Blackberry Center - Oglethorpe of Orlando

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 13640 Based on interview, and record review, the facility failed to ensure the medical record contained information that described the patient’s progress and response to nursing services in the form of assessments of a pulse in a patient who exhibited signs of a significant decline in one of three sampled patients, (#1). Findings: A review of the medical record for patient #1 reflected he was admitted to the facility on 7/16/20. A History & Physical read: 7/17/26 at 8:40 AM, “A 42-year-old alumnus here, he says, for psychiatric issues of depression, anxiety, insomnia, and nightmares. However, he tested positive for fentanyl, which was surprising to him. . . . Medical history: Pharyngitis, seizure disorder, hypertension, migraines, allergies. . . . Review of Systems: . . . Respiratory System: No shortness of breath, asthma/wheezing, emphysema, ... No productive or non-productive cough, no hemoptysis. No infections, bronchitis, pneumonia or other. No sinus problems... Cardiovascular: Positive for Hypertension. No rheumatic fever. No heart murmur (congenital or innocent). No palpitations... orthopnea. No angina or arrhythmia. No dizziness or lightheadedness. . . . Positive for seizure disorder... No disorder of sensation: pain/numbness/tingling. No focal weakness. . . Physical Examination: Vital signs: . . . Blood pressure 110/56, pulse 68, respiratory rate 18, oxygen saturation 97%, and temperatures 98.0 . . . Lungs: Clear to auscultation and percussion. Heart: normal... No murmur.. . . Assessment: Depression; anxiety; seizure disorder; hypertension, not evident at this time; clinical strep throat; migraine headaches.” A Psychiatric Evaluation read: 7/17/26 at 1:33 PM, “Plan / Recommendations for treatment: . . . The patient has a history of opioid use disorder and is placed on Subutex protocol, (Subutex is a synthetic opioid used to treat pain and opioid use disorder. Retrieved from https://www.ncbi.nim.nih.gov on 8/12/26). Physician Orders for Subutex dated 7/17/26 at 11:30 AM, read Subutex 4 milligrams (MG) sublingual (SL) by mouth (PO) now. Subutex 4 MG SL PO at 10:00 PM. Start Subutex protocol 7/18/26. On 7/30/26 at 4:00 PM, the Director of Nursing (DON) stated an assessment should have been done at 2:00 AM. She pointed to the Clinical Institute Withdrawal Assessment for Alcohol tool, which had a 2:00 AM time slot as the first assessment and indicated that this time also applied to the Clinical Opiate Withdrawal Scale (COWS) tool. She stated the assessment involved a check on vital signs, among other things. A nursing progress note dated 7/17/26 for the 7P-7A shift by License Practical Nurse (LPN) B indicated at 2:05 AM, the nurse alerted by the Mental Health Tech (MHT) of difficulty obtaining vitals. Please see attached note. The attached note read, At 2:05 AM, MHT A alerted this nurse that patient was sleeping and they couldn’t get his vitals and didn’t want to startle him. This nurse went in to patient’s room and assessed patient. Patient appeared to be sleeping. Patient was warm, with visual chest rise and fall. This nurse attempted to obtain blood pressure but obtained a machine reading error. MHT A reported back to this nurse that the patient’s vitals were unable to be collected. The note continued: “RN (Registered Nurse) supervisor arrived to room. Rescue measures were initiated by RN charge nurse and this nurse called 911.” On 7/31/26 at 7:18 PM, LPN B stated that MHT A found the patient’s arms under a blanket and was reluctant to uncover them and disturb him. She stated this was what was meant when she wrote, “couldn’t get his vitals.” She stated when she initially went into the room she had checked the patient’s radial and carotid pulses and found them to be present and regular. She said she thought she had documented this (review of the record revealed she did not). LPN B said that she discerned a faint radial pulse, however, this was not documented in the medical record. LPN B stated she went to see a patient with breathing problems when MHT A went for the new vital sign machine. LPN B stated when the MHT explained she could not get vital signs after obtaining a new machine, the nurse went to patient #1’s room. She stated she tried to arouse the patient without success. With no response, she called for the supervisor. A statement dated 7/18/26 by LPN B indicated, at about 2:05 AM, the MHT alerted her and she followed the MHT to the room without delay and found the patient had a pulse at this time. On 7/31/26 at 3:00 PM, LPN B stated that the preceding mention of the patient having a pulse was reported to him. He stated when he entered the room he detected a very faint radial and carotid pulse and within 2 to 3 minutes there was no pulse. Review of the medical record did not reflect any documentation of the performance of the efforts by the nurse to find a pulse. On 7/31/26 at 7:49 PM, MHT C stated he entered the patient’s room at 2:27 AM. He stated that LPN B entered with him. He said at that time, he did see the Supervisor check the patient’s neck for a pulse. Review of the Physician Order Sheet dated 7/18/26 at 2:50 AM, revealed an entry by LPN B which documented, “2:50 AM, transfer patient to hospital, indications, unresponsive.” Review of the hospital History & Physical dated 7/18/26 revealed: On Emergency Medical System (EMS) arrival the patient was asystole (without heart activity). . . The patient was completely unresponsive to all stimuli.” The Code (resuscitation effort) ended at the hospital at 3:19 AM. A review of facility policy Nursing Documentation revealed the following, “It is policy that nursing staff will maintain ongoing documentation on all patient objective data regarding the patient’s condition. The notes should include . . .the identification of any new problems that emerge during the course of treatment.” On 8/01/26 at 1:34 PM, the DON confirmed the nursing documentation policy had not been followed with respect to documenting the presence and quality of pulses that were assessed on 7/18/26 from 2:00 AM through the patient’s eventual departure to the hospital at 2:37 AM.”