fJ~/
From_
AI1CA

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366

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FOR MEDICARE & MEDICAID SERVICES

DEFIC.ENCIES
4( PLAN OF CORRECTION
U VEMENT OF

P.
015
004/

PRINTED. oe122/
FOAM APP ROVED
VE

DEPARTMEh T OF HEALTH AND HUMAN S':
RVICES

NTEAS

N104

C8/
2013
22/10:
15

OMB 0391
N0.
0938-

XI)PROVIDERJSUF PLIEFt^CUA

MULTIPLE CONSTRUCTION
2)

IDENTIFICATIOI NUMBER

X3)DATE SURVEY
COMPLETED

A. BUILDING

C
B. WING

1040 r1

ry
Vr.ME OF PROVIE ER OR SUPPLIER

O

3130 SW 27TH A/
E

OCAI.A,FL
REFIX
TAG

SUMMARY STATEMENT OF DEFICIEI ICIES
EACH DEFICIENCY MUST BE PRECEOEI)BY FULL
F:
EGIOLATORY OR LSC IDENTIFYING INFO RUTATION1

I

II

INIT AL COMMENTS

000

013

STREET ADDRESti. C17Y, STATE_ZIP CODE

ANES HOSPITAL

K4) ID

1

09

ID
PREFIX
TAG

34474

PROVIDERS PLAN OF CORRECTION
EACH CORRECTIVEACTION SHOULD BE
CROSS-Re FERENCEO TO THE APPROPRIATE

l

P
COMPLE 110N
DATE

DEFiCIENCYi

A 000

I
Unannounced compliance survey was conducted
81/13 for complaints, CCA 2013)
06384,
201-.
006833 and 2013007094, at lho Vines
Hospita, Ocala. There were discern ible
deficiencies identified during the surrey. The
CFR 492 as
facil'ry was not in compliance with 4::
it pellains to this investigation.
on

482.2)
b)(
13(PATIENT RIGHTS: INFORMED

131

A131

CONSENT
The.
3alient

or

his

or

her represenlat

I

Review of Palen[Rights
1. Revised admission policy to

as

ve (

allo%
ed under State law)has the right to make
informed decisions regarding his or Iper care.

the revieN of

or

patient's rights

include

being

notify the Nursing Director and
Baker Act Liaison via email of

reuse treatment. This right must not be
construed as a mechanism to demaiid the
provision of treatment or services deemed
or

unnecessary

or

patients who are unable to
participate in admission consents
and review of patient's rights.
The Nursing Director and Baker

inappropri;Lte.

i
This STANDARD is not met as evidr inced by.
Based on record review and staff inl erview, the

i facility failed

to determine who had a

determine the

care

samples patient
The

jthority

to

U.

Responsible person: Intake/Admissions

findings include:

2.

12!
13/and discharged c n 12126112.
facility of 12
The ))
atignt was 21 years old. The rt:
ceipt of
i Notice of Patient Rights/Resident Ric hts
12/
13/was
Responsibilities document dated 12
unsigned because patient ` poor jut Bement,

m

Act liaison will follow up to
ensure [hat this information is
reviewed with the patient once the
patient has stabilized

and treatment lot one

A review of the closed clinical record for sampled
patie-7t 63 revealed she was admitted to the

I IATORY DIRECT

OVIDE

8/
26113

admission documents with

her health status, being involved i It care
and treatment, and being a Ae to request

medically

tD include:

representative to review the

informed of his

planning
h

patient rights

attempt identifya patient

I

The

that it

ensure

clearly a.tdressed the process to be taken
when titre patient is unable to
participate in

!

i

i

UPPLIER REPRE :ENTATNE'S SIGNATURE

Director

Reed
educt[Intake Staff on:
the Wocess to

including

8128113
the

patenrs

designated representative in (he
adrr ission process as defined
by FSS.
Polil:y to notify (he Nursing Director
and the Baker Act Liaison when a
is unable to sign the
rights
er
Responsible F erson:
Intake/Admissions Director

pe F

TITLE

XE7 DATE

denote 1 a deficiency which the Institution may be excu);
ed from correcting providing pt Is datermined that
ending w;th n aslerrsk
( instructions.) Except for nursing homes, the findings slated above are disclosable 90 days
afeguards provide sufficient protection to the patient,.See
u ng the dare of survey whether or not a plan of coned 3n is provided. For nursing homes, the above findings and plans of correction are disdosable 14
I1llowing the doe these documents are made availabl ! to the tacilily. # deficiencies are cited, an apps oved plan of correctkn is requistte to continued

J )ficiency statement
r ;

M

ri rn

participation.

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If continuation sheet

Page

t of 4

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A11CA

AREA

3

FIOA

366

418

11104

16
08/
2013
22/10:

5300

PRINTED: 08122/2013
FORM APPROVED

C EPARTME-NT 01=
HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES
DEFICIENCIES
VI)PLAN OF C 3R 1ECTION
le TEMENT OF

P.
015
005/

OMB NO, 0938-0391

X))
PnOVIDER/SUPPLIERICLL4
IDENTIFICATION NUMBER:

X2)MULTIPLE CONSTRUCTION

X3)DATE SURVEY
COMPLETED

A. BUILDING

C
B.WING

104071

08/
2013
01/

N

OF PRO DICER Oa SUPPLIER

STREET ADDRESS. CITY, STATE. ZIP CODE

C5

3130 SW 27TH AVE

NES HOSPIIAL

OCALA, FL
X4)D
?

SUMMARY STATEMENT OF DEFICIENCIES

r REFIX

iEACI•I DEFICIENCY MUST BE PRECEDED BY FULL
FEGUTATORY OR LSG IDENTIFYING INFORMATION)

TAG

4131

Conl-nued From page 1

to PElilion for
I
I`

was

3.

clinical record
Notice of Right'

given a "
Writ of Habeas Corpus

patient

or

Re-ed icate
Liaison

on

I

for

Redress of Grievances' on 12113112. A
Cerlificale orProfessional Initiating Involuntary
I
Exarlinalion' dated 12/
00 PM
13112 at 3:
i
Indicated the patient had psychosis NOS and was
B2 ke r Acled at the facility, Further review of the
retold revealed the mother of patient #
3 had the
patio-it brought to the facility even though the
father of the patient was prepared to care for the

J

A

admissions consents
of admission

Requirement

physician's

agitation

note dated

mom and

ad ni iistration of

patient is stable

at 3:
42 PM,

12/
14112 stated

ask her to be health care

Ability

15 mg

or

Healthcare

on

a

ambien 10 mg.

fllg

I

have

I

health

care

2. Reedicate the

hysicisen '

s

order dated 12/
55 PM
15112 at 9:
to 20 mg po daily for mood

I inc•
ealsed ability

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pa

nursing

staff

on

tie process

I

8126/13

obtaining healthcare proxy fo1 patient's
determined to be incompetent
Respensible Person:

Baker Act -iaison

Implement a monthly

audit process of

to ensure
involuntary admissions (30 case.,.)

I

8123113

s

for

I

3.

proxy.

C1

tang

ProxyProxy

deemed incompetent
Responsible Person: Baker Act Liaison

I

phan
isici; s'order
permitted by

Proxy:

current policy and proc dur
dure
iReviea
:
i~
ifkevle ed Healthcare
ffor
Hen who

on 12114112 at 10:
00 PM
for Depakote ER 1000 mg at bedtime for
Mcoc stabilization. No evidence this medication

Cy1

and

signature/acknowledgenent

Aptysician's order dated 12114/12 at8:29 PM
Zyprexa 1.0 mg IM/Po, Ativan 2 mg
IM1pc Benadryl 50 mg IM/po for agitation and
ag!)
ssic
rE:n " .

AF

for review

patient and obtain the s
1afient'

was

I

daily on

Responsible: Person: Inlake/Admissions Director

ordered

I

to follow tip

time

the
p client to determine wt en th

admitting Physicians orders/initial

i ktivan f mg IM for

was

a.the

Peview the documents )v th the

morning (mood stabilization psychosis) ambien
10 m d q hs (insomnia).No evidence was found
he.ah 1 care proxy gave permission for the

A

8127/13
a

patient is not stable enough to
the -ights and

proxy and obtain permission from her for
medication administration ability 15 mg q

s

and Baker Act

rights

A •e),
iew of the

plE ace call

DATE

dearly understand

ple.n A treatment dated 12113112 revealed a slat
order for Haldol 10 mg IM, Benadryl 50 mg 1M
an

Nursing Director
following:

the

Notification process of ,When

palieit.

I

Xs)
COMPLETION

A 131

in;;
ig Tl, paranoid, psychotic." The
resealed the

34474

PROVIDER'S PLAN of CORRECTION
IFACII CORRECTIVE ACTION SHOL LO BE
CROSS REFERENCED TO THE APPROPRIATE
O EF ICI ENCY)

ID
PREFIX
TAG

8129113

that healthcare proxy have been obtained
for patients who are deemed incompetent

Respcnsible Person: Baker Act _iaison

I
D_
HL2396u073
Facility ?

If confh9ualion sheet

Page

2 of 4

 From=
AHCA

AREA

386

"QA

3

416

5300

11104

08/
2013
22/1017

PRINTED: 0812V2013
FORMAPPROVED

3=
PARTMENT OF HEALTH AND HUMAN:3ERVIGI S
:
f 1TE:RS FOR MEDICARE f:MEDICAID ;)
ERVIC E.S
DEFICIENCIES
Jr. PLAN OF CORRECTION

P FEI1ENr OF

P.
015
006/

OMB NO. 093B-0391

f(
t)PROVICIMSUPPLIERRA IA
IDENTIFICATION NUMB 711:

W)MULTIPLE CONSTRUCTION

M)DATE SURVEY
COMPLETED

A.BUILDING

C.

CV
o.

104071
J!Mi: OF

B. WING

PROVIDER OR SUPPLIER

STREET ADDRESS. CITY, STATE,ZIP CODE

0
z

08/
2013
01/
3130 sw 27TH AVE

1INKS HOSPITAL

OCALA, FL
SUMMARY STATEMENT OF DEFICIENCIES
EACH DEFICIENCY MUST eE PRECEDED BY FUL .
REGULATORY OR LSC:IDENTIFYING INI'
ORMATIOI I)

1K4) ID
FgEFIX

TAG

I

34474

H)

PROVIDERS PLAN OF CORRECTION

M1

PREFIX
TAG

EACH CORRECTNE ACTION SHOULD BE
CROSSREFERENCED TOTHE APPROPR•ATE

COMPLETION
OWE

DEFICIENCY)

Obtaining
4

13]'I;

Continued From page 2

A 131
1.

stabilization and psychosis. No ev dente was
found this increase in medical(on eras appr(nred
by a health care proxy.

i

Reviewed medication consent policy to
ensure

that the process for obtaining

consent from healthcare proxy when

i

physician ' s order dated 12116/12 at 5:4; AM
for ' ETO Zyprexa 10 mg,Ativan' mg.
.
Benadryl
50 mg IM now for eminent harm to others Aith
CPI hold for administ•alion.
2.
order dated 12/
36 ADA for an
17112 at 8:
increase of Depakole ER to 1500 rig at beidtime

Physician

Conduct education
a

healthcare proxy

medications when

with the consent of health care prof.y.
(
' T i3
health care proxy gave consent on 1
12/17/a at

determined to be

5:
20 PM . •

Responsible

Further review of the clinical

retort

reveah91t

A

justification

compliance

Director

for

8!
13
29/

obtaining

voluntary and

including both
involuntary patient records in the

review. This will consist of
was

Nursing

proper consent for medications

dated 121'.4/
12 at 11:45
to put hands aroind staff

for personal restraint
am for hitting and

a

retro review of 30

discharged charts per month. Oversight of the
data will be the Performance Improvement

dalc:d

kicking staff

Committee.

with ETO of Zyprexa_10 mg IM,A•
Ivan 2 Ing IM
and Benadryl 50 mg IM at 5:
50 AM. A Vinnn
hospital Integrated Assessment was dated

Petitioning of Court for Involuntary

12/
12•
13/

Placement:
8127113

t

Further review of the Ninical record revealind that
although the facility had deemed the patient was
incapable to make decisions regarding her care
and treatment and had Baker Acted the pall ant
13112, the facility had the
involuntarily on 12/
patient sign informed consent forme for DeFakote
Ambien, and Abilify cm the same c ay 12115/12,
the facility signed a document stating the rmifdenl
was unable to ask qul3stions and receive answers

1,
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8129113

incompetent

Person:

cocas review to monitor

was

49
12/
12
16/at 5:

requirement that
mus(provide consent for
a patent has been

Implement a monthly auditing process in
which the Director of Nursing will conduct a

combative toward staff " . AJustifiimtion for
PM for attempting
members neck.

on (he

13.

a

12
justification for resiralnt/seclusion c aced 1 ,JI 3/
30 PM for a " danger to sell alid others "
at 4:

Restraint/Seclusion

8126113
a

patient has been delennined to be
incompetent
Responsible Person: Nursing Director

A

r

Medication Clinsen.

1. Reviewed Baker Act law and TVH

for

policy
involuntary placement to ensure that the time
frame is in compliance to state regulations
Responsible Person: Baker Act Liaison
I

V46E61
Event II):

8129/13
2.

Implement a monthly audit process of
involuntary admissions (34 cases) to ensure fiat
healthcare proxy have been obtained for patients
Facility

ID:161123960073

If continuation sheet

Page

3 of 4

 AFEA
Fro+
AHCA
n:

3

386

HQA

416

18
08!
2013
22/10:

5300

H104

PRINTED: OE122/2013

LEPARTMENTOF AEALTHAND HUMAN SERVICES

FORMAP,'
ROVED

C ENTERS FOR MEDICARE & MEDICAID SERVICES
T;.
TEMEI4TOFOEFICIENCIES
A-)
PLAAOFCORRECTfOJ

OMB NO. 0930-0391

XI) PROVIDEP4SUPPLIERCUA

X2)MULTIPLE CONSTRUCTION

IDENTIFICATION NUMBER:

3)
DATE SLRVEY
COMPLETED

A. BUILDING

C

1X>

104071

e-WING

08101P013

N
a`

NWE OF PROVIDER OR::
UPPLIER

STREETADDRESS, CRY, STATE, ZIP CODE

O
z

P.
0071015

u NES

3130 SW 27TH AVE

HOSPITAL

OCALA, FL
SUNMARY STATEMENT OF DEFICIENCIES

K4)IO
s

REFIX

I

TAG

I

EACH DEFICIENCY MUST BE PRECEDED BY FULL
AEGUtAIORY OR LSC IDENTIFYING INFORMATION)

PREFIX

I

34474

PROVIDER'S PLAN OF CORRECTION
EACH CORRECTIVE ACTION SHOULD BE
CROSSREFERENCED TO THE APPROPRIATE

to
TAG

DEFICIENCY)

Continued =rom page 3
about treallnenl
state."

ION
OAT£

I

A 131

staling "unable/agitated

who

mental

I

I
revew of the clinical record revealed
the resident was Baker Acted on 12/
13112
Thursday)the facility failed to petition the courts
for a continied involuntary placement within 72
hours. The 72 hours would have been up on

i

Further

document
12/
18112.

deemed incompetent
Person: Baker Act Liaison

Included in (his corrective action plan
evidence of implementation of the

Policy

I

12/
16/however the law gives the
Sunday 12
i facility the next day after a weekend to petition
the courts. No evidence the facility petitioned the
court before

are

Responsible

though

i(

MPLETt

i

1

A 131

CC

I

as

plan

are:

and Procedures

Staff attestations of

training

Audit Farms

12/
12
18/could be found. A

petitioning

the court

was

found dated

I

I

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1

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Event ID:V48E It

Facility

ID.HL23%
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II oontinuation sheet P.ge 4 014