AHCA found 14 incident investigations with missing information including patient elopement from facility and sexual misconduct by staff member

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:
  1. 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.”
  2. AHCA revealed that “a patient walked with group of nursing students while exiting building and eloped once approaching the front door.”
  3. 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.”
  4. 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.
  5. 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.”
AHCA cited the facility for an incident when a Mental Health Technician “came to patient’s room…while her roommate was changing. She [a resident] stated he opened the door and remained standing there until she had dressed. He then returned in ten minutes in which she had gotten out of the shower and was undressed. She stated that again he remained in the doorway until she had dressed.” AHCA found that the facility “did not contact Law Enforcement due to the ‘allegation’ of sexual misconduct as is mandated by regulation.” AHCA also noted that “the facility policy fails to identify the mandated notification to Law Enforcement specific to the allegation as stipulated.” The facility was also cited for violations of sexual misconduct related to this incident. AHCA found that “the facility [did] not have written policies and procedures describing the scope of diagnostic and therapeutic respiratory services provided to patients of the hospital, there are no documentation with written guidelines for the transfer or referral of patients requiring respiratory care services not provided at the hospital.” The Director of Nursing stated “the hospital does not have a Respiratory Department and is contracted out with Airgas and Pro* for all their Oxygen needs. DON stated that at times there are patients that require Continuous Positive Airway Pressure (CPAP) machine. She stated that the patient will bring their own CPAP machine.” The DON was also “asked if the facility has a respiratory policy and procedure for the use of CPAP” and she replied “no, it is just a verbal standard policy.” AHCA also cited the facility for failing to “provide training and education to personnel who provide respiratory care services to the patients at the facility.” AHCA also noted that the “facility does not have a written contract with an outside respiratory care services providing their respiratory needs” and cited them for violations of regulations related to the safety/quality of respiratory therapy. AHCA also cited Vines Hospital for deficiencies related to staff education and training including the mandatory Baker Act orientation, treatment planning, policies and procedures for diagnostic radiology services, quality improvement, proper storage and preparation of medication, nutritional care, housekeeping, infection control policies, and the Patient Safety Committee. The inspection report did not include a plan of correction or actions the facility needed to take to address the violations.