FLORIDA AGENCY FOR HEALTH GORE ADMINISTRATION RICK SCOTT ELIZABETH DUDEK Better Health Care for all Floridians GOVERNOR SECRETARY March 18, 2013 VIA FAX (850)3140120 Administrator Gulf Coast Treatment Center 1015 Mar Walt Dr Fort Walton Beach, FL 32547 Dear Administrator: This letter reports the findings of a recertification survey and life safety code survey conducted on March 5,2013 through March 7,2013 by representatives of this office. It was determined the Hospital was not in compliance. Attached is the 2567 provider's copy of the Statement of Deficiencies and Plan of indicating the standard level deficiencies cited. You will not receive a Correction, Form CMS copy of this report in the mail; you will only receive this faxed report. You must provide the Agency with an acceptable Plan of Correction (PoC)for all deficiencies cited within ten calendar days from receipt of the Form CMS 2567. Please complete a Plan of Correction PoC)for the deficiencies, including the date corrective action was accomplished or is anticipated to be accomplished, sign and date page 1 on the bottom, and return to this Field Office within ten calendar days of receipt. Failure to submit a reply within this time frame may jeopardize your certification status. All deficiencies must be corrected no later than April 7,2013. In order for a PoC to be acceptable, it must include the following elements: Core Elements of PoC: How the corrective action will be accomplished for individuals found to have been affected by practice; How the facility will identify other individuals who have the potential to be affected by the same deficient and the how will act to practice, facility protect individuals in similar situations; What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; the deficient How the facility will monitor its corrective actions/performance to ensure that the deficient e. what program will be put into place to practice being corrected and will not recur, i. monitor the continued effectiveness of the systemic change to ensure that solutions are is permanent; and Headquarters 2727 Mahan Drive Tallahassee, FL 32308 http:// myflorida. ahca. c om 14 Tallahassee Field Office 2727 Mahan Drive, Mail Stop # 46 Tallahassee, FL 32308 Phone 4540; 850412-Fax (850)922-9162 . Gulf Coast Treatment Center March 18, 2013 Page 2 What will be put into place or what the deficient practice does not recur; and, measures When corrective action will be systematic changes you will make to ensure that accomplished. The Quality Assurance Questionnaire has long been employed to obtain your feedback following survey activity. This form has been placed on the Agency's website at as a first http:// myflorida. Publications/ shtml ahca. c F onns. om/ step in providing a web-based interactive consumer satisfaction survey system. You may access the questionnaire through the link under Health Facilities and Providers on this page. Your feedback is encouraged and valued, as our goal is to ensure the professional and consistent application of the survey process. Thank you for the assistance 8504540. 412- provided to the surveyors. If you have questions, please contact me at Sincerely, lei Donah Field M. S. Heiberg, W. Office Manager DH/kb Enclosure BNOB Apr. No. g5$~ IN 2$ 131 1~2. ;0$ PM050KG AHCA/hWFO 12 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS OR MED CARE & MEDIC ID SERVICE STATEMENT OF bEFICIENGiI:S AND PLAN OP CORRECTION X2) UiLDINGLE IDENTIFICATION NUMHER: 104032 M)ID qN3?~ X1L~ IFICIEN¢ USIEE~ P1 TAG STATE, ZIP G¢ pE 1015 MAR WALT DR FORT WALTON BEACH, FI_32547 VMMARY STATEMENT OF DEFICII3NCIES EG QE2t3Y FUt L EtEGUI Arp OR LSC IDENTIFYING PREFIX 9 CONSTRUCTION 8,WING STREET ADDRESS, CITY, GULF COAST TREATMENT CENTER INFORMATION) 04114 pouted: 03118/2013 FORM APPROVED x+ 1 NAME OF PROVIDER OR SUPPLIER 4 PAGE ID X3) PROVIDER'S PLAN OF CORRECTION fFACI G= 3BECIUF-BF TJONSHWLt). AC--g70N.•- - Sc2MY-!, CROSS-REFERENCED TO THE A" DATE OPRIATE MEEI TAG DEFICIENCY) A 000 /INITIAL COMMENTS A 000 By submitting this plan of 1 A 167 correctior>, the facility does not admit that it violated the rules, but submits the plan: of On 315113 - 3/ 7113, an unannounced federal recertification survey was conducted at Gulf Coast Treatment Center, The hospital was found out of compliance 42 OFR Subpart A-E. correction in accordance with 452,4)( e)( ii) 13(PATIENT RIGHTS: RESTRAINT OR SECLUSION A167 i I safety of patients This Standard is not met as evidenced try: on observation and interview, the facility failed to implement their policy on the seclusion room. The window in the door had been damaged which severely impeded the viewing of patients. Based bubble"window and door a new clear window that allows the staff to continuously monitor the patientwith 2The Daily Room Check Form will be addended to include inspection of the seclusion room window. On 13 3/ 5/at 28am, Staff E was approximately 1 o: observed sitting in a choir outside a seclusion room. Staff E stated that Clier)t k14 # was In the window to the room was observed to be severely scratched and had some sort of paper pieces inside it,The window room. The appealedAl# ed' opaquee t mp# a wlew the patient a through the window, and was unable to seta her. Staff E stated that she was by the door. a second Upon time, could just make outline of a blanket. out interview was conducted with Staff E during the observation. Staff E was asked how she was able to observe the client as the window was virtually opaque, Staff E stated that ahe unlocks and opens the door in order to view what the client is ovoing. Staff E nod the door and the RY DIRECTOR'S OR PROA any d2Bciertcy statemImt ending with UPPLTER How monitored: The Room Search Forms will be reviewed daily and a report will be given to the Patient X y denotes Safety Committee monthly and Committee of the Whole quarterly. REPRESENTATIVE'S SifjiNAI 0 esteft Person(s) Responsible: Program Director Charge Assigned Staff the An LAB0 is seclusion.: 1g Replaciz>the scratched findings: looking regulations to document by the facility to actions taken A167 4)( 482.ii) 13f(PATIENT RIGHTS: RPSTRAING OR SECLUSION The facility will ensure the State law, seclusion the address the cited deficiencies. the use of restraint or seclusion must be--) ii)implemented in accordance with safe and appropriate resMnt and seolusion techniques as determined by hospital policy in accordance with The 4/ 13 7/ vR@ TRL7` DA 0 eafagwrds provide sumoient prote(diotl to the patlBnt& (deAtdency which the In58tuf+on maybe excused from cof rung providing his detem}ined that See Instruourm.)Except for nurain homes, following the date of survey ht9her or not a ~+~ plan of cprnKtion is provraed- For nursing homes, the above fr days following the date these documents aro made available to tfie fadli~r. If defldendeEt are cited, an program bertlcipation, approved pion Of oauredlon is requisite to cbnYnued other a diRfindings npisneof FORM CM8.2587(Previous Versions Obsolete 02495) EPOE11 dlodram dIF& osabiad 7a If C4r1t}n AOM MX44 PlIge 1 of 8 AP r. 1 S. 2013 12:09PM 63/ 2613 16/ 16:43 OSH 1 N No, 0245 AHC4/HQA/ 1-2 FO 6569229162 P• 3 PAbE 2 Printed: D= PARTMENT OF HEALTH AND HUMAN-5ERVICES FQI iS rC:= NTE~ I MEDICARE & MEDICAID STATEMENT OF DEFICIENCIES j AP0 PLAN OF CORRECTION IDENTIFICATION NUMBER. Qht3f2013 FORM.7. V~~ APPR~ I~ S X1) PROVIDERIsURPLIEWCLIA 85114 OMB NO. 0938WD399 X2)MULTIPLE OONSTRUQTIPN FYX3)DAZE SUiz~ A. BUILDING COMPLETED I 104432 rlAUr=OFPROVIDER j GULF 9,wINA _ 03/3 201. 081- STREETADDRESS, CITY, S ATE,ZIP GODS OR SUPPLIER COAST TREATMENT CENTER E 1015 MAR WALT DR FORT WALTON BEACH, FL 32547 J l X4 ID I PR FIX TAG I SUMMARY STATEMENT of DEFiCIFNCIFS EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR OR L60 IDENTIFYING INFORMATION) ID PREFIX TAO PROVIDE RS PLAN OF CORRECTION EACH CORFIXTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE . x awai,~ 1 tt?~ r° DATE DEFICIENCY) A 167 Continued From page 1 A167 patient was clearly visible laying on a mattress in front of door covered by a blanket The program director, who was present during the observation, Stated that thewindow was 4 A358 c)( 482.5) 22(MEDICAL Fe. ESPONS1BIL> ST'AF'ITIES F going to be replaced. facility is in the process of notifying the Medicare Office The A record review was conducted of The Seclusion/Restraint/Hold Policy dated Physlcal that it is December 2011, The policy stated, During " seclusion episodes, staff is to continuously monitor the A 358 cancelled. patient through the window of the room door, If the patient moves our c)( 482. 22(MEDICAL STAFF 5) RESPONSIBILITIES The bylaws must;) Include a requirement that-- requesting the provider number be Medicare locked quiet of direct staff view, the staff is to open the door to maintain continual visual contact with the patient." I' f.•' S . Persons A 368 Respoxxsible: uHS Division of reimbursement Facility COO How !monitored: The facility COO will K - ensure the Medicare reviewer is notified of the cancellation A medical history and physical examination be i) completed and documented for each patient no I than 30 days before or 24 hours after registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must bA completed and documented bya physician (as defined in section 1861(r) of the Act), an more i admission or Until the Medicare number is cancelled the facility will ensure a physical - will be conducted with 2,4 hours of admission oromaxiilofacial surgeon, or other qualified Individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: Based on record review and staff interview, the facility failed to obtain a medical history and physical either 30 days before or 24 hours after admission for 9 of 15 sampled patients (# 1,3, 4, 5. 16, 9, 1 2, 13, and 14). The ftndings; FORM Previous CMs• 022567( 9 9) Versions Obsolete EPOE11 If ovnllnualloo Ow "' t 2 ore, AP r. 3, 2013 12.01 PM_ 16:v3 a;term OSH IN No. 9581 AHGA/HQA/ 1FO 2 a5892t~ 1nt PAUL CE TERS FOR MEDICARE & MEDICAID SEW= IDENTIFICATION NUMBER; B 0,0938-0391 fig)laATE SURVEY A. BUrLDING 104032 NAME OF PROVIDER OR SUPPLIER O X21 MULTIPLE CONSTRUCTION DEPJSUPPLIERICLIA X9) PRO" 97/14 Printed: 2013 03/ 18/ FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN -SERVICES STATEMCNT OF DEFICIENCIES AND !'LAN OP CORf~ CCTIdN P. 7 2 COMPt IMID 8,WING_ 03/ 2013 08/ STREET ADDRESS, CITY,STATE, ZIP CODE GULF COAST TREATMENT CENTER 1015 MAR WALT OR FORT WALTON BEACH, FL 32547 M)ID 010t V SUMMARY sTATEMENt OF DEFICIENCms EAGH B>FfCIENCY-MUST 9E ~ PRECEDED BY FULL REGULATOR . - TAG aRLSCIDFffIFYfNGINFORMATION) ID I PRL41X TAG PRWOER S KAN OF COI3RECT1oN EACI-4 GORRECTIVE.4CTION SHOUi.U BE CROSS-REFERENCED TO THE APPROPRIATE n) COMPLETION DA,TF. DEFICIEW-Y) A 358 Continued From page 3 An interview was conducted with the program director on 317113 at approximately 12: 00pm, The program director stated that all of the patients A 368 required to have a medical history and physical prior to admission at Gulf Coast Treatment Center_The history and physical documentation should be located with the other documentation from the transferring facility. This were documentation A 405 was A, 405 c)( 482. 23(ADMINISTRATION 1) DRUGS OF DRUGS A 405 The facility i receiving record review and staff interview, the to ensure that new medication orders were started timely and in accordance with staW policies, Antibiotics ordered on Friday were riot started untli Monday for 2 of 15 sampled FORM 1 of 15 sampled patients, 14. # The findings: 0$OMS2587(PmAous Wrsims O 99) on verbal consent for by the patient's family, legal guardian or responsible party. 3. The prescribing physician will 1 m ip..beof_ notifjed_ a ny_= the ordered receiving medication in a timely manner. 4.All nursing staff were inserviced on the policy updates. facility failed 15.Another medication had a patients, 01 and # 13 day delay between the order and the onset for a the medication Thl' Standard-is el notnret° vident~ ed by: on the next 2This issue is contingent in accordance with the approved medical staff and procedures., poliai% Based or delivery day. regulations, including applicable licensing requirements, and administered to the patient within 12 hours of sending the RX or physician's order to the offsite pharmacy other personnel in accordance with Federal and State laws and that all 1. All medication ordered by the physician will be received and as 1) All - drugs and biologicals must be administered by, or under supervision of, nursing or now ensures medications are administered safely and efficiently. Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care and accepted tpecified under § 48212(c), standards of practice. 482.1) c)( 23( ADMINISTRATION OF not observed. 1 Persons Responsible: Program Director Charge RN Director of Nursing cdate PaEh ~ 11 conftMllon gxw Pow 4 of a AP r. 1 2013 12.01 PM 181: 201J ul~ 16:4j OSN 1 N AHCA/HQA/ 1FO 2 2 PAGE X2)MULTIPLE X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFIQATION NUMBER GULF COAST PREFIX TAG TG SURVEY X3)gAT.. CO SURv S. WING 03108/2013 STREET ADDRESS, CrrY. STATE, T.IP CODE TREATMENT CENTER 1015 MAR WALT DR FORT WAt.TON X4)ID CONSTRUCTION A BUILDING 104032 NAME OF PROVIDER OR SUPPLIER 98/14 Printed: 03118/2013 FORM APPROVED OMB Np 1 0938-039, DEPARTMENT OF }HEALTH AND HUMAN SERVICES C TERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEPICIENG158 P. 9 No. 9581 85092tJibZ SUMMARY STATEMENT OF DEFICIENCIES EACH DEFIGIENCY MUST BE PREOEpED OY FULL-REGULATORY OR I. SC IDENTIFYING INFORMATION) ID PREFIX • TAG BEACH, F!. 32547 JE PROVIDER'S PLAN OP CORRECTION ACf+ C0RRi TIQN 01W[iAG-SHOULO Be- CROSS,REFERENC0 TO THE APPROPRIA'rE xsl XMF'LETIQN - - DATE DLT& ENCY) A 405 Continued From page 4 A modioat regard review was conducted for Patient 01. On Friday, 3/ 1113, the ordered 2 different antibiotics for physician ordered Septna DS 1 for 10 A 405 How monitored: physician patient 1 # .The tablet twice daily days and Vlbramycin 100mg 1 tablet twice daily for 10 days. Both of these antibiotics were started 3 days later on Monday, 3/ 4113. An fnterview was conducted with the nurse on duty, Staff I on 317113 at app)oximately 10.30am. Staff I confirmed that 5eptra and Vibramycln did not come in from the pharmacy until 314/13- of patient files will be 100% audited + monthly to insure be ( will compliance. A, . report g iven to the patient 3/ 13 29/ Safety Committee monthly and Committee of the Whole quarterly. A medical record revleW Wat d6rldl4cted for Patient 1 # 5.On Friday, 311/13, the physician ordered the antibiotic Septra DS 1 tablet twice daily for 10 days. The antibiotic were started 3 days later on Monday, 314113, There was no evidence that the physician was notified of the defy In starting the ordered antibiotics for etttter pOtlent. An interview manager was conducted with the unit 317113 at the delay in on approximately 12.00pm starting antibiotics. She stated that the medicat physician usually comes in vri Friday adtemoons. If a prescription is not favd_ fp ph;k Lpy yj: 90Rm, Aaw n't get A regarding following Monday, The unit manager also until the stated that until they could they got a the medication consent, we calf RX Advantage not start and say "hold for consent"before medication. An Interview was filling a conducted with the Director of at about 3. 00pm regarding Nursing (DON)317113 the delay in antibiotic therapy. The ICON stated that It was her understanding that the Noifity did not need to waft on a consent to start Antlblotics. PGRM Previous Vamions Ob9olste CMS-9 02. 2097( 1) EPOEt1 9 e 119 MI'11, ,shut Pale 5 of 9 3. ttA~p r, 20130C UJf LOf LU1J 12 ; 01 10.4J OSH 1 N PM]3~ UJttJ1Ut qf~ pp AHCA/HQA/ 1-2 F0 No, 9581 2 Panted; DEPARTMENT OF HEALTH AND HUMAN SERViC6S CENTERS FO MEDICARE & MEDICAID SERVICES STATEK ENT OF 9 E% FI0IENW. X1) PROVIDERISUPPLFER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 104032 NAME OF PROVIDER OR SUPPLIER P. 10 PA(at Q9/14 03/ 2ol3 18/ FORM APPROVED FMS B NONO 093 0391 Q)MULTIPLE GONSTkUCTION X3)DATE A, 13UILOING SURVEY COMPLETED s,WING ostoor2o13 STREET ADDRESS, CITY, STATE, ZIP CODE GULF COAST TREATMENT CENTER 1015 MAR WALT DR FORT WANTON BEACH, FL 32547 X4)ID PRC+ W SUMMARY STATEMENT OF DEFICIENCIES -( EA6H BE DUr;, IENCYWT.PfiESEDED.BY FULI. RWULATO OR LSC IDENTIFYING INFORMATION) TAG III PROVIDE=R'PLAN OF 0014RECTION S ACT1ONSHOULD EACHCoRRECTw-BE PREFIX- X5) . CROSS-REFERE.TO THE APPROPRIATE KeD TAG CDMPI srlpN aA DEFICI~NGY) A 405 Continued From page 5 If the medicine was ordered pharmacy should have sent A405 on a Friday, the enough to cover until I Monday. The patient should not have to wait until Monday, Medications are supposed to be started within 12 hours.We do not keep antibiotics in the pharmacy or in the after hours or emergency kits. A medical record review was conducted for Patient 1 # 4.On 13 1/ 8/a physician ordered the laboratory tests of a TSH (thyroid-stiinOtating hormone)and QBHcg (Quantitative Beta HCG) for patient 414.After the labs were obtained, the physlolan ordered to start the medication LoLoestrin 1 tab daily.The labs were not drawn until 1125113, 17 days later, however, the medications were stared on 13. 1/ 21/ An interview was conducted with the Unit Manager on 317/13 at about 12:00pm. The unit manager stated that the ordering physician did not realize that those labs were drawn on admission, and they did not need to be obtained. The medication was late in needing a consent signed, starting due to The Emergency Drug Procurement pollcy was reviewed. The Policy stated, it " is the policy of Gulf Coast Youth Services to use all the msource5 avail bl( tto procure a medication that is needed or a patient. A mechanism exists through the night cabinet and swndary supplier to accommodate this. Part C of the procedure stated, Notify " the physician and nursing station if any undue delay Is incurred, The medication policies of M " edication Ordering, Dispensing and Administration", Emergency " Drug ProcUrement",and "Procurement and of Medications"None of the policies addressed the timeframes from the ordering of Receiving FORM OMS-2MO2-Previous versions Obsolete 89) frp0E11 If M11muffim SW Pape 6 or a Ap 3. 2013 12: 01 PM r. rJJf IOf LUL,) 16. 4J QSH 1 N No. 9581 8509k/.-; xbz AHCA/HGIA/ 1FO 2 PAGE W)MULTIPLE CONSTRUCTION X9) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER, GULF COAST X3)DATE SURVEY COMPLETED A, BUILDING 104032 NAME OF PROVIDER OR SUPPLIER 10/14 Printed; 13 03118/2C) FORM APPROVED MB NO.0938 39 DEPARTMENT OF HE= ALTH AND HUMAN S15RVICES CENTERS POR MEDICARE & MEDIC ID E VICES STATEMENT OF DEFICIENCO AND PLAN OF CORRECTION P. 11 2 B. WING a~/ 2v13 ea/ STREET ADDRESS, GrrY, STATE, ZIP CODE TREATMENT CENTER 1015 MAR WALT DR FORT WALTON BEACH, EL 32547 SUMMARY STATEMENT OF D9FICI6NCIES x4)10 ID X PREr;) EACH DEFICIENCY MUST gy_ BEPRFQEDFI} F WLL REGULAT-ORY . PREFIX TAG OR LSC IDENTIFYING INFORMATION) TAG PROVIDERS PLAN OF CORRECTION X5y EACH SHOULDC4RRECTdv~ AGTIDNg G CO_ MP4ymou DATE CP06SREFERENGEDTOTHEAPPROPRIATE DEFICIENCY) A 405 A 467 Continued From page 6 medication to the patient rooilving it, The written policies also did not discuss the stated policy that new prescription orders are faxed to the pharmacy with the notice to "hold for consent" before filling a medication. A 405 CONTENT 4$ 24( 2)( 2)( c vi) , A 467 OF RECORD - A467 INFORMATION the facility now ensures all radiology and laboratory tests are reported to the facility timely manner. II - f the xray results following, as in a are abnormal the facility will apprppriate receive All practitlaners orders, nursing notes, reports of vetreading"or a " treatment, medication records, radiology and verbal report port from the laboratory reports, and andvital_ signs_ o ther_..-, or information neceesary to 2. The .6urse wzflnotify~ ail document in the medical record the notification of the abnormal monitor the patient's condition. This Standard is not met as evidenced by; Based on record review and staff interview, the ord results of Xfacility failed to rer,. rays results in the patient medical's record for 1 of 15 sampled patients, 1. ## The facility failed to ensure that all laboratory reports were flied In the patient's' record for 1 of 15 sampled patients, 12, # The findings: 1.On 317113 a record hospital I laboratory. - results or wet reading.' 3.A hard copy will be faxed delivered to or facility. 4. All results i are filed in the patient's record, 5If the test is postponed the prescribizkg physician will be notified. review was conducted for 1.On 12114/12 the physlpfan ordered patient # an possiblefrray. thedueo n t a cture4or oseofPatient # 1,The Xray was not completed for 2 weeks, on 12/ 28112, There were no Xray results in the medical record, The unit manager called and obtained a copy of the Xray results.The report was not signed by the ordering physician. The report stated, Impression Non-displac -d fracture of the nasal bones" Afurther record review revealed no evidenoe that the physician was notified of the nasal fracture, There were no orders regarding treatment for the fracture. FORM 3/ 13 29/ The OTHER INFORMATION All records must document 482. c)( CONTEN' 24( vii) T OF RECORD AND OTHER Prevtous Versions 99) CM97( 2W % Obsolete Person Responsible: x4gtattLl7izecfor Charge Nurse How monitored: 100% of medical records and the Lab Result Book will be audited monthly, A report will be Patient given to the Safety Comm ittee monthly and Committee of the Whole quarterly. SPDE11 oonknUElron shft pap 7 or 8 Ap r,V 320 130 7y 02PM~5e920SHN 1 N AHCA/HQA/ 1FO 2 No, 9581 2 Printed: 03/ 1812013 FORM APPROVED DEPARTMENT OP HEALTH AND HUMAN SERVICES CENTERS FOR E IC rz,& MEDICAID SE ICES R STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION X2)MULTIPLE CONSTRUCTION X1} ERlCLIA PRDVlDER/SUPPL{ IDENVFICATION NUMBER; A. BUILDING 104032 a,WINCE NAME QF PROVIDER OR SUPPLIER STREUADDRISS, CITY. STATE, ZIP CODE GOO COAST TREATMENT CENTER X4)ID PREFIX 1015 MAR WALT DR FORT WALTON BrActi, FL 32547 SUMMARY STATEMENT OF DEFICIENCIES 7 TAG A 467 ID FICI~ CEONCYMUSTUP~TORY E 08YFULLREGUJ.A,f pz~ EFI? OR LSC IoENT1FYING INFORMATION) 1 Continued From Page 7 An interview was conducted with the Unit PA(.~11/1,4 TAG 1 r PRbV1DER'S ACFICi OER X3) PLAN OF CORRECTION t TNEACTION DBE.... SJ{ QUI. CON~ ET~ 4 D y, , DATE CRQ$ REFERENCED STO THE APPROPRIATE DEFICIENCY) A 467 Manager on 317113 at approximately 12:00pm. The unit manager stated that the physician had called over and told us there was no fracture. No treatment was ordered. The unit manager stated that the 2 week delay in getting the Xray was due to the patient's behaviors. There were some behavioral issues documented In the nursing notes. 2.A record review was conducted for Patient 412. On 2125113 a physician ordered a CBC with diff complete blood count with differential).On 2J26113•physicianaudnalysis-)-theo U rdered-A( for culture and sensitivity. The laboratory reports were not located in the medical record. An Interview was conducted with the unit manager on 317113 at approximately 12: 00pm. The unit manager stated that the UA and the G3C were done on February 26th. She conffribed that the laboratory results were not In the medical record and had not been seen by the The lab usually mails the reports physician. out. We either get them, or they go down to the boys unit. We have a lab log, and when we get the lab results done we makes record it. Our sure 3rd shift goes through and that we get the results, At approximately 12:12pm, the unit manager called e a an go FORM 02CMS-l2am 567(Previous e resu ts ax - Vftlans Obsolete aveF--- E150211 1r* Cfwnwoom t: sheet page a of a