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Based on complaint survey PR00000593, review of facility employee list for the nursing department, review of jobs descriptions and interview with Ethic Coordinator (employee #1) it was determined that the facility failed to ensure that all personnel are licensed in accordance with State Law Number 254 of December 31, 2015 and federal requirements for 38 out of 38 Nursing Assistance (AE) and 9 out of 9 Mental Health Assistance (ASM).

Findings include:

On 04/06/17 at 9:35 am on interview Ethic Coordinator (employee #1) stated that "some AE are License Practical Nurse (LPN) and others are studying nursing. In the list the ones that are identified as LPN they have their credentials as LPN but the appointment is as AE. On 4/06/2017 at 9:45 am during the review of the nursing personnel list it was identified that the facility have as employee AE and ASM. The Jobs descriptions of the AE describe as responsibilities: Take Vital Sign (V/S), Electrocardiogram, Dextro and other nursing responsibilities. The ASM Jobs description describe as responsibilities Bathing assistance, Feeding assistance, V/S documenting in the clinical record and other nursing responsibilities.

The facility failed to ensure that the personnel who provide clinical interventions comply with the State Law Num. 254 of December 31, 2015 which regulates the nursing practice in Puerto Rico. The Nursing Assistance AE and Mental Health Assistance ASM are not contemplated in the Puerto Rico state law and did not have a valid certification or license for Puerto Rico.

Base on complaint survey PR00000593, sixteen Credential file (C.F.) review with Risk Management Coordinator (employee #2), it was determined that the facility failed to comply with federal and state local law related to Influenza Vaccine, in accordance to State Administrative Order #333 of 2/5/15 of the Department of health, Health Certificate, Membership of the College of Professional Nurses, CPR, Hepatitis B vaccine, Health Certificate, Law 300 and Membership of the College of Medical Surgeons of Puerto Rico. Deficiencies were identified on 16 out of 16 C.F reviewed (8 Physician (MD) MD#1, MD#2, MD#3, MD#4, MD#5, MD#6, MD#7, MD#8, ( 8 Health care personnel credential files ) (CF#1, CF#2, CF#3, CF#4, CF#5, CF#6, CF#7 and CF#8).

Findings include:

During the review of 8 employees C.F. with Risk Management Coordinator (employee #2) on 3/6/17 from 1:00 till 4:20 pm it was found the following:

1. Seven out of eight MD credential files did not provided evidence of an updated influenza vaccine accordance to State Administrative Order #333 of 2/5/15 of the Department of health (MD#1, MD#3, MD#4, MD#5, MD#6, MD#7, and MD#8).

2. One out of eight MD credential file did not provided evidence of an updated health Certificate (MD#8).

3. One out of eight MD credential file did not provided evidence of an updated membership of the college of Medical Surgeons of Puerto Rico (MD#8).





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During the review of 8 employees C.F. review on 3/6/17 from 1:00 till 4:20 pm it was found the following:

4. Five out of eight C.F credential files did not provided evidence of an updated influenza vaccine accordance to State Administrative Order #333 of 2/5/15 of the Department of health (CF#4, CF#5, CF#6, CF#7 and CF#8).

5. Two out of eight C.F credential file did not provided evidence of an updated health Certificate (CF#7 and CF#8).

6. Three out of eight C.F credential file did not provided evidence of an updated membership of the College of Professional Nurses (CF#1, CF#2 and CF#7).

7. One out of eight C.F credential file did not provided evidence of an updated CPR (CF#8).

8. Two out of eight C.F credential file did not provided evidence of the three Hepatitis B Vaccine (CF#7 and CF#8).

9. One out of eight C.F credential file did not provided evidence of the sing duties and responsibilities (CF#3).

10. One out of eight C.F credential file did not provided evidence of the back ground check "law 300" (CF#6).

Based on complaint survey PR00000593, review of facility policy and procedure manual and abuse and neglect policy with the Ethic Coordinator (employee #1) on 4/5/17 from 10:20 am till 1:00 pm, it was determined that the facility failed to maintain mechanisms or Protocol in place that ensure patients are free of all forms of abuse or harassment that follow the seven components necessary for effective abuse protection: Prevent, Screen, Identify, Train, Protect, Investigate, Report/Respond.

Finding Include:

During the review of facility policy and procedure manual and abuse and neglect policy on on 4/5/17 from 10:20 am till 1:00 pm, it was found that the facility provide and policy related to Management of possible case of abuse and neglect that description what the nursing personnel go to do in case that observe during the initial assessment sign of abuse.
However no evidence was provided related and abuse and neglect protocol that follow the seven component needed as Prevent, Screen, Identify, Train, Protect, Investigate, Report/Respond for an effective abuse protection.

Based on complaint survey PR00000593, record review (R.R.) and interview performed from 4/5/17 until 4/6/17 it was found that the facility failed to maintain the medical records accurately and completely documented for 9 out of 30 medical records (R.R. #4, #7, #9, #11 ,#12 ,#22, #23, #27, and #29).

Findings include:

1. Patient #9 is a 57 years old male patient, admitted on 03/14/2017 with a diagnosis of Bipolar Disorder. On 04/05/2017 at 1:45 pm the record review was performed, the following was found:

a. There is evidence that the physician order a dextrostix (DXT) before each meal. On 3/16/17 the DXT was taken at 6:00 am and at 5:45 pm; however there is no evidence that the DXT was taken before lunch time as ordered.

b. There is evidence in the "Observation of the Patient form" that the mental health specialist (MHS) documented that the patient was eating from 12:00 pm until 12:30 pm on 3/16/17.

c. Nursing progress notes for 3/16/17 were not found.

During interview with the Ethic and Joint Commission Coordinator (employee #1) on 4/5/17 at 2:23 pm, he stated: "There is a medical order for DXT before each meal and a cover, probably the DXT was taken but not documented. The nursing progress notes for 3/16/17 were not found."

2. Patient #29 is a 66 years old female patient, admitted on 03/29/2017 with a diagnosis of Mixed Bipolar Disorder. On 04/05/2017 at 4:07 pm the record review was performed, the following was found:

a. There is evidence that the nursing progress note from 3/30/17 of 6:00 pm and 4/2/17 of 5:30 am are not signed.

3. Patient #22 is a 70 years old male patient, admitted on 03/21/2017 with a diagnosis of Exacerbation of Chronic Paranoid Schizophrenia. On 04/05/2017 at 4:30 pm the record review was performed, the following was found:

a. There is evidence that the document for the evaluation of the cranial nerves does not have the date and time that it was signed by the physician.

b. Nursing progress note from 3/21/17 of 9:30 pm is not signed for the personnel who documented.

c. Vital Signs Chart form to document vital signs taken on 3/27/17, 3/28/17, 3/31/17, and 4/3/17 were not signed by the personnel who perform the procedure.





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4. Patient #4 is a 77 years old female patient, admitted on 02/21/2017 with a diagnosis of Mayor Depression with Psychosis. On 04/05/2017 at 11:23 am the record review was performed and the following was found:

a. The sheet of the clinical summary and examination at the time of the transfer (Resumen Clinic y Examen al momento del Traslado) made on 2/27/17 at 12:10 pm lack of the patient and / or representative / family member signature, date and time authorizing the transfer to the Hospital San Francisco by ambulance. Likewise, lack of the patient's and / or the caregiver's / family's signature as they received orientation from the physician explaining why she were moving to another hospital facility.

b. On the vital signs sheet of the patient that on February 28, 2017 at 8:00 am written and signed by nursing that was took vital signs; when this patient was already admitted to another hospital.

c. On the patient observation form (Formulario de Observacion a Paciente) of 02/26/17 from 11:00 pm to 7:00 am, it was found that the name and signature of the LPN filling out the form was not legible. The sheet provides for the name to be printed and provided for signature.

During interview with the Director of Nursing (DON) (employee #3) on 4/5/17 at 2:45 pm, he stated: "Maybe it was a mistake. Probably the LPN took the wrong record at the moment of write the vital sign."

5. Patient #11 is an 81 years old female patient, admitted on 03/13/2017 with a diagnosis of Mayor Depressive Disorder Psychosis. On 04/05/2017 at 4:10 pm the record review was performed and the following was found:

a. The sheet of the clinical summary and examination at the time of the transfer (Resumen Clinico y Examen al momento del Traslado) made on 3/27/17 at 9:00 pm lack of the patient and / or representative / family member signature, date and time authorizing the transfer to the Hospital San Francisco by ambulance.

b. On the vital signs sheet of the patient date March 22, 2017 it was identified that at the morning shift patient vital sign was not took by the nurse.

6. Patient #7 is a 74 years old male patient, admitted on 03/05/2017 with a diagnosis of Mayor Depressive Disorder Recurrent Severe without Psychotic Features. On 04/05/2017 at 1:20 pm the record review was performed and the following was found:

a. The sheet of the clinical summary and examination at the time of the transfer (Resumen Clinico y Examen al momento del Traslado) made on 3/7/17 at 10:30 pm lack of the patient and / or representative / family member signature, date and time authorizing the transfer to the Veterarn Adminsitration (VA) Hospital by ambulance.


7. Patient #12 is a 63 years old male patient, admitted on 03/27/2017 with a diagnosis of Mayor Depressive Disorder Recurrent Severe without Psychotic Features. On 04/05/2017 at 3:44 pm the record review was performed and the following was found:

a. The sheet of the clinical summary and examination at the time of the transfer (Resumen Clinico y Examen al momento del Traslado) made on 3/27/17 at 9:10 pm lack of the patient and / or representative / family member signature, date and time authorizing the transfer to the Hima Cupey by ambulance. Likewise, lack of the patient's and / or the caregiver's / family's signature as they received orientation from the physician explaining why she were moving to another hospital facility.



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8. RR#27 is a 56 years old male patient, admitted on 04/04/2017 with a diagnosis of Schizophrenia. On 04/05/2017 at 1:30 pm during record review the following was found:

a. There is an influenza vaccine form named "Vacunacion Contra La Influenza En Pacientes Hospitalizados" and is sing by the RN and dated on 04/04/2017 at 11:45 am. In the form is check marked as the patient refused the influenza vaccine but the patient, family member or the authorized person in charge of the patient did not sing the form refusing the vaccine. No evidence was found on the medical record of the reason for the missing signature.

9. RR#23 is a 79 years old male patient, admitted on 04/01/2017 with a diagnosis of Schizophrenia. On 04/05/2017 at 4:30 pm during record review the following was found:

a. There is an influenza vaccine form named "Vacunacion Contra La Influenza En Pacientes Hospitalizados" and is sing by the RN and dated on 04/01/2017 at 3:00 am. In the form is check marked as the patient is vaccinated with the influenza vaccine but the patient, family member or the authorized person in charge of the patient did not sing the form refusing the vaccine. No evidence was found on the medical record of the reason for the missing signature.