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.

WINTER HAVEN HOSPITAL 200 AVE F NE WINTER HAVEN, FL 33881 July 19, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and interviews the facility failed to provide nursing care and services to meet patient needs, prevent the development or worsening of pressure sores, and accurately assess the patient for 4 of 6 patients reviewed. (#2, 3, 4 and 5)

Findings included:

The policy titled, "Patient Care Team Process", policy # WHH-NCL-117, Review date 6/16, indicated the patient admission history should be initiated upon the patient's arrival to the patient care unit.

The Face Sheet indicated Patient #2 was admitted on [DATE] at 9:12 a.m. The review of the medical record failed to reveal a completed Patient Admission Data Base.

The Education Specialist in Infomatics confirmed the finding the nursing staff failed to complete the admission nursing assessment during the record review and interview conducted on 7/19/18 at 3:30 p.m.

The policy titled "Skin Care, Care of the Adult Patient Requiring" (BC-CS-914), revision date 2/18, indicated if a wound is present, the nurse should document the location, size, and wound characteristics, and reassess those indicators every shift. Measurements are done upon discovery and at least weekly. Calculate the Braden Score (an assessment indicating a patient's risk for skin breakdown) daily. If the score is less than or equal to 18, activate the pressure ulcer prevention order set. Paragraph 16 indicated the nurse should notify the physician and document in the medical record. Activate the Pressure Ulcer Management Order Set. The description of a Stage 1 Pressure Injury included the presence of blanchable [DIAGNOSES REDACTED] (redness) or changes in sensation, temperature or firmness may precede visual changes. The interventions for a Stage 1 Pressure Ulcer were to relieve pressure and apply either barrier film 2 times daily, barrier cream or ointment 2 times daily and as needed, or apply transparent film every 3 days and as needed, or apply foam or hydrocolloid dressing every 3 days and as needed.

The admission data base for patient #3 revealed the patient was admitted on [DATE], at 1738. The Admission Data base, dated 7/15/18, at 19:21, revealed that Present on Admission were: "Port, Pressure Ulcer/Redness/Bruising (location not specified). The Braden Score was documented at 19. Other nursing documentation on 7/15/18 included "skin not intact, abdominal bruising, coccyx-[DIAGNOSES REDACTED], blanchable. No care plan for prevention or treatment of pressure ulcers was found. Documentation in Clinical Patient Information on 7/15/18 found that the skin integrity was "intact" (contradictory to the admission database documentation). The skin was also documented as "intact" on 7/16/18. On 7/17/18 the skin was documented as "intact" and a Gaymar Mattress, Pillow was documented in use at 2100 and heels were floated. On 7/18/18 at 0814 the skin integrity was documented as "not intact". The Braden Score was documented at 15 on 7/18/18. On 7/18/18 at 1630 orders to "Activate Pressure Ulcer Prevention" which includes application of the Alevan foam pad. No Nursing documentation of wound description, location, staging, care planning, or notification of the physician or wound care nurse could be located in the record at the time of the survey.

Review of the Face Sheet of Patient #4 revealed that the patient was admitted to the facility on on [DATE], at 1710 and discharged on [DATE], at 1658. The Braden Scale ranged from 20 to 22 with the exception of 18 on 4/29/18. Nursing documentation on 4/28/18 revealed "coccyx red". The Braden Score generated the order "Activate Pressure Ulcer Prevention Protocol" on 4/29/18. Nursing documentation on 5-1-18 revealed "skin not intact" and on 5/1/18 at 3:51 pm revealed "tear" (location not specified). No Nursing documentation of wound description, location, staging, care planning, interventions or notification of the physician or wound care nurse could be located in the record. The physician documentation in the Discharge Summary, dated 5-2-18, at 14:27 pm revealed "no rashes" and did not document any skin breakdown.

The Face Sheet indicated Patient #5 was admitted on [DATE] at 5:48 a.m. for an elective surgical procedure. The shift assessment dated [DATE] at 8:55 p.m. included the patient's Braden score was 20. The skin integrity documentation indicated Patient #5 had a blanchable area on his coccyx. The detailed review of the medical record failed to reveal any evidence the nurse activated the Pressure Ulcer Management Order Set. There was no evidence the physician was notified. There was no evidence the wound was measured at any time during the patient's hospitalization . There was no evidence of reassessment of the blanchable area on Patient #5's coccyx in subsequent nursing shift assessments. The physician's order dated 7/6/18 at 6:00 p.m. included an order for the Wound Care Nurse to assess the patient. The detailed review of the medical record failed to reveal evidence Patient #5 was assessed by the Wound Care Nurse. The Consultation Report dated 7/6/18 at 9:00 p.m. and signed by the physician wound care specialist indicated Patient #5 had a Stage 3 pressure ulcer of his coccyx at the time of the physician's examination. The report did not include measurements of the wound. The Physician Progress Note dated 7/19/18 at 12:00 p.m. and signed by the attending physician included documentation Patient #5 now had a Stage 4 pressure ulcer of the coccyx.

The Education Specialist in Infomatics confirmed the finding the nursing staff failed to provide nursing care and services related to pressure ulcer treatment in compliance with facility policies during the record review and interview conducted on 7/19/18 at 5:35 p.m.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and interview, the facility failed to provide an appropriate discharge plan for two of six patients reviewed (#4 and 6).

Findings included:

In response to a request to provide all policies and procedures related to discharge planning, the facility provided the policy titled, "Discharge Planning", policy # BC-CC-104, revised 3/17. The policy indicated the final discharge note would reflect the services arranged upon discharge to include the discharge destination, the level of care needed, and the name of the agency providing care. The policy did not include any reference to procedures to be followed related to referring a patient for home health care services.

The Face Sheet for Patient #4 indicated the patient was admitted on [DATE] at, 1710 and discharged on [DATE], at 1658. A Care Coordination note dated 4/26/18, at 10:17 am documented "discussed HH (home health care) and that would be an option for patient at discharge." A physician's order, dated 5/2/18 at 12:57 p.m., documented "to home with home health." The Discharge Summary, dated 5-2-18, at 2:27 pm documented "consult to Home Health Care." The Care Coordination note dated 5-2-18, at 14:34 pm documented discharged to home with home health care. Further review of the record revealed that a Care Coordination Note was entered on 5/10/18, at 12:13 pm indicating "received call from Home Health Agency states they did not receive any HH orders for patient after discharge. CTC reviewed the chart and there were no HH orders placed for this patient. DME (durable medical equipment) orders where placed for a 2 w (heel) walker, which patient received. Per Home Health Agency the daughter called about patient's HH and was referred to a Home Health Agency for staffing for HH."

The Face Sheet indicated Patient #6 was admitted on [DATE] at 9:32 p.m. and discharged on [DATE] at 12:02 p.m. The Care Coordination note dated 5/1/18 at 3:19 p.m. indicated Patient #6 had been receiving home health care services prior to admission. The Care Coordinator informed the patient's nurse that Patient #6 would require a physician order to resume home health care with the agency he was established with, at the time of his discharge. The note indicated the nurse stated she would inform the patient's physician. The Physician's Order dated 5/3/18 at 11:59 a.m., three minutes prior to the patient's discharge, included an order to provide home health care to Patient #6 at the time of discharge. The detailed review of the medical record failed to reveal evidence of the name of the home health care agency or that services had been arranged at the time of the discharge of Patient #6.

The record for Patient #6 included documentation the referral to the home health care agency was sent on 5/10/18. The home health care agency acknowledged receipt of the referral and indicated Patient #6 would receive his first post-discharge home health visit on 5/11/18, 8 days following the patient's discharge. The visit log indicated Patient #6 was readmitted on [DATE].

An interview was conducted with the RN Care Manager on 7/19/18 at 4:00 p.m. She indicated the referral to the home health care agency should have been sent on or before the patient's discharge date to ensure the patient was evaluated by a registered nurse within 24 hours of the patient's departure from the hospital. The RN Care Manager confirmed the finding the discharge plan was not implemented on a timely basis for Patient #6.