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.

SOUTH FLORIDA STATE HOSPITAL 800 E CYPRESS DR PEMBROKE PINES, FL 33025 Dec. 4, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observation and interview, Registered Nurses failed to ensure adequate supervision of patients by staff according to physician orders and the care plan for 2 of 4 patients (Patients# 1 and 2). This may have resulted in a delay of necessary medical care for Patient #1 who was admitted on [DATE] with the diagnosis of stroke.

The findings included:

1) Patient #1 was admitted to the facility on [DATE]. Review of Precaution/Supervision Orders revealed Patient #1's most recent order, with status as "active," had been in place since 04/17/18 for supervision frequency (every) 30 minutes.

Evidence of 30-minute checks for Patient #1 were requested. The Director of Nursing reported the facility uses both electronic and paper records for "face checks." Logs from the electronic system were requested beginning 08/16/18 and compared to the paper records. Comparison of the 2 logs revealed no evidence of "face checks" on 08/17/18 between 8:31 PM and 9:46 PM or between 10:05 PM and 11:04 PM; no evidence of "face checks" on 08/18/18 between 5:45 AM and 7:02 AM or between 7:53 and 9:47 AM; and no evidence of "face checks" on 08/19/18 between 3:00 PM and 5:16 PM, between 5:42 PM and 7:22 PM, or between 8:05 PM and 9:28 PM.

Face Check Sheets for 08/01/18 through 08/21/18 had initials for Registered Nurse Assessment on 10 out of 40 12-hour shifts and only 3 selections out of 40 to indicate A, B, or C for whether they recommend to continue, increase, or decrease the current frequency of observations.

During interview on 12/04/18 at 4:20 PM the Director of Nursing stated the Registered Nurses should co-sign under "RN Assessment" for review of the Face Check Sheet and to indicate A, B, or C for whether they recommend to continue, increase, or decrease the current frequency of observations.

A nurse's note dated/timed for 08/20/18 at 10:42 AM documented Patient #1 was lying on the floor naked, kicked at staff when approached, presented a danger to himself and others, that de-escalation methods were unsuccessful, and he was medicated for agitation.

A nurse's note dated/timed for 08/20/18 at 1:20 PM documented Patient #1 was sent the hospital to rule out stroke at approximately 1:39 PM. However, the "face check sheet" for 08/19/18 to 08/20/18 documented that on 08/20/18 Patient #1 was "in room awake" every 30 minutes between 11:00 AM and 11:00 PM. A nurse's note dated/timed for 08/20/18 at 8:00 PM documented Patient #1 was admitted to the hospital with the diagnosis of stroke. However, the "face check sheet" for 08/20/18 through 08/21/18 documented Patient #1 was "in room asleep" every 30 minutes from 11:30 PM on 08/20/18 to 12:30 AM on 08/21/18, no entries for 1:00 AM and 1:30 AM, and again that he was "in room asleep" every 30 minutes from 2:00 AM until 6:30 AM, and that he was "in room awake" from 7:00 AM to 11:00 AM.

Picture records of the electronic "face checks" for Patient #1 were reviewed and revealed a group picture in a common area on 08/20/18 at 5:24 PM that documented Patient #1's activity as "mealtime" and his current behavior as "cooperative" although he was in the hospital at that time An entry on 08/20/18 at 6:37 PM documented Patient #1's activity as "hospital" and his current behavior as "cooperative." A group picture of multiple persons was tagged as including Patient #1 on 08/20/18 at 8:40 PM and documented Patient #1's activity as "recreational activity," behavior "cooperative," and a Note "sing happy birthday" (sic) after the nurse learned he was admitted to the hospital for stroke.

2) Electronic and paper records of 30 minute checks for Patient #2 were requested. The logs documented Patient #2 was also on 30 minute checks. Comparison of the 2 logs revealed no entries for 30 minute checks on 10/02/18 between 00:06 AM and 1:15 AM; between 10/04/18 at 11:15 PM and 10/05/18 at 1:15 AM; on 10/04/18 between 4:45 AM and 5:45 AM; on 10/12/18 between 5:15 AM and 7:07 AM; on 10/14/18 between 3:15 PM and 4:45 PM; on 10/16/17 between 3:45 AM and 4:45 AM; on 10/17/18 between 1:45 PM and 5:45 PM, between 8:45 PM and 10:08 PM, or between 10:08 PM and 11:15 PM; on 10/20/18 between 4:15 PM and 11:15 PM; on 10/23/18 between 4:15 PM and 5:45 PM; and on 10/24/18 between 3:15 PM and 11:15 PM.

During interview on 12/04/18 at 5:00 PM, the Compliance Officer stated a person on 30 minute checks must be checked every 30 minutes. During interview on 12/04/18 at 5:00 PM, the Director of Nursing, Assistant Administrator, and Risk Manager were apprised of numerous gaps in routine "face checks" and acknowledged staff should not document face checks for a person that they do not see, and that staff may not be "tagging" group pictures appropriately.

Policies and Procedures for "face checks" were requested but not provided by 5:00 PM on 12/04/18.