Failures in Patient Incident Reporting & Hospital Department Coordination

The Florida Agency for Health Care Administration (AHCA) cited Manatee Palms Group Homes for failing to comply with its written procedures for incident reporting. In one case, a patient was involved in a physical altercation which resulted in scratches on her face. Not only were the injuries undocumented, but an internal investigation was not conducted to determine how the patient sustained the scratches and whether appropriate supervision was provided during the incident. In another incident, a patient was restrained for allegedly engaging in self-injurious behaviors, but a clear description of the events precipitating the restraint (and the justification for its use), as well as the staff who participated in the restraint, were not properly documented.

AHCA also cited the facility for failing to maintain an organizational chart that clearly described each division within the facility and the authority relationships between them. AHCA determined that there were no lines of designated authority to show the hierarchy of communication or responsibility between the hospital’s governing board, human resources department, the plant operations department, and the quality assurance/performance improvement departments. This breakdown is illustrated by AHCA interviews conducted with the facility’s Risk Manager and the Group Home Director. The interviews revealed that both individuals believed the other person to be their superior or “senior management.” AHCA found that the examples of incident reporting break downs previously mentioned above “supported the lack of communication between the Group Home area and the Risk Management area by the lack of oversight for the Risk Manager Designee’s work process, the lack of investigation and the lack of follow thru for the facility event.”

These line of authority breakdowns are further illustrated by an incident involving staff disciplinary actions.  A staff member was issued several corrective actions for placing patients in safety risk situations (e.g.allowing patient access to scissors and letting another patient run away), but corrective actions were not taken until three weeks later. The Group Home director even wanted this staff member terminated, but the Human Resources Department denied this request. AHCA found that “the lag time for the corrective action to take place and the lack of consideration of the Director of Group Homes’ opinion regarding the performance of a direct care staff member were evidence of the lack of communication between the area of the Group Home and the area of Human Resources.”

AHCA also found lack of coordination between other departments within the facility. Specifically, AHCA found that “the Director of Plan Operations/Safety Officer had no documented lines of authority in the Group Home area #1.” Facility records showed that out of 18 documented maintenance requests in one month, 12 were not completed, nor was a reason for non-completion documented. AHCA surveyors also provided the following example of “the lack of coordination between the Group Home area and the Maintenance area.”

Observation … revealed 2 vans in the outer parking lot. This parking lot is adjacent to the main driveway that Group Home clients walk from the bus stop thru [sic] the driveway and the vans are approximately 40 yards from this driveway. The same Group Home clients have various behaviors such as elopement, hiding, self-harm, and aggressive outbursts. … [T]he Group Home Director confirmed that the vans were not locked, that chemicals were present in the vans, that the products represented potential hazards.

Additionally, a red wooden portable building was observed on the property and “noted to have broken boards and splintered wood, … notable debris from the building was lying next to the frame. The door to the building was open and a push mower was sitting next to the building unsecured.” A work order to demolish this building was documented on June 16, 2011, but the building was still standing unsecured on November 15, 2011.

As a result, the facility had to submit a plan of corrections to address its cited deficiencies and deficient policies and practices.