was manic"
4.) "At 9:35 AM he (resident #1) received zyorexia10 mg IM but he did not settle down"
5.) "Residents are to be observed every 15 minutes, recording shows he (resident #1) was not observed"
6.) Two techs (Mental Health Techs C and D) are suspended at this time"
CEO:
1.) "The video recording (hallway 400) clearly shows that no one opened the door to check on the 2 residents (residents #1 and #2 in room 402) from 2 PM to 4 PM"

Interview with Mental Health Technician C on 12/4/12 at 5:30 PM who stated:
1.)" I was suspended without pay because of the incident (Resident #1 and #2) on 11/30/12
2.)" I can't recall if I did a check on residents in 402 (room) at 3:45 PM"
3.)" I can't be sure if those are my initials (while looking at resident #1 and #2's 15 minute check logs"
4.) "I didn't notice any unusual behavior from him (resident #1) during the day"

Interview with Mental Health Technician D at 6:18 PM on 12/4/12 who stated:
1.) "He (resident #1) got an ETO at 9:30 AM or so for hitting me in the stomach"
2.) He (resident#2) has hit me more than once but I can't remember, I didn't report it; it depends how hard they (residents) hit me as to whether or not I report it"
3.) "He (resident #1) was reported to be masturbating and I found him naked on his floor cleaning it with his shirt; I told Dr. Weinbaum in the hallway about 3 o'clock (PM) and the doctor said I know, 'I seen him' and 'I got fooled big time'
4.) "I've come in (to work) and found 11 to 7 (11:00 PM to 7 am) not filled out (15 minute checks) and I don't fill em out---I go on with my work---I don't sign it for them---I don't know what everybody else does but I don't sign them---the charge nurse checks the clipboard to see if the 15 minute checks are done but that is hit or miss.
5.) "I hope things get better after this---techs (Mental Health Techs) are not listened to and we are not given the history's of the residents"
6.) "I see the males during my 15 minute checks and hear the females voices, and if they (females) don't sound right I'll go get a female staff"
Interview with Mental Health Technician B who discovered Resident #2 unresponsive on 11/30/12 at 4:00 PM under the mattress on the floor occupied by resident #1:
1.)" I heard about his (resident #1's) masturbating; why were these two people in a room together?"
2.) "I think there should have been an assessment made (about resident #1).
3.) "Staff are burned out"
4.) "Sometimes there are not enough staff to care for the residents and residents do not receive the care they should"
Interview with Mental Health Technician F on 12/5/12 at 5:10 PM revealed he stated resident #1 was psychotic from day 1 and needed constant redirection. He added that resident #1 didn't respond well to women and repeatedly hit and kicked at them.
Record review reveals resident #1 received an ETO PRN medication Zyprexia 20 mg at 9:35 AM IM an the follow-up observation was not completed according to facility policy (assessment is required to be completed within 1 hour after ETO medication. The Medical Administration Record dated 11/30/12 did not reflect the route of administration and the dose monitoring observation (for within 1 hour of administration) was blank. The MAR was also missing the nurses signature to correspond with the initials located next to the noted Zyprexia 20 mg medication.

Video from hallway 400 at 12:05 revealed resident #1 leaving his room and entering another residents room (406). Staff interview with RN-F on 12/5/12 at 3:45 PM revealed she stated resident #1 was naked in resident #5's room and had stolen resident #5's glasses and watch. She added that resident #1 had removed his depends brief and it contained feces. RN-F reported resident #5 was in his room (406) in his bed (A bed) with the covers pulled up over his head. She added that she spoke to resident #5 only ascertain if he was the owner of the glasses and watch in resident #1' a possession. RN-F stated she did not follow up with resident #5 to check to see what occurred in his room during the time resident #1 had entered. Video evidence reveals that resident #1 was left in resident #5's room after he was discovered while staff left to obtain gloves so they could remove the fecal filled depends brief.
Record review and police report dated 11/30/12 revealed that resident #1 was combative and psychotic when found in his room on a mattress on top of his unresponsive roommate, resident #2 at 4:06 PM.

Record review revealed resident #1 had a "The Vines Hospital Integrated Assessment Level of Care Determination" dated 11/28/2012 for resident #1 which notes: Inpatient Acute Care with behavior which is life threatening, destructive or disabling to self and others. Assessment was noted as reviewed via phone with Dr. Weinbaum and Dr. Boyapati.
Psychiatric Evaluation dated 11/29/2012 for resident #1 revealed diagnosis of Schizoaffective Disorder, bipolar type, mixed episode, severe with psychotic features.
Record review revealed the resident received his Zyprexa 10 mg PRN IM medication (ETO) which was administered on 11/30/2012 at 9:40 PM for resident #1 becoming combative and striking MHT D. No documentation was noted on the MAR of first dose monitoring assessment within one hour indicating response to medication to determine if improved or not improved or if side effects were noted. Nurse's signature to correspond with nurse's initials was noted to be blank
Physician's Progress Note dated 11/30/2012 for resident #1 revealed that the patient's chart was reviewed with the treatment team. Medications were reviewed and the patient was interviewed. Resident #1 was reported to be more floridly psychotic that day and had begun stripping himself naked. Earlier that day, he was masturbating openly in his room. When seen for interview, he had ineffectively barricaded the door with sheets and blankets from his bed and his roommates bed, along with clothes. His speech was pressured and hyperverbal. He was making clang associations. His thinking was very loose. He was responding to auditory and visual hallucinations, based on observation of his behavior. He has been on Risperdal Consta 25 mg every 2 weeks at the VA Clinic and he was between 7-10 days overdue for his injection. The note reflected: He seemed worse that day for no apparent reason. He was not aggressive for the most part. He made no aggressive or threatening statements. He did start fluffing one of the gowns at the psychiatrist but did not make contact and was more annoying. Risperal Constra injection was ordered by with 50 mg IBM every 2 weeks instead of 25 mg to get his psychosis under control as quickly as possible.
Nurse's Note dated 11/30/2012 at 4:00 PM revealed that during 15 minute room check resident #1 was observed the client on a mattress in between both beds, acting out in a sexual manner, she asked him what he was doing. He looked at her and shouted "get out of here". She stepped further into the room and observed resident #2's head at the other end of the mattress. She asked the Tech-B for help with getting resident #1 off the mattress because resident #2 was under the mattress. Resident #1 was combative and was not cooperating. She was unable to detect a carotid pulse and observed no respirations. Resident #2 was lying face down and was cyanotic. She requested additional help and 3 additional RN's responded and they were able to remove resident #1 off the mattress and the mattress was removed off of resident #2. He was noted to be cyanotic and unresponsive. Resident #2 was moved to the bottom of both beds. CPR was continued and an AED was applied with 3 attempts at analyzing and no shockable rhythm was noted. EMS arrived and took over CPR and resident was transported to the hospital. Resident #1 was taken to the day room and remained under observation during the incident. Director of Nursing and Administrator were noted on the unit and police was notified and in facility at 5:30 PM. Resident #1 was discharged to police at 6:45 PM.
Resident #1 was reported to be on level I observation and precautions (every 15 minute checks) during his 2 day stay at the facility and was not upgraded to level II (line of sight) or level III (high risk 1:1). Resident #2 was assaulted in his room on 11/22/12 by his roommate resident #3. Resident #3 jumped off the roof of the screened-in porch of the facility at 5:30 PM of the same day (11/22/12). Resident #3 attempted to access the roof of the facility twice and was successful the second time resulting in his hospitalization for internal injuries.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, observation, and record review the facility failed for 1 of 6 (residents #2)
to have a system in place to protect residents from abuse and/or neglect

Findings:

1. Review of the medical record for patient #1 revealed that the patient was involuntarily admitted to the facility on [DATE] at 6:16 PM utilizing the Baker Act criteria. The patient's medical diagnosis included hypertension, [DIAGNOSES REDACTED] and renal impairment. The psychiatric diagnosis include schizoaffective disorder, bipolar type with sever psychotic features. Review of the nursing admission assessment completed on admission on 11/28/2012 revealed under the SUICIDE & HOMICIDE/VIOLENCE RISK FACTORS the patient has history of suicide attempts, lack or loss of employment, sever problems with significant others, bipolar disorder, rapid mind changes, impulsivity, and violence/threats towards others. Review of the INTEGRATED assessment dated [DATE] revealed "Patient presents with Depression and Agitated Mood, Affect - anxious and labile, Appearance - Disheveled and Un-Kempt - Thought process -pressured and racing - Patient having auditory and visual hallucinations: threatened others". Review of the Admission Physician orders revealed under Special Precautions that Q (every) 15 minutes checks are performed. The Reason sections revealed Suicidal, Assaultive and Elopement.
Review of the care plan developed 11/29/2012 for resident #1 revealed that the problem list that included 1. Depression without suicidal ideation and 2. delusions and disorganized speech. The care plan made no mention of the patient's history of suicide attempts, lack or loss of employment, sever problems with significant others, bipolar disorder, rapid mind changes, impulsivity, and violence/threats towards others. Review of the care plan did not reveal the Mental Health Technicians were made aware of the behaviors or the triggers of the patient's behaviors.

2. Review of the medical record revealed that patient #2 is a [AGE] year old male that was involuntarily admitted to the facility on [DATE] utilizing the Backer Act criteria. The medical record revealed that suffers from the following diagnoses[DIAGNOSES REDACTED]#2 was placed under suicide and seizure precautions with every 15 minute checks. He was continued on his preadmission medications, including Aricept 5 mg at bedtime for cognition and Neurontin 300 mg twice a day for neuropathy.

Review of the care plan for patient #2 revealed that problem list included only Psychosis. The short term goal was a check box for "Patient will be free form delusional thoughts that interfere with functioning for 2 days prior to discharge" and a long term goal of "Patient will demonstrate decreased reaction to internal stimuli to two times per day" Target date of 11/29/2012

Review of the Acute Adult Nursing Daily Assessment on 11/26/2012 revealed the patient was listed as being on Elopement, Aggressive/Assaultive and fall precautions, with observed behaviors recorded included Anger, Aggressive, Bizarre and Impaired judgement. Written comments included "won't keep clothes on, won't keep pull-ups on" and "Banged several times on station glass hard enough to break it. Refused V/S, difficult to keep dressed and presentable.

3. Interview was conducted on 12/4/2012 at 6:10 PM with Bernard, Mental Health Tech-D. He stated Resident #2 was escorted into his room around 3:00 PM and he noticed that resident #1 was washing the floor with a t-shirt. He left resident #2 in the room with resident #1 and closed the door and went about his work. He did not do any more checks; he stated the rest of the checks during the shift were done by Tech-C. He did notice that resident #1 was masturbating more that day and also was in a cleaning frenzy. Tech-D told the doctor that resident #1 was naked and cleaning the floor and he reported that the doctor responded that he knew (resident #1 was naked and cleaning in his room), and nothing was done. He stated Resident #2 was noted to be aggressive at times, would hit him, and refused showers. He added that Resident #2 was not easy to re-direct at times. On 11/30/2012 at 9:30 AM, resident #1 punched Tech-D in the stomach and Tech-D let the doctor know and an ETO was received. Tech D stated he learned that resident #2 was sodomized from the housekeeper. He reported that he did not know very much about resident #1, and that he did not know what his background was. He added that he did not know what would trigger resident #1's behavior; he stated he was never provided this information. He shared that he finds out what a resident is like by talking to the resident and felt he was not prepared for what happened because he wasn't provided history of resident.

4. Interview with Mental Health Technician B who discovered Resident #2 unresponsive on 11/30/12 at approximately 4 PM under the mattress on the floor occupied by resident #1:
1.)" I heard about his (resident #1's) masturbating; why were these two people in a room together?"
2.) "I think there should have been an assessment made (about resident #1).
3.) "Staff are burned out"
4.) "Sometimes there are not enough staff to care for the residents and residents do not receive the care they should"
Interview with Mental Health Technician F on 12/05/12 at 5:10 PM revealed he stated resident #1 was psychotic from day 1 and needed constant redirection. He added that resident #1 didn't respond well to women and repeatedly hit and kicked at them.

5. Review of the medical record for resident #3 revealed was re-admitted to the facility on [DATE] with the diagnosis of [DIAGNOSES REDACTED]. Included with the physician order included ETOs, (Emergency treatment orders).

Review of the medical record for patient #3 revealed Care Plan from the 11/09/2012 admission that included; 1. Schizophrenic 2, Aggressive/Assaultive Behaviors, 3 DVT, (Deep Venous Thrombus). Review of the medical records did not reveal any Care Plan approaches directed to the nursing staff including the MHTs. Review of the medical record revealed that the patient was transferred to the hospital for a condition related to the DVT.

Following medical treatment the resident was readmitted to the facility on [DATE]. Review of the medical record for the 11/19/2012 admission only revealed a ADMITTING PHYSICIANS ORDERS/INITIAL PLAN OF TREATMENT. Under the Special Precautions section the Level check every 15 minutes was checked and the reason given was Assaultive. The medical did not contain the facility's standard Care Plan or did it contain any direction that the nursing staff should take when the patient exhibits his aggressive behaviors.

Interview with Mental Health Tech D on 12/4/12 at 6:12 PM revealed he stated resident #3 rolled a metal picnic table next to the screened in porch and attempted to climb on the roof on 11/22/12 by turning the picnic table on its side. MHT D stated he "coached" resident #5 down from the picnic table and returned the picnic table to its base and moved it away from the porch/roof. MHT D stated he went to light someone's cigarette and observed resident #3 on the roof after he had turned another picnic table over on its side and successfully climbed to the roof. He stated he asked resident #3 to come down and he jumped to the ground from 8-10ft high. He stated the resident was evaluated by EMS and was taken to the hospital. When asked if the resident was on 1:1 status, MHT D stated "I don't think they have levels on adults", then stated resident #3 was on Q15 minute checks.

Record review of Justification for Restraint/Seclusion form for Resident #3, dated 11/22/12 revealed that time intervention started was noted as 1:50 AM. Personal restraint intervention and chemical restraint intervention utilized due to resident behavior that is harmful to others. At 1:40 resident #3 attempted to choke roommate (resident #2), threatened to hit resident #2 in the eye with a pencil that he had, and hit staff. Emergency Treatment Order (ETO) of Geodon 20 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM ordered and administered. Monitoring continued. Plan was to discuss with physician the possibility of resident #3 not having a roommate.

The medical record revealed that following the attack on patient #2 by patient #3, the facility patient #2 was moved in the same room as patient #1

6. Review of the Nurse's Note dated 11/30/2012 at 4:00 PM revealed that during 15 minute room check resident #1 was observed the client on a mattress in between both beds, acting out in a sexual manner, she asked him what he was doing. He looked at her and shouted "get out of here". She stepped further into the room and observed resident #2 ' s head at the other end of the mattress. She asked the Tech-B for help with getting resident #1 off the mattress because resident #2 was under the mattress. Resident #1 was combative and was not cooperating. She was unable to detect a carotid pulse and observed no respirations. Resident #2 was lying face down and was cyanotic. She requested additional help and 3 additional RN's responded and they were able to remove resident #1 off the mattress and the mattress was removed off of resident #2. He was noted to be cyanotic and unresponsive. Resident #2 was moved to the bottom of both beds. CPR was continued and an AED was applied with 3 attempts at analyzing and no shockable rhythm was noted. EMS arrived and took over CPR and resident was transported to the hospital. Resident #1 was taken to the day room and remained under observation during the incident. Director of Nursing and Administrator were noted on the unit and police was notified and in facility at 5:30 PM. Resident #1 was discharged to police at 6:45 PM.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on staff interviews and record review the facility failed for 3 of 5, (patient #1, patient #2 and patient #3), patients, to ensure the nursing department develops, implements and updates patient care plans.

Findings:

Reference H0396; Based on staff interview and record review the facility failed for 3 of 5, (patient #1, patient #2 and patient #3), to ensure that the nursing staff developed and keep current patient treatment plans.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on staff interview and record review the facility failed for 3 of 5, (patient #1, patient #2 and patient #3), to ensure that the nursing staff developed and keep current patient treatment plans.

Findings:

1. . Review of the medical record for patient #1 revealed that the patient was involuntarily admitted to the facility on [DATE] at 6:16 PM utilizing the Baker Act criteria. The patient's medical diagnosis included hypertension, [DIAGNOSES REDACTED] and renal impairment. The psychiatric diagnosis include schizoaffective disorder, bipolar type with sever psychotic features. Review of the nursing admission assessment completed on admission on 11/28/2012 revealed under the SUICIDE & HOMICIDE/VIOLENCE RISK FACTORS the patient has history of suicide attempts, lack or loss of employment, sever problems with significant others, bipolar disorder, rapid mind changes, impulsivity, and violence/threats towards others. Review of the INTEGRATED assessment dated [DATE] revealed "Patient presents with Depression and Agitated Mood, Affect - anxious and labile, Appearance - Disheveled and Un-Kempt - Thought process -pressured and racing - Patient having auditory and visual hallucinations: threatened others". Review of the Admission Physician orders revealed under Special Precautions that Q (every) 15 minutes checks are performed. The Reason sections revealed Suicidal, Assaultive and Elopement.

Review of the care plan developed 11/29/2012 for resident #1 revealed that the problem list that included 1. Depression without suicidal ideation and 2. delusions and disorganized speech. The care plan made no mention of the patient's history of suicide attempts, lack or loss of employment, sever problems with significant others, bipolar disorder, rapid mind changes, impulsivity, and violence/threats towards others. Review of the care plan did not reveal the Mental Health Technicians were made aware of the behaviors or the triggers of the patient's behaviors.
Review of the Nurse's Note dated 11/30/2012 at 4:00 PM revealed that during 15 minute room check resident #1 was observed the client on a mattress in between both beds, acting out in a sexual manner, she asked him what he was doing. He looked at her and shouted " get out of here " . She stepped further into the room and observed resident #2 ' s head at the other end of the mattress. She asked the Tech-B for help with getting resident #1 off the mattress because resident #2 was under the mattress. Resident #1 was combative and was not cooperating. She was unable to detect a carotid pulse and observed no respirations. Resident #2 was lying face down and was cyanotic. She requested additional help and 3 additional RN's responded and they were able to remove resident #1 off the mattress and the mattress was removed off of resident #2. He was noted to be cyanotic and unresponsive. Resident #2 was moved to the bottom of both beds. CPR was continued and an AED was applied with 3 attempts at analyzing and no shockable rhythm was noted. EMS arrived and took over CPR and resident was transported to the hospital. Resident #1 was taken to the day room and remained under observation during the incident. Director of Nursing and Administrator were noted on the unit and police was notified and in facility at 5:30 PM. Resident #1 was discharged to police at 6:45 PM.


2. Review of the medical record revealed that patient #2 is a [AGE] year old male that was involuntarily admitted to the facility on [DATE] utilizing the Backer Act criteria. The medical record revealed that suffers from the following diagnoses[DIAGNOSES REDACTED]#2 was placed under suicide and seizure precautions with every 15 minute checks. He was continued on his preadmission medications, including Aricept 5 mg at bedtime for cognition and Neurontin 300 mg twice a day for neuropathy.

Review of the care plan for patient #2 revealed that problem list included only Psychosis. The short term goal was a check box for "Patient will be free form delusional thoughts that interfere with functioning for 2 days prior to discharge" and a long term goal of "Patient will demonstrate decreased reaction to internal stimuli to two times per day" Target date of 11/29/2012

Review of the Acute Adult Nursing Daily Assessment on 11/26/2012 revealed the patient was listed as being on Elopement, Aggressive/Assaultive and fall precautions, with observed behaviors recorded included Anger, Aggressive, Bizarre and Impaired judgement. Written comments included "won't keep clothes on, won't keep pull-ups on" and "Banged several times on station glass hard enough to break it. Refused V/S, difficult to keep dressed and presentable.

Review of the care plan for resident #2 did not reveal a plan for the nursing staff to address the resident's behaviors included Anger, Aggressive, Bizarre, Impaired judgement and failure to keep his cloths on.

3. Review of the medical record for resident #3 revealed was re-admitted to the facility on [DATE] with the diagnosis of [DIAGNOSES REDACTED]. Included with the physician order included ETOs, (Emergency treatment orders).

Review of the medical record for patient #3 revealed Care Plan from the 11/09/2012 admission that included; 1. Schizophrenic 2, Aggressive/Assaultive Behaviors, 3 DVT, (Deep Venous Thrombus). Review of the medical records did not reveal any Care Plan approaches directed to the nursing staff including the MHTs. Review of the medical record revealed that the patient was transferred to the hospital for a condition related to the DVT.

Following medical treatment the resident was readmitted to the facility on [DATE]. Review of the medical record for the 11/19/2012 admission only revealed a ADMITTING PHYSICIANS ORDERS/INITIAL PLAN OF TREATMENT. Under the Special Precautions section the Level check every 15 minutes was checked and the reason given was Assaultive. The medical did not contain the facility's standard Care Plan or did it contain any direction that the nursing staff should take when the patient exhibits his aggressive behaviors.

Interview with Mental Health Tech D on 12/4/12 at 6:12 PM revealed he stated resident #3 rolled a metal picnic table next to the screened in porch and attempted to climb on the roof on 11/22/12 by turning the picnic table on its side. MHT D stated he "coached" resident #5 down from the picnic table and returned the picnic table to its base and moved it away from the porch/roof. MHT D stated he went to light someone ' s cigarette and observed resident #3 on the roof after he had turned another picnic table over on its side and successfully climbed to the roof. He stated he asked resident #3 to come down and he jumped to the ground from 8-10ft high. He stated the resident was evaluated by EMS and was taken to the hospital. When asked if the resident was on 1:1 status, MHT D stated "I don't think they have levels on adults", then stated resident #3 was on q 15 minute checks.
Record review reveals resident #3 received an ETO medication earlier on 11/22/12 after he attacked his roommate (resident #2) and was found choking him (resident #3's hands were observed around resident #2's neck)

The medical record revealed that following the attack on patient #2 by patient #3, the facility patient #2 was moved in the same room as patient #1.