- Chemical ETO (Emergency Treatment Order) was initiated for a patient who was becoming increasingly agitated. AHCA noted “the form fails to contain the information regarding the initiation and termination of the chemical restraint.”
- AHCA revealed that “a patient walked with group of nursing students while exiting building and eloped once approaching the front door.”
- AHCA found that “a Post Fall Assessment was left incomplete for one incident [and] a request [was submitted] for Pharmacy to review medications to determine if medications had an effect on patient falling. This area was left blank after request.”
- AHCA found an “allegation of sexual misconduct was reported to staff when [a] male Mental Health Technician was observed standing in the room’s doorway of * female patients the day earlier, watching them in varying stages of undress.” AHCA noted that “the report fails to identify reporting to Law Enforcement, Department of Health or to the Department of Children and Families.” Two other deficiencies were cited regarding this incident.
- AHCA wrote “during routine removal of expired meds, pharmacy tech found Cardizem ER *** in the drawer pocket mixed with Verapamil ER *** mg. This patient may have received two doses of the wrong med…There is no documentation on the inspection report regarding the notification of the physician or Director of Nursing.”
Vines Hospital was cited by the Florida Agency for Health Care Administration (AHCA) for deficiencies related to incident reporting, sexual misconduct, and other standards. In its review, AHCA found 14 investigative reports initiated by the facility which were missing required information such as witness names, physician contact data with dates and times, and fields marked “N/A” when they should have been filled out. In one of the incidents investigated, a resident eloped from the facility by walking out with a group of nursing students. Another “Life Threatening/Change in Condition” incident report indicated “Patient still vomiting, not able to keep medications in; blood pressure still high. Physician notified and recommended send to hospital.” Another patient was given duplicative medication, but there was no indication of the outcome in the investigative report. Yet another patient “may have received two doses of the wrong med,” but there was no indication that either the patient’s physician or the Director of Nursing was notified. For the incidents cited in the investigation report, AHCA confirmed “the facility failed to ensure investigative reports initiated by staff and approved by the Risk Manager were completed as identified in regulation and in facility policy” for 14 identified incidents. A review of the reports revealed “the lack of information to include witness names, physician contact date with dates, times, and information identified as “N/A” when information specific to the investigation should have been included to complete the investigation.” A few examples of the incidents outlined in the report include: