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 34474 Aug. 1, 2013
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the facility failed to determine who had authority to determine the care and treatment for one sampled patient #3.

The findings include:

A review of the closed clinical record for sampled patient #3 revealed she was admitted to the facility on [DATE] and discharged on [DATE]. The patient was [AGE] years old. The receipt of Notice of Patient Rights/Resident Rights Responsibilities document dated 12/13/12 was unsigned because patient " poor judgement, insight, paranoid, psychotic. " The clinical record revealed the patient was given a " Notice of Right to Petition for Writ of Habeas Corpus or for Redress of Grievances " on 12/13/12. A "Certificate of Professional Initiating Involuntary Examination" dated 12/13/12 at 3:00 PM indicated the patient had psychosis NOS and was Baker Acted at the facility. Further review of the record revealed the mother of patient #3 had the patient brought to the facility even though the father of the patient was prepared to care for the patient.

A review of the admitting Physicians orders/initial plan of treatment dated 12/13/12 revealed a stat order for Haldol 10 mg IM, Benadryl 50 mg IM and Ativan 1 mg IM for agitation at 3:42 PM.

A physician ' s note dated 12/14/12 stated " please call mom and ask her to be health care proxy and obtain permission from her for medication administration ability 15 mg q morning (mood stabilization psychosis) ambien 10 mg q hs (insomnia). No evidence was found a health care proxy gave permission for the administration of Abilify 15 mg or ambien 10 mg.

A physician ' s order dated 12/14/12 at 8:29 PM ordered Zyprexa 1.0 mg IM/Po, Ativan 2 mg IM/po Benadryl 50 mg IM/po for agitation and aggression " .

A physician ' s order on 12/14/12 at 10:00 PM was for Depakote ER 1000 mg at bedtime for Mood stabilization. No evidence this medication was permitted by health care proxy.

A physician ' s order dated 12/15/12 at 9:55 PM increased ability to 20 mg po daily for mood stabilization and psychosis. No evidence was found this increase in medication was approved by a health care proxy.

A physician ' s order dated 12/16/12 at 5:45 AM for " ETO Zyprexa 10 mg, Ativan 2 mg , Benadryl 50 mg IM now for eminent harm to others with CPI hold for administration. "

Physician order dated 12/17/12 at 8:38 AM for an increase of Depakote ER to 1500 mg at bedtime with the consent of health care proxy. " The health care proxy gave consent on 12/17/12 at 5:20 PM .

Further review of the clinical record revealed a justification for restraint/seclusion dated 12/13/12 at 4:30 PM for a " danger to self and others " " combative toward staff " . A Justification for Restraint/Seclusion was dated 12/14/12 at 8:45 PM for attempting to put hands around staff members neck.

A justification for personal restraint was dated 12/16/12 at 5:49 am for hitting and kicking staff with ETO of Zyprexa, 10 mg IM, Ativan 2 mg IM and Benadryl 50 mg IM at 5:50 AM. A Vines hospital Integrated Assessment was dated 12/13/12.

Further review of the clinical record revealed that although the facility had deemed the patient was incapable to make decisions regarding her care and treatment and had Baker Acted the patient involuntarily on 12/13/12, the facility had the patient sign informed consent forms for Depakote , Ambien, and Abilify on the same day 12/15/12, the facility signed a document stating the resident was unable to ask questions and receive answers about treatment stating "unable/agitated mental state."

Further review of the clinical record revealed though the resident was Baker Acted on 12/13/12 (Thursday) the facility failed to petition the courts for a continued involuntary placement within 72 hours. The 72 hours would have been up on Sunday 12/16/12 however the law gives the facility the next day after a weekend to petition the courts. No evidence the facility petitioned the court before 12/18/12 could be found. A document petitioning the court was found dated 12/18/12.