In January 2012, the Florida Agency for Health Care and Administration (AHCA) cited Manatee Palms Group Homes for uncorrected deficiencies first identified in November 2011. AHCA found the facility failed to implement written procedures in compliance with regulations, including incident investigation and reporting, staff-to-resident supervision ratios, and contraband search guidelines.
For example, the facility’s written policies for adverse incidents indicated that staff should submit incident reports to the Risk Manager, but, “no mention of the Incident Report should be made in the medical record. The incident report shall never be placed in the medical record.” To correct this policy, AHCA required Manatee Palms to “ensure a clear description of the event is documented in the medical record,” and “ensure that events requiring reporting to the Agency for Health Care Administration are reported accordingly.” The facility’s Risk Manager Coordinator also acknowledged that during investigations of adverse incidents, “they … do not look at time records for staff to determine if there was sufficient supervision at the time of the event.”
In one incident, a client was injured while “making several attempts to elope and property destruction,” and being restrained by staff. Even though the injuries were documented and the client was sent for x-rays and evaluation, there was no facility event report completed.
The facility was also unable to explain why it appeared that there was no coverage for six overlapping lunch breaks on one night shift reviewed.
As a result of this citation, the facility was required by law to submit a plan of correction to address the deficiencies.