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.

UNIVERSITY BEHAVIORAL CENTER 2500 DISCOVERY DRIVE ORLANDO, FL 32826 July 8, 2020
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and record review, the facility failed to ensure a registered nurse (RN) evaluated a patient's admission status and care needs per facility policy for 1 of 4 sampled patients (#1).

Findings:

Review of patient #1's record revealed he was admitted as an inpatient under an involuntarily Baker Acted on 5/10/2020 at 6 PM. The record showed an RN assessment "Nursing Assessment" was dated 5/11/2020 at 7:10 PM.

Review of the facility policy "Nursing Assessment-Inpatient Programs", revised 1/2020 read, ""Policy: It is the policy of (name of facility) for a registered nurse to complete a nursing assessment in a timely manner in order to obtain information pertinent to the care of the patient. Procedure: 1. The Nursing assessment form in to be completed within eight (8) hours of admission...."

On 7/07/2020 at 2:50 PM, the Chief Nursing Officer and the Risk Manager stated the nursing assessment by the RN was late and not completed per policy. They related there are situations that occur where the assessment could not be completed due to the patient's condition, however the form did not document that and therefore should have been completed within the 8 hour time frame.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to ensure that a physician ordered medication was given as ordered for 1 of 4 sampled patients (#1).

Findings:

Review of patient #1's record revealed he was admitted to the facility under an involuntary Baker Act on 5/10/2020 at 6 PM and transferred to an acute care hospital on [DATE] at 1 AM as a direct admission as requested by family. The record showed a Medication Administration Record (MAR) which listed a seizure medication called Briviact 100 milligrams (mg.) PO (by mouth) BID (twice daily). Medication administration times were documented to be given at 8 AM and 8:30 PM. There was no documentation on the MAR for the date of 5/10/2020.

The MAR documented a date of 5/11/2020 and showed the circled initials of the re3gistered nurse (RN), and the initials "N/A". The Legend on the MAR included instructions for "Meds not given- R-Refused, P-On pass, N-No consent" There was no further documentation observed on the MAR to explain what the initials N/A meant or that the medication was given or not given.

On 7/07/2020 at 3 PM, the Chief Nursing Officer and Risk Manager said the MAR showed the medication was not given and N/A meant it was not available, meaning not on the hospital formulary and unable to obtain in the facility. They replied in that case, Pharmacy would generate a non-formulary form that would be given to the physician for further decision making regarding the medication. They stated the MAR should not contain the initial of "N/A" if not given, and should have documented the reason it was not given, following the MAR legend that was provided on the form with an explanation.

Review of the facility policy "The Pharmacy Profile/Medication Administration Record, PHR-143" read, "1.0 Statement of Purpose: Pharmacy Profiles and Medication Administration Records (MAR's) will be maintained on all patients to ensure accurate and safe therapeutic regimens. 2.0 The nursing staff will maintain a Medication Administration Record (MAR) on each patient. The Pharmacy will maintain a computerized medication profile on each patient....4.2. The nursing staff will maintain Medication Administration Records and will use the MAR to document all doses given omitted, and PRN effectiveness...."
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to ensure that a physician ordered medication was given as ordered, and failed to complete the facility policy for non-formulary medication for 1 of 4 sampled patients (#1).

Findings:

Review of patient #1's record revealed he was admitted to the facility under an involuntary Baker Act on 5/10/2020 at 6 PM and transferred to an acute care hospital on [DATE] at 1 AM as a direct admission as requested by family. The record showed form "ADMISSION MEDICATION INVENTORY/RECONCILIATION ORDER FORM' that was dated as a 'T.O.R.B. (Telephone Order Read Back) on 5/10/2020 at 6 PM and signed by a registered nurse (RN). The form listed 7 medications, one being Briviact 100 milligrams (mg.) by mouth BID (twice daily) for Seizures and last taken 5/10/2020 at 9 AM. The form had a circled "Y" meaning "Continue on Admit". "Briviact (brivaracetam) is an anti-epileptic drug....is used to treat partial onset seizures in people with epilepsy...." (drugs.com).

Review of patient #1's Medication Administration Record (MAR) revealed that Briviact medication was transferred to the MAR and marked "N/A" (not available) by the RN, showing the patient did not receive the medication.

On 7/07/2020 at 3 PM, the Chief Nursing Officer (CNO) and Risk Manager (RM) revealed the MAR showed the medication was not given and N/A meant it was not available, most likely meaning not on the hospital formulary and unable to obtain in the facility. They said in that case, Pharmacy would generate a non-formulary form that would be given to the physician for further decision making regarding the medication.

In an interview with the facility Pharmacist, CNO, and RM on 7/07/20 at 3:10 PM, the Pharmacist related that when the patient arrives on the floor, the Medication Reconciliation form is faxed to the pharmacy for review and if a medication is not on the hospital formulary, the pharmacist prints a non-formulary form, fills it out, and hand walks the form across the hall to the Physician's clinical office where he sees the patients. The Pharmacist stated the physician makes a decision at that time whether to change the medication to a like medication, contact the family to bring in the medication for pharmacy review, orders it from an outpatient pharmacy, or orders it whole-sale. Review of the patient's record did not reveal any documentation in the record that the non-formulary process was performed or completed, and there was no further physician orders observed regarding the Briviact medication. A visit to the Pharmacy for computer review with the Pharmacist, CNO and RM following the interview, found a faxed medication reconciliation form for patient #1 dated 5/10/2020 at 7:45 PM, when he was transferred to the nursing unit. The computer also showed a form entitled "Non-Formulary Drug Order-Not to be place in Patient's Chart". The form showed patient #1's name, the Briviact 100 mg. medication and a date of 5/11/2020 at 8:30 AM.

At 3:15 PM on 7/07/2020, the Pharmacist related the pharmacist would print out the form, fill it out, and take it to the medical team for follow-up or leave it in the office on their desk in their locked office. She related there was no documented follow-up to this non-formulary medication found in the record, and review of the MAR revealed the patient did not receive it. The pharmacist related she comes in at 7 AM, leaves at 3:30 PM, and on-call-remote pharmacists check for any new patient medication orders until 1 AM. She related the next pharmacy review was at 7 AM.

Review of facility policy "Remote Order Entry, PHR-237 Reviewed 6/2020" read, "Statement of Purpose: To ensure that medication orders entered remotely into a patient's drug profile shall be in compliance with Board of Pharmacy rules and regulations as outlined in Florida Statutes 64B16-28.606....Procedure: 4.7.8 ..."If non-formulary, the user will leave the communication on the desktop for the pharmacist and fax the nursing unit. 4.8 All orders should be completed in MyFax until 10:00 p.m. (Do not leave orders from 8:00 p.m. without being reviewed and completed within the timeframe allotted.)....4.10 Hours on duty fir the remote entry employees: The schedule is determined by the upper management and is subject to change. The schedule is determined by the needs of each pharmacy account and contractual agreement with the client...."

Review of the facility Policy "Non-Formulary Drug Procurement PHR 121" read, "1.0 Statement of Purpose: Continuity of patient care will be assured by obtaining non-formulary medication(s) not supplied by the facility. 2.0 Statement of Policy: It is the policy of this facility to use all the resources available to procure a medication that is not on the hospital approved formulary....4.0 Procedure: 4.1 When a non-formulary medication order is received by the pharmacy dept. the medication will be evaluated to determine if a suitable alternative drug listed on the Automatic Substitution List is available (as pre-approved by the PTC members.) If an alternate medication is not on the auto sub list, the RPh (registered pharmacist) may contact the prescriber with a formulary alternative....4.2 If step 4.1 is not feasible, the Pharmacist will determine if a patient's own medication is available. If the medication was not brought into the hospital by the patient, the RPh will determine if the home supply may be obtained by sending a Non-Formulary Drug Form to the unit. When the RPh is not on duty, \the Nurse or Physician will determine if a [patient's own medication is available for use during hospitalization ."

Patient #1's record documented that the non-formulary medication, Briviact, was ordered by the physician on 5/10/2020 at 6 PM for administration dosages of BID. Documents showed the orders were faxed to the Pharmacy on 5/10/2020 by the nursing unit at 7:45 PM. There was no documentation observed that any non-formulary process was followed until a Non-Formulary Drug Order form was found documented in the Pharmacy computer with the patient's name and a date of 5/11/2020 at 8:30 AM.

Patient #1's MAR reflected that Briviact was to be given at 8 AM, and 8:30 PM. The MAR showed the patient did not receive any medications on 5/10/2020, and the patient did not receive the physician ordered Briviact Seizure medication while he was at the facility.