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.

GULF COAST MEDICAL CENTER LEE HEALTH 13681 DOCTORS WAY FORT MYERS, FL 33912 March 8, 2018
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of 3 of 5 discharge records, review of hospital policy and procedure, and interview with administrative staff, the hospital failed to ensure the care plans for 3 patients (Resident #2, #3, and #5) were not update and assessed at discharge from the facility.

The findings include:

1. Patient #2 was admitted on [DATE] and was discharged on [DATE]. Patient #3 was admitted on [DATE] and discharged on [DATE]. Patient #5 was admitted on [DATE] and discharged on [DATE]. The patient's care plan was not completed and assessed at discharge.

2. Policy and procedure Plan of Care-Interdisciplinary policy #725 revealed the following information: Problems should be resolved as the patient progresses. "All problems need to be resolved upon discharge.."

3. On 3/8/18 at 10 a.m., the associate director of nursing agreed the care plan should be completed, resolved, and assessed at discharge of the patient from the hospital. This should be done no matter what reason the patient is discharged .