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Based on the review of documents, medical records, credential files, observations and interviews from 3/24/10 through 3/25/10 from 8:00 am till 6:00 pm during the recertification survey, it was determined that the Governing Body failed to carry out its responsibility for the operation and management of the hospital. It did not provide the necessary oversight and leadership as evidenced by the lack of compliance with: (42 CFR 482.25) Pharmaceutical Services, (2 CFR 482.26) Radiological Services, (42 CFR 482.41) Physical Environment, (42 CFR 482.42 ) Infection Control, (42 CFR 482.43) Discharge Planning and (42 CFR 482.57) Respiratory Care Services.

Based on observations and the review of licenses, documents and policies and procedures of the X-Ray department on 3/25/10 from 11:35 am till 4:00 pm, it was determined that the facility failed to maintain all radiological services provided by the hospital in accordance with acceptable standards of practice and failed to meet professionally approved standards for safety and personnel qualifications including contracted services and that this service is integrated into the Quality assessment and performance improvement program and no evidence was provided of in-services training all of which makes this condition "Not Met".

Based on tests performed on equipment, interviews, review of documents and observations made during the survey for the physical environment with the facility's Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 and 3/25/10 from 8:15 am till 3:30 pm, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well being of patients receiving services related to maintenance closets found unlocked, fire hose cabinets with glass doors that are a risk for patients and staff if accidentally broken, patient's sleeping room windows are locked shut, nursing call systems were not found for pediatric cubicles #6 and #7, the emergency call system at the X-ray department bathroom is a push button and not pull cord and did not emit an alarm when activated, the nursing counter in the emergency room was found with missing formica on the side panel creating a cutting hazard, this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to mops placed leaning up against walls (mop heads up and the poles down), defibrillator plugged into a multi-plug, an open cabinet was found with a full sharp container and an overflowing dirty linen container, the minor surgery room is not safe guarded against unauthorized access, this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff related to handicapped bathrooms located throughout the hospital, the emergency room does not provide privacy for patients receiving respiratory therapy and receiving Intravenous solutions, pediatric area of the emergency room is not appropriately designed, the operating room department is not appropriately designed, Cidex OPA is not used in an appropriate area, maintenance and biohazardous closets do not have extractors or smoke detectors, patient's closets in double occupancy rooms are not labeled or separated, patient's room doors can be locked from the inside, toilet room emergency call systems are push button, handrails are needed at two outside staircases and no evidence was provided of cleaning performed on the water reserve tank at Santa Rosa I, the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas, they are not equipped with an air disinfection system, also it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101, cited tags are K0018, K0019, K0022, K0027, K0046, K0050, K0051, K0130, K0144 and K0147. All of the above findings makes this condition "Not Met".

Based on observations, interviews with staff and infection control officer, review of policies/procedures and documents on 3/24/10 from 9:00 am till 3:00 pm and 3/25/10 from 9:00 am till 11:00 am, it was determined that the facility failed to ensure that there is an active infection control program for the prevention, control and investigation of infections related to the failure to designate a qualified infection control officer (C.F #26) to perform duties related to this position, failure to ensure that standards of infection control are followed related to expired medications, materials exposed to the environment, dust, rust, insects in the medicine department and nursing credential files, radiologist technicians credentials files, failure to revise the infection control organigram the last revision was performed in February of 2008, failure to present a infection control program to new employees, failure to presented the requirements for disinfectants, germicides and antiseptics used on the facility and in accordance with the manufacturer, failed to present the required educations, failure of the pharmacy department to participate in the infection control committee because the facility lacks a licensed pharmacist, failed to present evidence of housekeeping cleaning and disinfection program, failure to ensure that a log of incidents related to infections and communicable diseases is maintained and failed to ensure that the infection control program gathers and is part of the Quality Assessment and Performance Improvement program, failed to address problems and implement successful corrective actions, failed to ensure that the hospital-wide quality assurance program and training program addresses problems identified by the infection control officer.

Based on observations and the review of licenses, documents and policies/procedures of the Discharge planning department on 3/25/10 from 10:30 am till 4:45 pm, it was determined that the facility failed to maintain a discharge planning process that applies to all patients, no evidence of patient's care plans for discharge planning interventions. This service was not provided by the hospital in accordance with acceptable standards of practice and failed to meet personnel qualifications including contracted services and this service is not integrated into the Quality assessment and performance improvement program and no evidence was provided of in-services training, all of which makes this condition "Not Met".

Based on observations and the review of medical records, documents and the lack of policies and procedures on 3/24/10 from 9:00 am till 2:00 pm, it was determined that the facility failed to meet the needs of its patients in accordance with acceptable standards of practice, no evidence was provided that respiratory services are integrated into the Quality assessment and performance improvement program and no evidence was provided of in-services training for the department.

Based on the review of Medical Staff Bylaws Rules and Regulations, Medical Record Department policies/procedures, Emergency Room policies/procedures and twenty-five closed and active clinical records, it was determined that the facility failed to ensure that approved medical staff bylaws and regulations take into account Medical Record Department and Emergency Room Department policies/procedures related to the timeliness of consultations in the Emergency room and failed to ensure that proper discharge summaries are performed in accordance with medical record regulations for eleven out of twenty-five records reviewed (R.R) #50, #51, #52, #53, #56, #57, #58, #59, #60, #61 and #62.

Findings include:

1. Medical Staff Bylaws Rules and Regulations, Medical Record policies/procedures and Emergency Room policies/procedures related to consults were reviewed on 3/25/10 at 2:00 pm. It was found that medical staff Bylaws Rules and Regulation states that medical consults should be performed with 24 hours, urgent requests within 6 hours, requests for emergency consultations should be honored promptly, a complete consultation report should be placed in the medical report within 48 hours and all consultations must be written and signed by the consultant. Emergency room policies/procedures states that the consultant should respond within 3 hours after requested and Medical Record policies/procedures states that all consults should be answered within 24 hours after requested. The facility failed to ensure that all policies/procedures related to the timeliness of answering consultation requests are the same to ensure that medical staff provide services to meet patient's needs.

a. R.R #50 is a male patient who was admitted to the hospital on 12/6/09 with a diagnosis of Acute Myocardial Infarct and died on 12/8/09. The record review was performed on 3/25/10 at 10:30 am and provided evidence that seven consults were requested from different disciplines. However, no evidence was found on seven out of seven consult request orders of the date and hour when the consult requests were placed. Also three out of the seven consults requested did not include documentation on the consult request order of the consulted physician's response to the consult.

b. R.R #51 is a male patient who was admitted to the hospital on 10/7/09 with a diagnosis of Bilateral Bronchopneumonia and Sepsis and died on 10/14/09. The record review was performed on 3/25/10 at 10:40 am and provided evidence that three consults were requested from different disciplines. However, no evidence was found on three out of three consult request orders of the hour when the consult requests were placed and one out of three did not include the date when the consult request was placed.

c. R.R #52 is a male patient who was admitted to the hospital on 2/13/10 with a diagnosis of abdominal Pain and died on 2/15/10. The record review was performed on 3/25/10 at 11:00 am and provided evidence that four consults were requested from different disciplines. However, no evidence was found on three out of four consult request orders of the hour when the consult requests were placed.

d. R.R #53 is a male patient who was admitted to the hospital on 11/6/09 with a diagnosis of Bronchopneumonia and died on 11/19/09. The record review was performed on 3/25/10 at 11:15 am and provided evidence that three consults were requested from different disciplines. However, no evidence was found on three out of three consult request orders of the hour when the consult requests were placed and two out of three did not include the date when the consult request was placed. Also one out of the three consults requested did not include documentation on the consult request order of the consulted physician's response to the consult.

2. R.Rs #56, #, #58, #59, #60, #61 and #62 performed on 3/25/10 from 3:00 pm till 4:00 pm provided evidence that the information sheet used by medical personnel has an area described as discharge instructions. The discharge instruction area has different choices to allow medical personnel to perform check marks for those areas that correspond to the patient. However, according with discharge summary regulations "All patient medical records must contain a discharge summary. A discharge summary discusses the outcome of the hospitalization, the disposition of the patient and provisions for follow-up care. Follow-up care provisions include any post hospital appointments, how post hospital patient care needs are to be met, and any plans for post-hospital care by providers such as home health, hospice, nursing homes, or assisted living".

Based on two medical records reviewed (R.R) with "Do Not Resuscitate" (DNR) or "Do Not Intubate"(DNI) orders, review of DNR and DNI protocols and policies/procedure and interview, it was determined that the facility failed to ensure that policies and procedure related to advance directives for DNR and DNI orders are followed for two out of two records reviewed (R.R #28 and #39).

Findings include:

1. Two out two records reviewed (#28 and #39) on 3/25/10 from 11:00 am till 5:00 pm with the coordinator of quality improvement (employee #5) with DNR and DNI physician orders did not follow the facility's DNR and DNI Protocols:

a. R.R #28 is a 65 years old male, admitted on 3/17/10 with Bronchopneumonia (BKP) and Colon Cancer as reviewed on 3/25/10 at 11:00 am. A consent form for "Do Not Resuscitate" was found and signed by the patient's relatives on 3/23/10 in the patient's clinical record. The consent form of Do Not Resuscitate was not signed by the doctor who took the order. The physician ordered DNR "Do Not Resuscitate"on 3/12/10 at 3:30 pm. The consent form of DNR was signed eleven days after. No evidence was found that the patient was re-evaluated by the physician in charge to justify continuing the DNR order. No evidence was found of the re-evaluation of the DNR order according with the patient's clinical condition.

b. R.R #34 is an 81 years old male, admitted on 1/3/10 with Congestive Obstructive Pulmonary Disease (COPD) and R/O BKP as reviewed on 3/25/10 at 11:40 am. A consent form for "Do Not Intubate" was found and signed by the patient's relatives on 3/1/10 in the patient's clinical record. The physician order on 1/3/10 at 4:50 pm says DNR concern. The relative of patient consented for the DNI order but not for DNR.

2. No evidence was found of a process or mechanism that is developed and implemented to ensure that medical care issue are managed accord with the patient's needs in a manner to ensure that adequate and necessary services are provided and that patient's rights are ensured as reviewed on 3/25/10 from 11:00 am till 5:00 pm.

3. During interview with the coordinator of quality improvement (employee #5) she stated the monitoring of compliance with Do Not Resuscitate protocols were started in January of 2010 as reviewed on 3/25/10 at 3:27 pm. Monitoring of appropriateness of advance directives procedures at the facility were not followed.

Based on the observational tour and three patient's records reviewed (R.R) with restraints with the coordinator of quality improvement (employee #5), it was determined that the facility failed to promote the patient's right to be free from restraints and failed to continually assess and monitor three out of three patients (R.R #35, #36 and #37).

Findings include:

1. Three out three records reviewed (R.R #35, #36 and #37) on 3/25/10 from 11:00 am till 5:00 pm with the coordinator of quality improvement (employee #5) related with the patient's right to be free from restraints and physician's orders did not follow the facility's Protocols:

1. R.R #35 is a 60 years old male who was admitted on 2/3/10 with a diagnosis of Congestive Heart Failure. The physician places an order on 2/4/10 at 8:30 am for restrictions. The physical restraints orders sheet did not provide evidence of the restraint of the patient's right wrist, left wrist, right ankle and left ankle and for how long. The education sheet of the patient or relative does not have the date of the education, signature of someone that received the education and signature of the nurse.

2. R.R #36 is a 67 years old male who was admitted on 2/13/10 with a diagnosis of Abdominal Paint. The physician places an order on 2/14/10 at 11:45 am for restrictions. The physical restraints orders sheet did not provide evidence of the restraint of the patient's right wrist, left wrist. right ankle and left ankle, for how long and nurse's signature. The education sheet of the patient or relative does not have date of the education and the signature of the nurse.

3. R.R #37 is an 86 years old female who was admitted on 2/20/10 with a diagnosis of Septicemia. The physician places an order on 2/27/10 at 5:30 am for restrictions as needed (prn). The physical restraint order sheet did not provide evidence of the patient's restraints and for how long.

Based on the observational tour, records reviewed (R.R) and review of policies and procedures with the coordinator of quality improvement (employee #5), it was determine that the facility failed to ensure that restraints are not written as a standing order or on an as needed basis (PRN) for one out of three patients (R.R #37).

Findings include:

R.R #37 is an 86 years old female who was admitted on 2/20/10 with a diagnosis of Septicemia. During the record review on 3/25/10 at 3:00 pm, it was found that the physician ordered restraints on 2/27/10 at 5:30 am and it was documented "as needed".

Based on the review of forty-five medical staff credential files, it was determined that the facility failed to examine credential files (C.F) to ensure that medical staff have updated Health Certificates, Cardio-pulmonary Resuscitation Certificates (CPR), Hepatitis B vaccines, State Narcotic License and Federal Narcotic License, Mal practice insurance updated and 2010 medical association for twenty-nine out of forty-five medical staff's C.Fs (C.F #3, #4, #5, #7, #8, #10, #11, #12, #17, #19, #20, #21, #22, #23, #26, #27, #28,
#30, #31, #32, #33, #34, #35, #36, #37, #38, #43, #44 and #45).

Findings include:

1. During the review of forty-five medical staff credential files on 3/25/10 from 1:20 pm till 2:20 pm the following was found:

a. Fifteen out of forty-five medical staff's credential files did not provide evidence of updated Health Certificates (C.F #4, #8, #11, #17, #19, #21, #23, #25, #26, #28, #30, #31, #35,
#36 and #37). Two out of forty-five medical staff's credential files provided evidence of expired Health Certificates until February 2010 (C.F #5 and #20).

b. One out of forty-five medical staff's credential files provided evidence of expired cardio-respiratory certificates (C.F #26 (from 2/010). Ten out of forty-five medical staff's credential files did not provide evidence of an updated cardio-respiratory certificates (C.F #12, #17,
#19, #27, #28, #30, #32, #33, #37 and #38).

c. Two out of forty-five medical staff's credential files did not have evidence of their hepatitis profiles or responsibility exoneration (C.F #12 and #32).

d. Five out of forty-five medical staff's credential files did not have evidence of their updated federal narcotic license (C.Fs #5, #22, #23, #32 and #45).

e. Seven out of forty-five medical staff's credential files did not have evidence of their updated State narcotic license (C.Fs #12, #23, #28, #30, #32, #33 and #37).

f. Six out of forty-five medical staff's credential files did not have evidence of their updated mal practice insurance (C.Fs #12, #23, #30, #32, #33 and #44).

g. Eighteen out of forty-five medical staff's credential files did not have evidence of their updated medical association (C.Fs #3, #7, #8, #10, #12, #19, #23, #24, #26, #28, #29,
#30, #31, #32, #33, #34, #35 and #36).

Based on documents reviewed and interview with the Director of Nursing (D.O.N) at Santa Rosa I, it was determined that the facility failed to ensure that sufficient nursing services are provided for the pediatric ward, surgery ward, OB-Gyn and nursery room for all shifts.

Findings include:

1. On 3/25/10 at 10:00 am, weekly nursing staffing patterns were reviewed from 3/14/10 though 3/20/10 and no evidence was found of assigned registered nurses for all shifts as is required by the Nursing Board of Puerto Rico State Law #9 from October 1987.

a. No evidence was found of registered nurses assigned to the Surgery ward, OB-Gyn ward and Nursery room for the following shifts: on 3/14/10 for shifts 7-3, 3-11, on 3/15/10 for shifts 3-11, 11-7, on 3/16/10 for shifts 3-11 and 11-7, on 3/17/10 for shifts 11-7, on 3/18/10 for shifts 11-7, on 3/19/10 for shifts 11-7 and on 3/20/10 for shifts 3-11 and 11-7.

b. No evidence was found of registered nurses assigned to the Intensive Care Unit for the following shifts: on 3/14/10 for shift 11-7, on 3/15/10 for shift 11-7, on 3/18/10 for shift
11-7, on 3/20/10 for shift 11-7 and on 3/21/10 for shifts 11-7.

2. The Director of Nursing (D.O.N) (employee #3) at Santa Rosa I was interviewed on 3/25/10 at 10:30 am and she stated that shifts 3-11 and 11-7 are not covered by a supervisor. Nursing personnel during these shifts are instructed to call a cell phone in the event that they have an emergency.

Based on the review of thirty-seven nursing credential files (C.F), it was determined that the facility failed to ensure that four personnel are licensed in accordance with state and local laws related to health certificates for four out thirty-seven C.F (C.Fs #1, #4, #11 and #13).

Findings include:

1. Thirty-seven nursing credential files were reviewed on 3/25/10 at 2:00 pm and provided evidence of the following:

a. Four out of thirty-seven nursing credentials files do not contain evidence of their Health certificates (C.F #1, #4, #11 and #13).

Based on the review of eight clinical records and policies/procedures with the Director of Nursing (D.O.N) at Santa Rosa I, it was found that the facility failed to ensure that six out of eight records reviewed (R.R #7, #8, #9, #15, #16 and #17) have developed nursing care plans, are updated and implemented.

Findings include:

1. Six out of eight records reviewed for care plans on 3/25/10 from 10:00 am till 11:00 am with The Director of Nursing (D.O.N) (employee #3) at Santa Rosa I, provided evidence that care plans do not have written evidence of revisions during the patients' hospital stay related to their needs and some did not have evidence of care plans:

a. R.R #7 is a 63 years old male who was admitted on 3/18/10 with Abdominal Pain and Pancreatitis, no evidence was found of care plan revisions. No evidence was found of goals and objectives established to coordinate patients' nursing care.

b. R.R #8 is a 66 years old female who was admitted on 3/23/10 with Cerebrovascular accident (CVA) and no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

c. R.R #9 is a 50 years old male who was admitted on 3/22/10 with Acute Coronary Syndrome and no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

d. R.R #15 is an 86 years old male who was admitted on 3/23/10 with Cellulitis of the Left Leg and no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

e. R.R #16 is a 67 years old female who was admitted on 3/24/10 with Diabetes Mellitus and no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

f. R.R #17 is a 65 years old male who was admitted on 3/17/10 with Cancer of the Colon and no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

Based on documents reviewed with the Director of Nursing (D.O.N) at Santa Rosa I, it was determined that the facility failed to ensure that nursing progress notes were performed and completed for three out of six records reviewed (R.R #7, #8 and #17).

Findings include:

1. Two out of six clinical records reviewed on 3/25/10 from 8:30 am till 12:00 pm provided evidence that nurses progress notes were not performed for the following shifts:

a. R.R #7: on 3/20/10 for the 7-3 shift, on 3/20/10 for the 3-11 shift, and on 3/19/10 for the 3-11 pm.

b. R.R #17: on 3/18/10 for the 3-11 shift.

2. Two out of six clinical records reviewed on 3/25/10 from 8:30 am till 12:00 pm have incomplete nursing progress notes for the following shifts:

a. R.R #7: on 3/21/10 for the 7-3 and 3-11 shifts.

b. Record Review (RR) #8: on 3/23/10 for shift 7-3 pm.

Based on the observational tour of the medical records department with the medical record supervisor, it was determined that the facility failed to ensure the proper storage and placement of medical records in the medical record department, in three storage trailers and in the storage area under the general storage room related to boxes with records directly on the floor, dust covered records and records exposed to possible water damage.

Findings include

1. During the observational tour of three storage vans located at Santa Rosa II used to place medicals with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/25/10 at 11:00 am, it was found that the first van opened had 20 boxes of medical records directly on the floor, the second van opened had 45 boxes directly on the floor and the weight of the boxes crushed the boxes open that were closest to the floor and the third van opened had 5 boxes of medical records directly on the floor.

2. During the observational tour of the medical record storage area located under the general storage area at Santa Rosa II with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/25/10 at 11:20 am, it was found that this area has over 100 boxes directly on the floor, carton boxes were broken and their contents were on the floor, the entire area was dusty (on shelves, boxes and floor) and medical records and financial records and other documents were found on the same shelves or piled on top of each other.

3. During the observational tour of the medical record department located near Santa Rosa I with the medical record supervisor (employee #22) on 3/25/10 at 9:30 am, it was found that an area where records are reviewed and stored does not have metal bars on the windows to safe guard the records. Also, medical record personnel use desks to place records on that are close to the windows (approximately 300 to 400 medical records). These windows are not hermetically sealed and during rain storms these windows can allow rain water to leak through and damage the records on the desks.

4. During the observational tour of the medical record department located near Santa Rosa I with the medical record supervisor (employee #22) on 3/25/10 at 9:45 am, it was found that eight boxes filled with medical records (a total of approximately 160) were directly on the floor.

Based on the observational tour of the medical records department with the medical record supervisor, it was determined that the facility failed to ensure that unauthorized individuals cannot gain access to or alter patient records.

Findings include

During the observational tour of the medical record department located near Santa Rosa I with the medical record supervisor (employee #22) on 3/25/10 at 9:30 am, it was found that the area used by the facility to allow record revision by facility personnel and health plan auditors does not ensure medical record unauthorized access. This area contains desks that medical record personnel have placed approximately 300 to 400 medical records. When facility staff or health plan auditors are allowed access to this area to review selected records, they are in the same area where other non selected records are placed which does not allow confidentiality for these other records.

Based on the review of Medical Staff Bylaws Rules and Regulations, Medical Record policies/procedures, Emergency Room policies/procedures and eighteen closed and active clinical records, it was determined that the facility failed to ensure that all records with consultation requests contain evidence of the results, date and hour of the consultations for four out of eighteen records reviewed (R.R) #50, #51, #52 and #53).

Findings include:

1. R.R #50 is a male patient who was admitted to the hospital on 12/6/09 with a diagnosis of Acute Myocardial Infarct and died on 12/8/09. The record review was performed on 3/25/10 at 10:30 am and provided evidence that seven consults were requested from different disciplines. However, no evidence was found on seven out of seven consult request orders of the date and hour when the consult requests were placed. Also three out of the seven consults requested did not include documentation on the consult request order of the consulted physician's response to the consult.

2. R.R #51 is a male patient who was admitted to the hospital on 10/7/09 with a diagnosis of Bilateral Bronchopneumonia and Sepsis and died on 10/14/09. The record review was performed on 3/25/10 at 10:40 am and provided evidence that three consults were requested from different disciplines. However, no evidence was found on three out of three consult request orders of the hour when the consult requests were placed and one out of three did not include the date when the consult request was placed.

3. R.R #52 is a male patient who was admitted to the hospital on 2/13/10 with a diagnosis of Abdominal Pain and died on 2/15/10. The record review was performed on 3/25/10 at 11:00 am and provided evidence that four consults were requested from different disciplines. However, no evidence was found on three out of four consult request orders of the hour when the consult requests were placed.

4. R.R #53 is a male patient who was admitted to the hospital on 11/6/09 with a diagnosis of Bronchopneumonia and died on 11/19/09. The record review was performed on 3/25/10 at 11:15 am and provided evidence that three consults were requested from different disciplines. However, no evidence was found on three out of three consult request orders of the hour when the consult requests were placed and two out of three did not include the date when the consult request was placed. Also one out of the three consults requested did not include documentation on the consult request order of the consulted physician's response to the consult.

5. Medical Staff Bylaws Rules and Regulations, Medical Record policies/procedures and Emergency Room policies/procedures related to consults were reviewed on 3/25/10 at 2:00 pm. It was found that medical staff Bylaws Rules and Regulation states that medical consults should be performed with 24 hours, urgent requests within 6 hours, requests for emergency consultations should be honored promptly, a complete consultation report should be placed in the medical report within 48 hours and all consultations must be written and signed by the consultant. Emergency room policies/procedures states that the consultant should respond within 3 hours after requested and Medical Record policies/procedures states that all consults should be answered within 24 hours after requested. The facility failed to ensure that all policies/procedures related to the timeliness of answering consultation requests are the same to ensure that medical staff provide services to meet patient's needs.

Based on the review of eighteen closed and active clinical records, it was determined that the facility failed to ensure that discharge summaries are performed with all pertinent information for seven out of fifteen records reviewed (R.R) #56, #57, #58, #59, #60, #61 and #62).

Findings include:

R.Rs #56, #57, #58, #59, #60, #61 and #62 performed on 3/25/10 from 3:00 pm till 4:00 pm provided evidence that the information sheet used by medical personnel has an area described as discharge instructions. The discharge instruction area has different choices to allow medical personnel to perform check marks for those areas that correspond to the patient. However, according with discharge summary regulations "All patient medical records must contain a discharge summary. A discharge summary discusses the outcome of the hospitalization, the disposition of the patient and provisions for follow-up care. Follow-up care provisions include any post hospital appointments, how post hospital patient care needs are to be met, and any plans for post-hospital care by providers such as home health, hospice, nursing homes, or assisted living".

Based on observations and review of documents with the administrator, interview and review of policies and procedures from 3/24/10 through 3/25/10 from 8:00 am till 5:30 pm, it was determined that the facility failed to ensure that pharmaceutical services meet the needs of the patients, the institution has pharmacy services without competent supervision of a registered pharmacist, adverse drug reactions, and incompatibilities are not reported to the pharmacist to determine the presence of medication therapy problems, safe controlled medication management and disposition were not promoted and counseling about food and drug interactions for patients who need it were not performed. All of the above findings makes this condition "Not Met".

Based on observations and review of documents with the administrator, interview and review of policies and procedures, it was determined that the facility failed to ensure that a pharmacist is responsible for coordinating all activities of pharmacy services.

Findings include:

1. Facility failed to evidence that a pharmacist are responsible for the overall administration of the pharmaceutical services and to coordinate all the activities of the hospital wide pharmacy services as determined from 3/24/10 through 3/25/10 from 8:00 am till 5:30 pm.

2. During the two days of the survey from 3/24/10 through 3/25/10 from 8:00 am till 5:30 pm
pharmacy assistants were observed located in the pharmacy area without supervision of the pharmacist. Facility administrator (employee #18) stated during an interview on 3/24/10 at 11:55 am that they have a pharmacist under contract who works from 1:00 pm though 8:00 pm in order to supervise pharmacy services and drug storage at the facility since September 2009. However this pharmacist were not available or seen during the survey procedure. Time registration that shows evidence that this pharmacist is available on a part time basis were not provided after requested several times during survey. Nursing personnel (employees #3 and #19) of Santa Rosa II (medicine ward and ICU) stated during an interview on 3/24/10 at 1:23 pm that pharmacy assistants are the personnel who deliver medications as needed through the pyxis medication station on a daily basis. Nursing personnel (employees #3 and
#20) of the surgery and nursery wards stated during interviews on 3/24/10 at 1:23 pm that pharmacy assistants are the personnel who deliver medications as need in the pyxis medication stations on a daily basis. This practice is against pharmacy state law #247 from 2004 (article number 1.02 and article number 1.03) which provided evidence that a licensed pharmacist must be present for the entire time that the pharmacy department is opened, and pharmacy assistants can not dispense medications with out the presence of the pharmacist. Furthermore, the pharmacist is the only professional allowed to assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each patient.

Based on observations and review of documents with the administrator, interview and review of policies and procedures, it was determined that the facility failed to ensure that
drugs and biologicals are managed in accordance with applicable standards of practice and
counseling about food and drug interactions for patients who need it were performed.

Findings include:

1. Safe controlled medication management and disposition were not promoted nor followed at the facility as reviewed on 3/24/10 at 4:00 pm. The Medicine ward was visited on 3/24/10 at 3:26 pm and provided evidence of 10 controlled intravenous medications and 13 oral (PO) controlled medications residues from January and February 2010 in the narcotic box. The Surgery Ward was visited on 3/25/10 at 9:12 am and provided evidence of 6 intravenous controlled drug residues dated from the year of 2008 in the narcotic box. Facility's policy reviewed on 3/25/10 at 4:35 pm establishes that these residues shall be removed from the area by the pharmacist every Friday.

2. A mechanism to ensure that intervention with patients that need interventions with food and drug interaction was not promoted, nor followed according with information given by the dietitian (employee # 21) during an interview on 3/24/10 at 3:00 pm, she stated that patients who need this intervention are identified by pharmacy services and are referred to dietary services, but due to the lack of a pharmacist this is not performed because the cases are not identified and sent to the dietary department.

Based on observations and review of documents with the administrator and review of policies and procedures, it was determined that the facility failed to ensure that drug administration errors, adverse drug reactions and incompatibilities must be reported to the pharmacist to determine the presence of medication therapy problems.

Findings include:

During October, November and December 2009 medication irregularities, adverse drug reactions and medications errors were not identified, not reported or informed to the Quality Assessment program of the facility as reviewed on 3/25/10 at 10:23 am. Medication irregularities, adverse drug reactions and medications errors from the months of January and February of 2010 were reported to the Quality Assessment program of the facility and does not include the intervention of the pharmacist or determination by pharmacy services of the presence of medication therapy problems.

Based on observations and the review policies and procedures with the supervisor of the X-Ray department at Santa Rosa I and Santa Rosa II and interview, it was determined that the facility failed to ensure that the X-Ray department is free from hazards for patient's and personnel, this services lacks to reviewed and actualized policies and procedures manual, infection control guide, not performed quality indicators for January and February of 2010, lacked the signature of the radiologist director on the dosimeters protocol, lacked to performed departmental meetings and lacks to maintain the X-Ray condition on adequate conditions.

Findings include:

1. The X-Ray Manual for policies and procedures lacks the Radiologist's signature, date and year when reviewed as determined on 3/25/10 at 1:15 pm.

2. The Institutional Quality Program was reviewed by the facility on February of 2009, however no evidence was found on 3/25/10 at 1:20 pm of revision of this manual in February of 2010.

3. No evidence was found of the X-Ray Quality Assessment Performance and Improvement program for January and February of 2010 as reviewed on 3/25/10 at 1:25 pm.

4. The Dosimeters Protocol lacked the signature of the Radiologist director on 3/25/10 at 1:30 pm.

5. The last Infection Control Guide was reviewed on March 20, 2008 as determined on 3/25/10 at 1:35 pm.

6. The last departmental meeting was performed on November 21, 2008 as determined on 3/25/10 at 1:40 pm. .

7. The facility has a portable X-Ray machine, however no evidence was provided on 3/25/10 at 1:00 pm that all personnel working with this machine have a badge test.

8. During the observational tour of the X-Ray Department located at Santa Rosa I with the Infection Control Officer (employee #26) and X-Ray Department Supervisor (employee #21) on 3/24/10 from 8:30 am till 11:30 am and 3/25/10 from 1:00 pm till 4:00 pm, it was found that the main entrance door of the X-Ray department opened (unlocked) all the time. At the main entrance of the X- Ray department of Santa Rosa I, aproximatelly a hundred of X-Ray plates were observed on the top of a counter and thirteen carton boxes containing X-Ray plates waiting to be filed were observed under the open counter directly on the floor expose to dust, uncovered and exposed to possible water damage.

9. The X-Ray department was observed on 3/24/10 at 8:30 am and 3/25/10 at 1:00 pm. with limited space and clerical personnel are exposed to accidents.

10. During the observational tour on 3/25/10 at 2:30 pm. of the medical surgical storage area located at the right side of the X-Ray department at Santa Rosa I, it was found that this area is dusty, the floor was observed dirty and garbage was observed on the floor, carton boxes were broken, the entire area was dusty (on shelves, boxes and floor) and medical surgical material (syringes, gauzes, underpad, ect.), office materials and plates and other documents and materials were found on the same shelf and on top of other shelves.

11. No evidence was found on 3/25/10 at 2:30 pm. of adequate labeling of radioactive materials, waste and hazardous areas.

12. All areas of the X-Ray department were observed on 3/24/10 at 8:30 am. and 3/25/10 at 1:00 pm. with a lot of dust, dirty and papers.

13. On 3/24/10 at 8:30 am, the interior part of the washstand, used for X-Ray personnel located at the main corridor, were found with two empty carton boxes, around the washstand were observed on a deteriorated wood board with dust, water, dirty and food residues were observed on the interior of the washstand. The washstand lacks a hand paper and soap dispensers.

14. The patient's bathroom for ladies at Santa Rosa I did not have a "call system" as observed on 3/25/10 at 2:00 pm. The bathroom door can be locked from the inside and staff do not have a device with them to open the door in the event of an emergency.

15. The ceiling at the X-Ray department of Santa Rosa I of the bathroom was observed with damage, the air conditioning blows hot air and water was observed on 3/25/10 at 3:00 pm. from the air conditioner on the floor, the air conditioner lacks a protective cover, and the water fell to the ground near the entrance of the bathroom exposing patient's and personnel to falls and accidents. The patient's bathroom lacks an identification label.

16. During the visual tour at the X-Ray department accompanied by the X-Ray nurse (employee #2) on 3/25/10 at 4:05 pm, an opened crash cart was observed without a security lock, it did not have a monitor, the defibrillator did not work, it was observed dirty and with dust in the interior and exterior of the crash cart and no evidence was found of the daily registry. The nurse performed the test at the defibrillator on 3/25/10 at 4:10 pm and a "flat line" was registered on the "trace paper", no evidence was found of the date and hour when the nurse performed the defibrillator test. The X-Ray nurse (employee #2) was interviewed on 3/25/10 at 4:15 pm related to this situation and she stated "the security lock of the crash cart broke and the defibrillator has not worked for awhile, however I performed the daily medication emergency review".

17. No evidence of the defibrillator maintenance was found on 3/25/10 at 3:15 pm. in the equipment log.

Based on observations and the review policies and procedures with the supervisor of the X-Ray department at Santa Rosa I and Santa Rosa II and interview, it was determined that the facility failed to ensure that the X-Ray department performed periodic inspection of equipment must be made and hazards identified must be promptly corrected related to crash cart security lock and the defibrillator did not work.

Findings include:

1. During the visual tour at the X-Ray department accompanied by the X-Ray nurse (employee #2) on 3/25/10 at 4:05 pm, an opened crash cart was observed without a security lock, it did not have a monitor, the defibrillator did not work, it was observed dirty and with dust in the interior and exterior of the crash cart and no evidence was found of the daily registry. The nurse performed the test at the defibrillator on 3/25/10 at 4:10 pm and a "flat line" was registered on the "trace paper", no evidence was found of the date and hour when the nurse performed the defibrillator test. The X-Ray nurse (employee #2) was interviewed on 3/25/10 at 4:15 pm related to this situation and she stated "the security lock of the crash cart broke and the defibrillator has not worked for awhile, however I performed the daily medication emergency review".

2. No evidence of the defibrillator maintenance was found on 3/25/10 at 3:15 pm in the equipment log.

Based on the review of thirteen X-Ray credential files (C.F), it was determined that the
facility failed to ensure that eleven personnel are licensed in accordance with State and local laws related to health certificates, cardio pulmonary resuscitation certificate, current evaluations, competencies and job descriptions for eleven out thirteen credential files (C.F #2, #3, #4, #5, #6, #7, #8, #9, #11, #12 and #13).

Findings include:

1. Thirteen X-Ray credential files were reviewed with the supervisor of the Human Recourses department (employee #29) at Santa Rosa I and Santa Rosa II on 3/25/10 from 10:30 am till 11:35 am and provided evidence of the following:

a. Three out of thirteen X-Ray credentials files do not contain evidence of their Health certificates updated (C.F #2 and #3 expired on March 12, 2010) and (C.F #9 expired on February 24, 2010).

b. Six out of thirteen X-Ray credentials files do not contain updated current evaluations (C.F #4, #5, #7, #9, #12 and #13).

c. Ten out of thirteen X-Ray credentials files do not contain updated cardio pulmonary resuscitation certificates (CPR) (C.F #2, #5, #6, #8, #9, #11, #12 and #13 (lack CPRs), (C.F #4 expiration date was January 11, 2009 and C.F #7 expiration date was February 27, 2006).

d. Five out of thirteen X-Ray credentials files did not provide evidence of Hepatitis vaccinations (C.F #5, #6, #11, #12 and #13).

e. Six out of thirteen X-Ray credentials files do not contain updated competencies (C.F #4,
#5, #7, #9, #11 and #12).

f. Six out of thirteen X-Ray credentials files do not contain updated job descriptions (C.F #4, #5, #7, #9, #11 and #12).

g. Two out of thirteen X-Ray credentials files do not contain certifications related to sonograph and cardio vascular technician (C.F #6 and #8).

Based on the observational tour of the facility's kitchen, review of menus, policies and procedures and interview, it was determined that the facility failed to store, maintain and prepare food in a safe and sanitary manner related to the maternity formula room found in poor condition.

Findings include:

1. A mechanism to ensure that enteral feeding nutrition is prepared in a safe manner was not followed nor promoted at the facility as reviewed on 3/24/10 at 9:43 am. The facility does not prepare enteral feeding in the kitchen area. When a patient has an enteral feeding ordered dietary services sends the supplement to the ward and nursing personnel with the enteral feeding kits put the supplement in the bag and administer it to the patients. However this procedure may expose the patients receiving enteral nutrition to cross infection or contamination of the enteral feed during preparation of the dilution and decanting. No policies were evidence on 3/25/10 at 10:54 am related to this process of dilution and decanting of supplements performed by nursing personnel. Safe preparation of enteral feeding guidelines in health care facilities year 2003 establishes that enteral feeding must be prepared in a specific location using aseptic technique that ensures the delivery of safe enteral feedings.

2. Maternity sterile ready to use infant formulas were stored in the nursery area on a cabinet that also has papers, medications and other office items as observed on 3/24/10 at 11:00 am. During interview on 3/24/10 at 11:16 am with the dietitian (employee # 21 ) she stated that the facility uses ready to use infant formula, but if a baby needs special formula preparations that the facility does not have available, the nurses prepares the formula in the area. The international Code for Hygiene Practice for foods for infants established that the infant formula must be stored in a safe manner and if powered formula is prepared correct preparation and handling must be maintained in order to reduce the risk of illness. Safe preparation storage and handling of infant formula guidelines establishes that in care settings in order to control the preparation and safe storage of infant formula a central preparation area must be used.

Based on the review of policies/procedures and five records reviewed (R.R) and interview with the dietitian, it was determined that the facility failed to ensure that nutritional needs of patients have been met according with standards of practice as identified in four out of five cases reviewed (R.R #16, #18, #32 and #33).

Findings include:
1. R.R #18 is a 56 years old male patient admitted to the intensive care unit on 3/9/10 with a diagnosis of Lower Gastrointestinal Bleeding and Symptomatic Anemia as reviewed on 3/25/10 at 9:55: am. This patient was NPO (nothing by mouth) since admission. No evaluation by the dietitian was performed until 3/25/10 when the dietitian evaluated the patient that day and recommended Clinimix Periferal Nutrition at 42 cc/hour which was provided to the patient. No nutritional priority status was considered or followed for this patient based on his condition and the amount of days on NPO in order to ensure appropriate nutritional care.
2. R.R #32 is a 23 years old female patient admitted to the medicine ward on 3/21/10 with a diagnosis of Intractable Epigastric Pain, vomit and diarrhea as reviewed on 3/25/10 at 10:10 am. This patient was NPO since admission. No evaluation was found of the dietitian during the patient's stay at the unit for this patient on NPO for three days in order to assess the patient's nutritional status, delineation of the course of nutritional care and evaluation of the patient's treatment. This patient was discharge home on 3/24/10 at 1:35 pm, however, no diet was ordered in order to ensure that the patient tolerated her food before discharge. The facility failed to include nutritional assessments and care incorporated into the total treatment plan of the patient. No nutritional priority status was considered or followed for this patient based on the patient's condition and the amount of days NPO in order to ensure appropriate nutritional care.
3. R.R #16 is a 67 years old female patient admitted to the medicine ward on 3/24/10 with a diagnosis of Symptomatic Hyponatremia and Diabetes Type II as reviewed on 3/25/10 at 10:23 am. According with facility nutritional assessment policies and procedures, patients with sodium alterations must be evaluated by the nutritionist in order to incorporate nutritional assessment needs in the plan of care, however this patient was not consulted or evaluated by the nutritionist.
4. R.R #33 is a 60 years old male patient admitted on 2/2/10 with a diagnosis of Septic Shock and Metabolic Acidosis as reviewed on 3/25/10 at 10:45 am. This patient was NPO and had a nasogastric tube. The patient was referred to the nutritionist on 2/2/10, was evaluated by nutritionist on 2/14/10 and recommended Renalcal enteral nutrition at 40 ml/hour. This patient was not re-evaluated by the nutritionist until 2/10/10 when another consult was requested by the patient's physician. Dietitian (employee #21) stated during interview on 3/24/10 at 10:39 am that this patient's food preferences must be evaluated following the next 24-48 hours in order to evaluate if the patient is tolerating nutritional recommendations.
5. Policies and procedures related with nutritional assessment needs of patients were reviewed with the dietitian (employee #21) on 3/24/10 at 10:00 am. Based on this review and discussion, it was determined that mechanisms in order to address the following processes does not include time-frames where the evaluations are to be performed, which cases are evaluated according with the physician's consult, which cases are evaluated according with nutritional risk criteria and the time frame, no evidence was found of policies and procedures related to a defined time frame to perform assessments after the screening.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Safety Officer and Physical Plant Manager, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well being of patients receiving services related to maintenance closets found unlocked, fire hose cabinets with glass doors that are a risk for patients and staff if accidentally broken, patient's sleeping room windows are locked shut, nursing call systems were not found for pediatric cubicles #6 and #7, the emergency call system at the X-ray department bathroom is a push button and not pull cord and did not emit an alarm when activated and the nursing counter in the emergency room was found with missing formica on the side panel creating a cutting hazard.

Findings include:

1. Maintenance closets located at Santa Rosa I and II were observed with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 from 8:30 am till 3:45 pm and on 3/25/10 from 8:30 am till 12:00 noon. These closets were found at the emergency room, operating room department and both wards with chemicals and equipment to clean the facility and were found unlocked and accessible to non-authorized persons.

2. During the observational tour of Santa Rosa I and II with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 from 8:30 am till 3:45 pm and on 3/25/10 from 8:30 am till 12:00 noon, it was determined that fire hose cabinets have glass doors. The fire hose cabinets are located throughout the hallways of the hospital. The fire hose cabinets do not require a key to open or a device to break the glass to gain access to the hoses. The glass doors are approximately three feet by three feet in size and pose a potential hazard if broken by accident. The glass is not tempered, laminated or wire mess to prevent shattering.

3. Patient's sleeping room windows were tested at Santa Rosa I and II with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 from 8:30 am till 3:45 pm and on 3/25/10 from 8:30 am till 12:00 noon were found locked (could not be opened). The facility is designed with air conditioner units in each room with thermostats, however in the event of a fire or explosion where electrical power is lost and smoke fills the hallways or enters the rooms, patients would not have access to fresh air. Minimum requirements of "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) section 8.2.2.5(1) states if operable windows are provided in patient rooms, operation of such windows shall be restricted to inhibit possible escape or suicide (it states restricted, it does not state closed or sealed). Appendix A 3.1.1.3 also states that window use is essential for life safety reasons and in the event of mechanical ventilation system failure. Also the code of federal regulations for "Americans with Disabilities Act" appendix A4.12 (Windows) states that windows intended to be operated by occupants in accessible spaces should require no more than 5 lbf to open or close.

4. Nursing call systems with push buttons (with extension cords) to be placed at bedside for patients to summon nursing personnel were not found for pediatric cubicle #6 and #7 on 3/24/10 at 9:20 am in the emergency room as observed with the Safety Officer (employee #14) and Physical Plant Manager (employee #15).

5. The emergency call systems in the bathroom of the X-ray room at Santa Rosa II was tested with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/25/10 at 10:35 am and provided evidence that it did not emit an alarm when activated. Also, the bathroom of the X-ray rooms used for patients were visited at Santa Rosa I and II on 3/24/10 at 3:00 pm and on 3/25/10 at 10:35 am provided evidence that the call systems are activated by push buttons (pull cords are needed).

6. The nursing counter in the emergency room was observed with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 at 9:15 am with missing formica on the side panel creating a cutting hazard.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Safety Officer (employee #14) and Physical Plant Manager (employee #15), it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed from 3/24/10 through 3/25/10 from 8:30 am till 3:30 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0018, K0019, K0022, K0027, K0046, K0050, K0051, K0130, K0144 and K0147).

Based on tests and observations made during the survey for the physical environment with the Safety Officer and Physical Plant Manager, it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to mops placed leaning up against walls (mop heads up and the poles down), defibrillator plugged into a multi-plug, an open cabinet was found with a full sharp container and an overflowing dirty linen container and the minor surgery room is not safe guarded against unauthorized access.

Findings include:

1. Mops were observed in the operating room maintenance closets and the other maintenance closets of Santa Rosa I and II on 3/24/10 from 8:30 am till 3:45 pm and on 3/25/10 from 8:30 am till 12:00 noon with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) leaning up against the wall (mop heads up and the poles down). This procedure contaminates the walls and allows water from the wet mops to leak down the poles and is not an acceptable practice related to infection control standards.

2. The crash cart was observed with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 at 9:55 am with a defibrillator that was plugged into a multi-plug extension cord.

3. A cabinet was observed with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) in the emergency room on 3/24/10 at 10:30 am located near the minor surgery room and cubicle #4. The cabinet was found with a full sharp container on the top shelf and the bottom area of this cabinet was found with an overflowing dirty linen container. The doors to this cabinet were also found unlocked and the sharp container and dirty linen were accessible to anyone in this area which does not ensure infection control standards to prevent cross contamination.

4. The minor surgery room located in the emergency room was visited on 3/24/10 at 10:15 am with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and provided evidence that the double glass doors to enter this room were not locked to protect the contents of this room that is out of the line of sight of nursing personnel at the nursing counter. Even though the nursing station has a camera toward this area, staff have to be watching the monitor constantly to watch over this area which is not possible in an emergency room.

Based on tests performed on equipment, interview and observations made during the survey for the physical environment with the facility's Safety Officer and Physical Plant Manager, it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff related to handicapped bathrooms located throughout the hospital, the emergency room does not provide privacy for patients receiving respiratory therapy and receiving Intravenous solutions, pediatric area of the emergency room is not appropriately designed, the operating room department is not appropriately designed, Cidex OPA is not used in an appropriate area, maintenance and biohazardous closets do not have extractors or smoke detectors, patient's closets in double occupancy rooms are not labeled or separated, patient's room doors can be locked from the inside, toilet room emergency call systems are push button, handrails are needed at two outside staircases, grease traps are not properly maintained and no evidence was provided of cleaning performed on the water reserve tank at Santa Rosa I.

Findings include:

1. The pediatric area of the emergency room was visited with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 at 8:30 am and provided evidence that the pediatric cubicles #6, #7, #8 and #9 are located in an area that is shared by adult patients at cubicles #4 and #5 and the respiratory therapy office. The organization and layout of the emergency room does not allow for the proper privacy and safety of these minor patients due to the traffic.

2. The hospital's emergency room (adult and pediatric) was visited with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 from 8:30 am till 11:00 am and provided evidence that there are four lounge chairs that are placed up against a wall in the observation area that are used to provide respiratory therapy and give intravenous solutions to patients. The lounge chairs are placed side by side with little space between them and no curtains were found between the lounge chairs. In order to provide emergency treatment to a patient at least four feet between lounge chairs is needed to accommodate emergency staff and equipment and curtains are needed to provide privacy during treatment. Also, four regular seats were observed in front of the lounge chairs with patients on I.V solutions with their seats touching one another, no curtains and they were looking directly at the patients on the lounge chairs.

3. Handicapped toilets were observed and inspected with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) at Santa Rosa I and II on 3/24/10 from 8:30 am till 3:45 pm and on 3/25/10 from 8:30 am till 12:00 noon and the following was observed:
a. The bathrooms at the emergency room waiting area provided evidence that a grab bar is needed behind the toilet of the male bathroom (a grab bar must be installed behind the toilet to allow for easy maneuvering by the user) and a mirror and an emergency call system is also needed. The female bathroom in this area was not equipped to comply with "Americans with Disabilities Act" (Ley ADA).
b. The female bathroom in the emergency room observation area provided evidence that a grab bar is needed behind the toilet (a grab bar must be installed behind the toilet to allow for easy maneuvering by the user).
c. The male and female handicapped bathrooms at the waiting area of Santa Rosa II was visited on 3/25/10 at 9:50 am and provided evidence that the toilet seats were 15 ½ inches in height, however according with "Americans with Disabilities Act" (Ley ADA) (section 4.16-water closets) requirements for toilet heights, the toilet seat must be between 17 and 19 inches in height. Also the paper towel dispenser handles (manual) were measured at 52 inches high and in order for these bathrooms to comply with Ley ADA requirements for paper dispenser heights, the handle of the dispenser must not exceed 48 inches in height for front access dispensers.

4. Maintenance closets throughout the Santa Rosa I and II located in hallways, emergency room and operating room department were observed on 3/24/10 and 3/25/10 from 8:30 am till 3:30 pm with the Safety Officer (employee #14) and Physical Plant Manager (employee #15). These closets were found with chemicals and equipment to clean the facility and did not have air extractors or smoke detectors connected to the fire alarm system.

5. Biohazardous waste closets located within the facilities of Santa Rosa I and II were observed on 3/24/10 and 3/25/10 from 8:30 am till 3:30 pm with the Safety Officer (employee #14) and Physical Plant Manager (employee #15). These closets do not have air extractors or smoke detectors connected to the fire alarm system.

6. The operating room department at the Santa Rosa I was visited on 3/24/10 from 11:00 am till 12:00 noon with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and provided evidence of the following:
a. Observations made during the initial tour provided evidence that the operating room department (dressing room-street clothes to operating room attire, pre-induction room, surgical area and recovery room) are divided into different designated areas (unrestricted, semi-restricted and restricted) with signs at each area indicating the surgical attire required. Lines on the floor are needed with different colors and these colors are to be integrated into the signs placed at the different areas. Also, strict vigilance is required at the main entrance of the operating department where the dressing rooms are located due to personnel with scrubs and with street clothes in the same area.
b. The hospital's operating room department does not have a designated phase II area. It does not have lounge chairs to place patients after they change back into their street clothes to continue with their stabilization process (lounge chairs should be separated by at least four feet from one another, should have curtains between the chairs). The phase II area needs a hand washing station, should have designated storage space or space for family members, the lounge chairs should be set up so that patients have privacy from one another, but are in the direct line of sight of the nurse. The phase II area also needs a patient's bathroom that complies with "Americans with Disabilities Act" (Ley ADA) related to door width (a minimum of 32 inches is needed), toilet seat height (height should be between 17 and 19 inches) and grab bars (should be located behind and on the side of the toilet).
c. The room used to process equipment with Cidex OPA was found with its door open in the semi-restricted area and it did not have an exhaust hood: Manufacturers' recommendations suggests that the solution is used in a well-ventilated area and stored in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media.
d. Biohazardous trash is placed in the same room that is used to wash equipment with Cidex OPO. A large container filled with biohazardous trash was found in this room near the sink used to wash the equipment.
e. The male and female dressing rooms are not constructed to provide one-way traffic. Staff enter through a door located in a non restricted hallway, into the dressing room where they change from their street clothes into their scrubs and then access the same non restricted hallway in their scrubs and then pass through a door that opens into the operating room area (semi-restricted) near the recovery room.
f. Suites #1 and #2 do not have working hands free intercom systems within the suites connected to the nursing station and recovery room.
g. Rust was found on the large overhead operating lamp in operating suite #3.
h. The pre-induction area is located in a non-restricted room away from operating suites and after patients are dressed in surgical attire they moved through a common non-restricted hallway of the hospital.
i. Operating room personnel (employee #16) in scrubs, shoe covers, head head cap was found on 3/24/10 at 11:55 am in the hospital's common non-restricted hallway.
j. The room used to store sterile supplies after they are taken from the autoclave was visited and provided evidence that it is under the control of employee #17 and she stated during an interview on 3/24/10 at 11:30 am that staff enter and help themselves when they need something during operating procedures. In order to avoid cross contamination different staff shall be limited access this room.

7. The dirty linen room located at Santa Rosa II was observed on 3/25/10 at 11:00 am with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and provided evidence that it is also used to store biohazardous waste (and other things such as a metal file cabinet with material inside of it and an umbrella on the top of it). The dirty linen closet and biohazardous waste can not share the same area (biohazardous waste needs its own closet if store within the facility) and these closets can not be used to store other items (file cabinet and umbrella). Also, the dirty linen closet did not have an air extractor or smoke detectors connected to the fire alarm system.

8. All patient's double rooms (two beds) were observed on 3/24/10 and 3/25/10 from 8:30 am till 3:30 pm with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and provided evidence of the following:
a. The closets are not labeled "A" or "B" for patients to identify which closet belongs to which bed.
b. The closets are not physically separated, when the doors are open its one closet and not two separate areas within the same closet to ensure that patient's personal items are not mixed together.

9. Written evidence about cleaning performed on the water reserve tank at Santa Rosa I was requested on 3/25/10 at 2:00 pm. No evidence was provided of this reserve tank annual cleaning in accordance with state law requirements (Chapter XXV, Article #1, from November 7, 1999).

10. Two outside exit staircases at Santa Rosa II were observed on 3/25/10 from 10:30 till 11:00 am with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) without handrails on both sides of the staircase. These staircases are located near the communication rooms (back of the hospital) and where the cafeteria leads to the administration offices.

11. All patient's sleeping rooms (including the isolation room at the emergency room and family birthing rooms) located at Santa Rosa I and II were visited on 3/24/10 and 3/25/10 from 8:30 am till 3:30 pm with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and provided evidence that they can be locked from the inside by patients. Nursing staff and personnel must have instant access to the patients and their rooms at all times and the doors must open without using any type of device to unlock them.

12. Patient's bathrooms (toilet rooms) at Santa Rosa I and II were observed on 3/24/10 and 3/25/10 from 8:30 am till 3:30 pm with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and provided evidence that the emergency nursing call has push buttons and not pull cords to summon nursing personnel to the toilet in the event of an emergency.

13. The minor surgery room located in the emergency room was visited on 3/24/10 at 12:15 pm with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and provided evidence that the facility was attending a patient in this room. There are double glass doors to enter this room and the patient was not allotted privacy; staff were providing treatment to the patient and were observed from the outside near cubicle #4.

14. A handle is needed on the double doors leading to the operating room hallway near the dressing rooms as observed on 3/24/10 at 11:55 am with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) in the event that power is lost and staff need to exit the operating suite/recovery area.

15. The kitchen area was observed on 3/24/10 at 3:45 pm with a grease trap located near the food preparation area within the kitchen. The Physical Plant Manager (employee #15) stated on 3/24/10 at 3:50 pm that the kitchen has two grease traps, one is accessible on the outside of the kitchen and the other is accessible in the kitchen and physical plant personnel clean the traps as needed. According with the Guidelines for Design and Construction for Health Care Facilities section 2.1-10.1.2.5 paragraph 5 (Drainage systems) (page 116) (2006 edition) states "kitchen grease traps shall be located and arranged to permit easy access without the need to enter food preparation or storage areas. Grease traps shall be accessible from outside the building without need to interrupt any services". The Physical Plant Manager (employee #15) also stated that when the traps are emptied the grease is discarded into the regular trash of the hospital. No evidence was found if the facility is using special enzymes to dissolve and inactivate harmful bacteria and to control odors in the kitchen and if discarding the grease into the regular trash is an acceptable practice allowable under their municipality.

Based on observations made during the survey for the physical environment with the Safety Officer and Physical Plant Manager, it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas, they are not equipped with an air disinfection system.

Findings include:

The emergency room was visited with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) on 3/24/10 from 8:45 am till 11:00 am and provided evidence that the waiting area, triage area and the observation area of the emergency room is not equipped with an air disinfection system (for example: Ultraviolet lights). According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) the triage area is the point of entry of undiagnosed and untreated airborne infections and should be designed and ventilated to reduce exposure of staff, patients and families to airborne infectious diseases. Through the facility's infection control program, determinations must be made related to general ventilation and air disinfection similar to inpatient requirements for airborne infection isolation rooms according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". The waiting area and observation area are other areas to provide protection with an air disinfection system.

Based on infection control credential files (C.F) reviewed, it was determined that the facility failed to ensure that the person designated as the infection control officer to develop and implement policies governing control of infections and communicable diseases maintains an updated and ongoing evaluation and job descriptions (C.F #26).

Findings include:

During the review of the infection control officer's credential file on 3/24/10 at 1:30 pm, no evidence was found related to her job description and no evidence was found related to ongoing evaluations (C.F #26).

Based on the observational tour with the Infection Control Officer, review of policies and procedures and interview, it was determined that the facility failed to provide standards for infection control related to the adequate infection control standards at the to surgery ward, pediatric ward, medicine ward, intensive care unit, catheterism area and X- Ray department.

Findings include:

1. During the observational tour with the infection control officer on 3/24/10 from 8:35 am till 3:30 pm and on 3/25/10 from 8:30 am till 4:00 pm, to surgery ward, pediatric ward, medicine ward, intensive care unit, catheterism area and X- Ray department, the following was found:

I. In the medicine ward the following was observed on 3/24/10 at 9:15 am.

a. In empty and cleaned patient's rooms #102, #105, #108, #116 and #118, full sharps containers were observed with identification label and the date when placed was February 22, 2010.

b. Two I.V pumps were observed in patient's room #104 directly on the floor.

c. Three plastic gallons with water were observed in the refrigerator in patient's room #109, however the room was cleaned and did not have patients.

d. Four canisters of the suction machine without covers were observed on the shelf in the closet of patient's room #110, the closet lacked acoustic ceiling tiles and water was observed draining from the air conditioner on the top of the closet door. The vinyl tile was observed sealed to the wall on the closet.

e. The wall was broken in the closet of patient's room #111.

f. A bed pan was found directly on the floor in patient's room #114.

g. A used patient's towel from room #119 (B) was observed on the clean patient's bed (A).

h. A Foley catheter was observed without labels with the nurse's signatures, Foley number, date and hour when started on the patient in room #127.

i. The I.V storage area of the nursing station was observed opened without a security lock and lacked acoustic ceiling tiles. An open betadine plastic bottle with a broken lid and without identification label was observed.

j. On the top of the wash stand of the nursing station area of the medicine ward on 3/24/10 at 10:00 am, two used coffee pots containing dirty water and a mosquito was observed inside of one of the pots.

k. The crash cart was observed with dust in medicine ward.

II. In the nursery ward, the following was observed on 3/24/10 at 10:30 am.

a. A roll of hand paper and a bottle of liquid soap were observed on the top of the counter near the handwashing station, however the paper dispenser and soap dispenser were observed empty.

b. A roll of hand paper was observed on the top of the formula refrigerator.

III. In the intensive unit care ward the following was observed on 3/24/10 at 11:00 am.

a. The employees bathroom of the nursing station lacked of acoustic ceiling tiles.

b. The refrigerator used by employees to place food was observed dirty and lacked a thermometer.

IV. In the catheterism area the following was observed on 3/24/10 at 11:10 am.

a. A gallon of clorox, a bedpan, a bag of sand (used for patients to make pressure post- catheterism area) were observed inside the washstand area, dust and dirt were also observed.

b. The washstand was observed with apparent rust.

c. The medical surgical material storage lacked identification labels. Three blue blood samples tubes were observed with expiration dates of January 2010.

d. A refrigerator used by employees to place food was observed with rust on the door and maintained in the house keeping room.

V. In the surgery ward the following was observed on 3/24/10 at 11:30 am.

a. The refrigerator used for pediatric formulas lacked a thermometer.

b. The ice maker machine lacks the cleaning registry, interview with the infection control nurse (employee #26) on 3/24/10 at 11:35 am, she stated "The external cleaning of the ice maker machine is provided by the domestic services of the ward and internally and filter cleaning and maintenance is performed by a privacy company, however the infection control nurse and the supervisor of this private company did not provided evidence of the external and internal ice machine cleaning".

c. The water fountain near the elevator was observed dirty and with dust.

VI. In the X-Ray department at Santa Rosa I the following was observed on 3/25/10 at 2:30 pm.

a. During the observational tour on 3/25/10 at 2:30 pm of the medical surgical storage area located at the right side of the X-Ray department at Santa Rosa I, it was found that this area is dusty, the floor was observed dirty and garbage as observed on the floor, carton boxes were broken, the entire area was dusty (on shelves, boxes and floor) and medical surgical material (syringes, gauzes, underpad, ect.), office materials and plates and other documents and materials were found on the same shelf and on top of other shelves.

b. No evidence was found on 3/25/10 at 2:30 pm of adequate labeling of radioactive materials, waste and hazardous areas.

c. All areas of the X-Ray department were observed on 3/24/10 at 8:30 am and 3/25/10 at 1:00 pm with a lot of dust, dirt and papers.

d. On 3/24/10 at 8:30 am, the interior part of the washstand, used for X-Ray personnel located at the main corridor, were found with two empty carton boxes, around the washstand were observed on a deteriorated wood board with dust, water, dirty and food residues were observed on the interior of the washstand. The washstand lacks a hand paper and soap dispensers.

e. The ceiling at the X-Ray department of Santa Rosa I of the bathroom was observed with damage, the air conditioning blows hot air and water was observed on 3/25/10 at 3:00 pm. from the air conditioner on the floor, the air conditioner lacks a protective cover, and the water fell to the ground near the entrance of the bathroom exposing patient's and personnel to falls and accidents. The patient's bathroom lacks an identification label.

f. During the visual tour at the X-Ray department accompanied by the X-Ray nurse (employee #2) on 3/25/10 at 4:05 pm, it was observed dirty and with dust in the interior and exterior of the crash cart.

Based on interviews with the social worker in charge of the Discharge Planning Program and eighteen medical records reviewed (R.R) for discharge planning, it was found that the facility failed to ensure that discharge planning evaluations are performed or the final dispositions are complete for patient's during the first 24 hours for eighteen out of eighty-eight patients admitted to the facility (R.R #2, #25, #26, #27, #28, #29, #30, #31, #63, #64, #65, #66,
#67, #68, #69, #70, #71 and #72), no evidence of participation in administrative meetings, maintaining informed through narrative reports and statistics monthly, no evidence was found of an in-service training program and no evidence was provide of the participation in the Quality Program.

Findings include:

1. Discharge planning evaluations are "not performed for all patients admitted at the facility" R.R #2, #25, #26, #27, #28, #29, #30, #31, #63, #64, #65, #66, #67, #68, #69, #70,
#71 and #72 did not have discharge planning evaluations as reviewed on 3/25/10 from 10:30 am till 4:45 pm. The social worker (employee #23) was interviewed on 3/25/10 at 4:15 pm and she stated "The facility has one social worker for Santa Rosa I and Santa Rosa II, I had an agreement until May 13, 2009 and I provide on call services twenty-four hours a day and seven days a week, however I work in another agency from 8:00 am till 3:00 pm, I try to do everything with the time that I have. I respond directly to the hospital's administrator. I don't have documents of some evaluations related to discharge planning here; all of my documents are not in the hospital because I complete them when I can". The social worker (MTS) did not provide evidence of the in-service training program and did not provide evidence of her participation in the Quality Program.

2. Review of policies/procedures and the social worker's contract on 3/25/10 at 4:25 pm provided evidence that the social worker is the person responsible for developing plans of care and administrative tasks and all technical aspects to provide efficient services to all patients in accordance with the patient's social needs. However, the facility has a registered nurse who performs the discharge planning, but she did not perform the discharge planning for all patients admitted at the facility because she performs other functions at the facility. Interview with the discharge planning nurse (employee #22) on 3/25/10 at 9:30 am provided evidence of the following: "I verify the daily census and I identify the new admissions, then I interview the patient to identify the patient's needs. However on occasions I don't see the admissions because I perform other functions. I try to evaluate all patients but it ' s impossible. When I'm over loaded I take the cases that are in need of evaluations and I work with them. There are cases that are left without being seen because I do not have time. I perform everything of the social worker functions. The cases of the past week I did not do and the patient was discharge home without discharge planning intervention except for one case.''

3. No evidence was found on 3/25/10 at 4:15 pm. that the social worker (MTS) participated in administrative meetings as needed and she did not maintain informed through narrative reports and statistics on a monthly basis the administrator in accordance with her functions.

4. No evidence was found on 3/25/10 at 4:15 pm when the social worker and the discharge planning nurse performed meetings to maintain inform through narrative reports and statistics monthly.

5. The social worker did not provide evidence on 3/25/10 at 4:15 pm of how many cases she attend, no evidence of documentation related to performed initial estimates (Initial Assessment) to identify patient's needs during the first 24 hours (biopsychosocial needs, the patient's and caregiver's understanding discharge needs and identification of post-hospital care resources) after admission to develop a discharge plan for Medicare, Medicaid and all patients with high risk diagnosis and others patients are referred by physicians or the case manager director.

Based on the review of social worker credential files (C.F), it was determined that the facility failed to ensure in-service training one out of one social worker and that she was qualified in accordance with consistent with State laws related to annual evaluations, health certificate , hepatitis vaccine, current evaluations and job descriptions and current evaluations (C.F #1 ).

Findings include:

1. During the review of the social worker credential file on 3/25/10 at 4:15 pm with the human resource C.F #1 no evidence of current health certificate, hepatitis vaccine, current evaluations and job descriptions.

2. During interview with the social worker (employee #23) related to the her functions, responsibilities and in-service training program on 3/25/10 at 4:15 pm, she stated: '' that in-service training was not performed, she has an agreement until May13, 2009, I provided my services on call twenty four hours seven days a week because I working in another agency from 8:00 am. to 3:00 pm., I tried to do more than the time I have.''

3. Review of policies and procedure and the social worker agreement on 3/25/10 at 4:25 pm. provided evidence that the director of the department is the person responsible for developing and conducts the administrative and social techniques ' aspects to provide efficient services to all the patients in accordance of patient ' s social needs.

Based on eighteen medical records reviewed (R.R) with the nurse in charge of the Discharge Planning Program and review of policies/procedures, it was determined that the facility failed to ensure that ongoing reassessments are performed and documented for patient's needs for factors that may affect continuing care for fifteen out of eighteen patients admitted to the facility (R.R #2, #26, #27, #29, #30, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72).

Findings include:

1. Policies and procedures provided evidence on 3/25/10 at 9:30 am that the assessment is not performed for the first 24 hours and reassessment notes are not performed. A mechanism to ensure that the discharge planning process is reassessed on an on-going basis was not performed nor followed as found on 3/25/10 from 8:40 am till 4:30 pm:

a. R.R #2 is a 94 years old male admitted with a diagnosis of Cardiac Heart Failure, Acute Bronchitis v/s Bronchopneumonia on 3/20/10. The discharge planning services was initiated on 3/20/10 and the patient has a permanent foley catheter, on the initial evaluation it was identified that a service to provide foley care at her home, but did not provide evidence of a progress note indicating the plan for this patient. No evidence was found of changes in the patient's health status and no evidence was found of an ongoing mechanism to reassess the discharge planning process. No evidence of discharge planning plan of care.

b. R.R #26 admitted at medicine ward with a diagnosis of Acute Bronchitis on 3/23/10. The initial discharge planning evaluation was performed on 3/24/10 and provided evidence that the patient has speaking problems for the health condition however no evidence in the progress note indicating the plan for this patient. No evidence was found of an ongoing mechanism to reassess its discharge planning process. No evidence of discharge planning plan of care.

c. R.R #27 admitted at the medicine ward with a diagnosis of Leg Cellulitis, Lymphangitis, Morbid Obesity and Cardiovascular Disease on 3/20/10. The patient's medical record lacks the nurse's initial assessment and nursing history, no evidence of plans of care related to the patient's condition and discharge planning, the initial discharge planning evaluation was performed on 3/23/10 three days later which is not in accordance with the discharge planning policies and procedures and patient needs. The patient needs social worker evaluation and no evidence of physician consult. No evidence on progress notes indicating the plan for this patient. No evidence was found of an ongoing mechanism to reassess its discharge planning process. No evidence of discharge planning plan of care.

d. R.R #29 female transferred to the Intensive Unit Care from the medicine ward on 3/25/10 with a diagnosis of Chest pain and Acute Coronary Syndrome. No evidence of plans of care related to the patient's condition and discharge planning patient needs. The initial discharge planning interview was performed on 3/24/10. No evidence on progress note indicating the plan for this patient. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

e. R.R #30 is an 86 years old male admitted at medicine ward with diagnosis of Severe Cellulitis of Left Leg and Cardiovascular Disease on 3/24/10. No evidence of plans of care related to the patient condition and discharge planning patient needs. The initial discharge planning interview was performed on 3/24/10. No evidence on progress note indicating the plan for this patient. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

f. R.R #63 is a 28 years old female admitted at Intensive Unit Care with a diagnosis of Bronchial Asthma on 3/18/10. No evidence of plans of care related to the patient condition and discharge planning patient needs. No evidence of the initial discharge planning evaluation.

g. R.R #64 is a 79 years old female admitted at medicine ward with a diagnosis of Gangrene Left foot and Diabetes Mellitus on 3/17/10. No evidence of the initial discharge planning evaluation. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

h. R.R #65 is a 44 years old female admitted at emergency room on 1/04/10. No evidence of the initial discharge planning evaluation. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

i. R.R #66 is a 63 years old male admitted at medicine ward with a diagnosis of Abdominal Pain on 3/18/10. No evidence of the initial discharge planning evaluation. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

j. R.R #67 is a 39 years old female admitted at medicine ward on 3/21/10. No evidence of the initial discharge planning evaluation. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

k. R.R #68 is a 39 years old female admitted at emergency room on 3/24/10. No evidence of the initial discharge planning evaluation. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

l. R.R.#69 is a 24 years old female admitted at emergency room on 3/23/10. No evidence of the initial discharge planning evaluation. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

m. R.R #70 is a 42 years old male admitted at emergency room with a diagnosis of Acute Depression with psychosis on 1/07/10. No evidence of the initial discharge planning evaluation. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

n. R.R #71 is a 15 years old female admitted at pediatric emergency room on 1/04/10. No evidence of the initial discharge planning evaluation. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

o. R.R.#72 is an 18 years old female admitted at emergency room on 1/07/10. No evidence of the initial discharge planning evaluation. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

Based on the observational tour, interview and review of policies/procedures with the Operating Room (OR) Supervisor (employee #6), the Safety Officer (employee #14) and Physical Plant Manager (employee #15), it was determined that the facility failed to maintain standards of practice for patients' care, related to rust found on the large overhead operating lamp, water fountain was observed with rust, expired medication in the crash cart, bed with scratched paint and rust, night table with detached formica, lack of lines on the floor identified with different colors non restricted, semirestricted and restricted areas, lack of a designated phase II area, lack of an exhaust hood to manage Cidex use, lack of a biohazardous room, lack of two-way traffic in the male and female dressing rooms.

Findings include:

1. During the observational tour of the operating room department on 3/24/10 from 9:00 am till 12:00 pm the following was found:

a. Rust was found on the large overhead operating lamp in operating suite #3 on 3/24/10 at 9:20 am.
b. The water fountain was observed on 3/24/10 at 9:15 am with rust near the housekeeping room.
c. A paper dispenser was observed near the water faucet and when personal removed paper it touched the faucet on 3/24/10 at 9:30 am.
d. A stool was observed in the recovery room area with cracked vinyl as observed on 3/24/10 at 9:40 am.
e. The crash cart of the recovery room was reviewed on 3/24/10 at 9:45 am and was found with the following: The last review by the pharmacy department was in October 2009. The following medication were expired: two vials of Lidocaine 100 mg expired since February 1, 2010, ten vials of Atropine 0.4 mg/ml expired in February 2010, one vial of Propranolol Hydrochloride 1 mg/ml expired since January 2010.
f. The Material Safety Data Sheet (MSDS) was reviewed on 3/24/10 at 11:00 am and provided evidence that it is in the English language. During interview with the housekeeping (employee #27) designated to the Operation room on 3/24/010 at 11:10 a.m. she state that she don't know to read the English language.
g. The house keeping room was observed on 3/24/10 from 9:00 am to 11:30 am near the recovery room area and was observed opened all the time and was observed with four yellow pails with the mop inside. Two pails inside the housekeeping room and two pails at the door of the housekeeping room. The housekeeping room is to small to maintain the pails and mops inside of it and the door can not be closed.

2. The pre-induction area was observed on 3/24/10 at 11:30 am and the following was observed:
a. Three beds with scratched paint and rust on the bed rails (beds A, B and C).
b. Four night tables with detached formica at cubicle A, B, C).
c. The crash cart of the recovery room was reviewed on 3/24/10 at 11:45 am and the following was determined: The last review by the pharmacy department was in October of 2009. The following medications were found expired: two vials of Aminophylline 250 mg/10 ml expired on February 1, 2010, 2 vials of Atropine 0.4 mg/ml expired in February 2010 and two blue sample tubes and two red sample tubes expired in February 2010.

3. The operating room department at the Santa Rosa I was visited on 3/24/10 from 11:00 am till 12:00 noon with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and provided evidence of the following:
a. Observations made during the initial tour provided evidence that the operating room department (dressing room-street clothes to operating room attire, pre-induction room, surgical area and recovery room) are divided into different designated areas (unrestricted, semi-restricted and restricted) with signs at each area indicating the surgical attire required. Lines on the floor are needed with different colors and these colors are to be integrated into the signs placed at the different areas. Also, strict vigilance is required at the main entrance of the operating department where the dressing rooms are located due to personnel with scrubs and with street clothes in the same area.
b. The hospital's operating room department does not have a designated phase II area. It does not have lounge chairs to place patients after they change back into their street clothes to continue with their stabilization process (lounge chairs should be separated by at least four feet from one another, should have curtains between the chairs). The phase II area needs a hand washing station, should have designated storage space or space for family members, the lounge chairs should be set up so that patients have privacy from one another, but are in the direct line of sight of the nurse. The phase II area also needs a patient's bathroom that complies with "Americans with Disabilities Act" (Ley ADA) related to door width (a minimum of 32 inches is needed), toilet seat height (height should be between 17 and 19 inches) and grab bars (should be located behind and on the side of the toilet).
c. The room used to process equipment with Cidex OPA was found with its door open in the semi-restricted area and it did not have an exhaust hood: Manufacturers' recommendations suggests that the solution is used in a well-ventilated area and stored in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media.
d. Biohazardous trash is placed in the same room that is used to wash equipment with Cidex OPO. A large container filled with biohazardous trash was found in this room near the sink used to wash the equipment.
e. The male and female dressing rooms are not constructed to provide one-way traffic. Staff enter through a door located in a non restricted hallway, into the dressing room where they change from their street clothes into their scrubs and then access the same non restricted hallway in their scrubs and then pass through a door that opens into the operating room area (semi-restricted) near the recovery room.
f. The pre-induction area is located in a non-restricted room away from operating suites and after patients are dressed in surgical attire they moved through a common non-restricted hallway of the hospital.
g. Operating room personnel (employee #16) in scrubs, shoe covers, head head cap was found on 3/24/10 at 11:55 am in the hospital's common non-restricted hallway.
h. The room used to store sterile supplies after they are taken from the autoclave was visited and provided evidence that it is under the control of employee #17 and she stated during an interview on 3/24/10 at 11:30 am that staff enter and help themselves when they need something during operating procedures. In order to avoid cross contamination different staff shall be limited access this room.

Based on the review of two active and four closed medical records and policies/procedures of the operating room with the Operating Room Supervisor (employee #6), it was determined that the facility failed to execute complete surgery informed consents that include date, hour, surgeon's name, complete diagnosis, physician authorization and type of procedure risk of transfusion for six out of six records reviewed (R.R #19, #20, #21, #22,
#23 and #24).

Findings include:

1. During the review of two active records and four closed records on 3/24/10 from 3:00 pm till 4:00 pm and on 3/25/10 from 8:45 am till 11:00 am, the following was determined:

a. R.R #19 provided evidence that the surgical procedure consent form did not include the risk to accept the transfusion.

b. R.R #20 provided evidence that the surgical procedure consent form did not include the risk to accept transfusion and alternative of treatment without surgery.

c. R.R #21 provided evidence that the surgical procedure consent form lacks the hour when the consent was taken.

d. R.R #22 provided evidence that the surgical procedure consent form lacks the printed patient's name, hour that the consent was taken, type of procedure, the risk to accept transfusion and alternative treatment without surgery.

e. R.R #23 provided evidence that the surgical procedure consent form lacks the date that the consent was taken and the risk to accept transfusion.

f. R.R #24 provided evidence that the surgical procedure consent form lacks the hour that the consent was taken and the risk to accept transfusion and alternative treatment without surgery.

Based on the review of two active and four closed medical records and policies/procedures of the operating room with the Operating Room Supervisor (employee #6), the Safety Officer (employee #14) and Physical Plant Manager (employee #15, it was determined that the facility failed to ensure the availability of a call-in system for suites #1 and #2.

Finding include:

1. The operating room department at the Santa Rosa I was visited on 3/24/10 from 11:00 am till 12:00 noon with the Safety Officer (employee #14) and Physical Plant Manager (employee #15) and provided evidence of the following:

a. Suites #1 and #2 do not have working hands free intercom systems within the suites connected to the nursing station and recovery room.

Based on the observational tour through the operating rooms (O.R) and review of policies/procedures of anesthesia services with the anesthesiologist and Operating Room Supervisor (employee #6), it was determined that the facility failed to be integrated into the hospital wide QAPI program, failed to maintain educational plans and maintain updated credential files for anesthetist nurses (CRNA) for Credential files (C.F #1, #2 and #3) to ensure appropriate scope of anesthesia services.

Findings include:

1. Anesthesia is a contracted service and no evidence was found related to quality assurance plan or activities for improvement for the natural year of 2009 and the months of January and February 2010 as reviewed on 3/25/10 at 9:00 am.

2. No evidence was found on 3/25/10 at 9:30 am of the educational plan for 2010.

3. Anesthetist credential files were reviewed on 3/25/10 from 9:30 am till 10:00 am, the following was found:

a. Anesthesia services did not provide evidence of updated credential files of contracted anesthetist nurses that provide services at the facility.
b. The operation room supervisor (employee #6) provided evidence of updated license, nursing association, health certificate and hepatitis B vaccine. However, no evidence was provided of influenza vaccine or if it was denied, job description, competencies and updated annual evaluations, since February 2009 for three out of three contracted anesthetist nurses (C.F #1, #2 and #3).

Based on the review of two active records and four closed records for anesthesia services, it was determined that the facility failed to ensure that informed consent forms are properly executed for six out of six records reviewed (R.R #19, #20, #21, #22, #23 and #24).

Findings include:

1. During the review of two active records and four closed records on 3/24/10 from 3:00 pm till 4:00 pm and on 3/25/10 from 8:45 am till 11:00 am, the following was determined:

a. R.R #19 provided evidence that the anesthesia consent form was incomplete for the patient's printed name, date, hour and type of anesthesia that the patient consented.

b. R.R #20 provided evidence that the anesthesia consent form was incomplete for the type of anesthesia that the patient consented.

c. R.R #21 provided evidence that the anesthesia consent form was incomplete for the type of anesthesia that the patient consented.

d. R.R #22 provided evidence that the anesthesia consent form was incomplete for the type of anesthesia that the patient consented.

e. R.R #23 provided evidence that the anesthesia consent form was incomplete for the type of anesthesia that the patient consented.

f. R.R #24 provided evidence that the anesthesia consent form was incomplete for the type of anesthesia that the patient consented.

Based on the review of two active records and four closed records for anesthesia services, it was determined that the facility failed to ensure that a pre-anesthesia evaluation was completed and fully documented by the anesthesiologist within 48 hours prior to surgery or a procedure requiring anesthesia services related to documentation of the patient's laboratory results for five out of six records reviewed (R.R. #19, #20, #22, #23 and #24).

Findings include:

1. During the review of two active records and four closed records on 3/24/10 from 3:00 pm till 4:00 pm and on 3/25/10 from 8:45 am till 11:00 am, the following was determined:

a. R.R #19 provided evidence that the pre-anesthesia evaluation form was incomplete for the patient's laboratory results.

b. R.R #20 provided evidence that the pre-anesthesia evaluation form was incomplete for the patient's laboratory results.

c. R.R #22 provided evidence that the pre-anesthesia evaluation form was incomplete for the patient's laboratory results.

d. R.R #23 provided evidence that the pre-anesthesia evaluation form was incomplete for the patient's laboratory results.

e. R.R #24 provided evidence that the pre-anesthesia evaluation form was incomplete for the patient's laboratory results.

Based on the review of two active records and four closed records for anesthesia services, it was determined that the facility failed to ensure that an intraoperative anesthesia record was completed and fully documented with pertinent events taking place during anesthesia for six out of six records reviewed (R.R #19, #20, #21, #22, #23 and #24).

Findings include:

1. During the review of two active records and four closed records on 3/24/10 from 3:00 pm till 4:00 pm and on 3/25/10 from 8:45 am till 11:00 am, the following was determined:

a. R.R #19 provided evidence that the intraoperative anesthesia record was incomplete for the American Society of Anesthesiology (ASA) guidelines, patient's age, weight, height and the post-operative diagnosis that was filled in with the word "Same" and not with the full Diagnosis and no indication of how long the patient did not have anything by mouth (NPO).

b. R.R #20 provided evidence that the intraoperative anesthesia record was incomplete for the American Society of Anesthesiology (ASA) guidelines, patient's age, weight, height and the post-operative diagnosis that was filled in with the word "Same" and not with the full Diagnosis.

c. R.R #21 provided evidence that the intraoperative anesthesia record was incomplete for the American Society of Anesthesiology (ASA) guidelines, patient's age, weight, height and the post-operative diagnosis that was filled in with the word "Same" and not with the full Diagnosis.

d. R.R #22 provided evidence that the intraoperative anesthesia record was incomplete for the American Society of Anesthesiology (ASA) guidelines, patient's age, weight, height and the post-operative diagnosis that was filled in with the word "Same" and not with the full Diagnosis.

e. R.R #23 provided evidence that the intraoperative anesthesia record was incomplete for the American Society of Anesthesiology (ASA) guidelines, patient's age, weight, height and the post-operative diagnosis that was filled in with the word "Same" and not with the full Diagnosis.

f. R.R #24 provided evidence that the intraoperative anesthesia record was incomplete for the American Society of Anesthesiology (ASA) guidelines, patient's age, weight, height and the post-operative diagnosis that was filled in with the word "Same" and not with the full Diagnosis and no indication of how long the patient did not have anything by mouth (NPO).

Based on the review of two active records and four closed records for anesthesia services, it was determined that the facility failed to ensure that a post-anesthesia evaluation is completed and documented legible with the date and hour for six out of six records reviewed (R.R #19, #20, #21, #22, #23 and #24).

Findings include:

1. During the review of two active records and four closed records on 3/24/10 from 3:00 pm till 4:00 pm and on 3/25/10 from 8:45 am till 11:00 am the following was determined:

a. R.R #19 provided evidence that the post-anesthesia evaluation was incomplete due to lack of a legible evaluation.

b. R.R #20 provided evidence that the post-anesthesia evaluation was incomplete due to the lack of the hour of the evaluation and legible evaluation.

c. R.R #21 provided evidence that the post-anesthesia evaluation was incomplete due to the lack of a legible evaluation.

d. R.R #22 provided evidence that the post-anesthesia evaluation was incomplete due to the lack of the hour of the evaluation and legible evaluation.

e. R.R #23 provided evidence that the post-anesthesia evaluation was incomplete due to the lack of a legible evaluation.

f. R.R #24 provided evidence that the post-anesthesia evaluation was incomplete due to the lack of the hour of the evaluation and legible evaluation.

Based on five medical records reviewed (R.R), policies/procedures manual and the observational tour with the emergency room (E.R) nursing supervisor and interview, it was determined that the facility failed to monitor the patient's vital signs during transfers for three out of five medical records (R.R #44, #45 and #47), no signs were posted in the entrance area, emergency room personnel do not have a plan or assignments for all specific tasks in the event of an emergency, medications and controlled medications are not protected from non authorized access, the crash cart was last inspected in February of 2010, the housekeeping closet was found unlocked with unlabeled cleaning chemical, a dirty storage cabinet was found unlocked and accessible to non authorized persons, a newborn treatment tray was found accessible to non authorized persons, I.V sites were not labeled and clean sheets are exposed to the environment, patients and staff.

Findings include:

1. The following was observed related to the review of the policies/procedures manual and observations of the emergency department on 3/24/10 from 8:45 am till 12:30 pm:

a. No signs were posted at the entrance area (ambulatory/ambulance) for the notification of the rights of the individuals who enter the E.R as observed on 3/24/10 at 8:55 am.

b. No evidence was found on 3/24/10 at 11:45 am that emergency personnel have a plan or assignments for all specific tasks in the event of an emergency. All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

2. During the observational tour on 3/24/10 at 9:00 am a bottle of Tylenol tablets, a bottle of liquid Tylenol and five suppositories of acetaminophen were observed in the triage area. The triage area is near to waiting area and when the nurse leaves the area the door stays open which does not limit the access to this room and its contents to only authorized personnel.

3. The last revision by pharmacy services of the crash cart in the adult observation area was on 10/23/09 as reviewed on 3/24/10 at 9:20 am. Two aminophylline vials were observed on 3/24/09 at 9:25 with expiration dates of February 2010. The auxiliary pharmacist (employee #12) stated during an interview on 3/24/10 at 10:30 am that the medication crash cart is reviewed every two months.

4. The medication room located between the nursing counter and observation area (cubicle
#1) was observed on 3/24/10 at 10:00 am with its doors unlocked. A cabinet used to store medications in this room was found open and could be accessed by non authorized persons.
Also, the cabinet used to storage the narcotic medication in this room was found with the first door open. The nursing supervisor (employee #13) stated during an interview on 3/24/10 at 10:30 am that the door broke this week and he sent it to be repaired (during the inspection process the door was repaired on 3/25/10).

5. On 3/24/10 at 9:15 am the area used to keep housekeeping equipment and supplies was found with its door open and one gallon of Disinfectant and one gallon with clear solution without a label indicating the use of the solution, lot number and expiration date. This procedure of leaving the door open does not limit the access to this room and its contents to only authorized personnel. Also, no evidence was found of the material safety data sheet for the solutions used and available for housekeeping personnel..

6. A large newborn treatment tray for patients during delivery was observed on 3/24/10 at 10:20 am located inside of a bassinet in the minor surgery room, unlocked, accessible to patients and visitors. The newborn treatment tray contained suction catheter, non-sterile gauze, syringes and equipment for management the patient during the delivery.

7. The area assigned to place dirty linen and dirty equipment was observed on 3/24/10 at 11:00 am with a full sharp container, bedpans, urinals and a full dirty linen container with dirty linen also on the floor. The door was observed unlocked and is in the observation area and does not limit the risk of cross contamination if access by non authorized persons.

8. The following was observed in the emergency room on 3/24/10 from 9:30 am till 12:00 noon related to infection control procedures:

a. One bottle of single use sterile water (10 ml) for drug dilution was observed in the medication room with a label indicating the date when opened on of 3/24/10 and one vial of Lorazepam single use without the date and hour when it was opened which is not in accordance with manufacturer's recommendations and CDC recommendations to discard after opened.

b. I.V sites were observed on 3/24/10 from 8:45 am to 11:30 am in observation area #1, #2, #3, #4 and in cubicles #6, #7 and #8 in the pediatric area without a label indicating the date, hour, number of catheter and the nurse's signature when the site was accessed.

c One sharp container (1 gallon size) was observed directly on the floor of the venepuncture area in the adult observation area on 3/24/10 at 11:00 am. This area is also used to venepuncture pediatric patient's. The sharp container was not secured to prevent its removal from this area and was accessible to pediatric patient. This area is located in the corridor in front of the nursing observation and near the triage area. Also, other sharp containers were observed on 3/24/10 at 9:00 am till 12:00 noon not secured to basis to protect from removal in the triage room, medication room and minor surgery room on the top of the counter.

d. Fifteen clean sheets were observed on a cabinet in the isolation room on 3/24/10 at 10:30 am uncovered and available for patient use in the emergency room. The nursing supervisor (employee #13) stated on 3/24/10 at 10:40 am, "the emergency room has a limited amount of space so we store them there". This procedures does not limit the risk of cross contamination from patients and staff entering the isolation room.

9. Ten medical records were reviewed from 3/24/10 through 3/25/10 from 10:30 am till 3:00 pm for emergency room services and provided evidence of the following:

a. Three out of five clinical records reviewed on 3/25/10 from 1:30 pm till 3:00 pm for transfers during emergency room services, provided evidence that the physician documented the same vital signs, that the nurse took during the triage process, at the moment of the transfer to another facility. The patient's were evaluated and stabilized with diagnosis of Suicide Attempt, Upper Gastrointestinal Bleeding and Multiple Body Trauma after the initial evaluation of the emergency room visit (R.R #44, #45 and #47).

Based on the review of physician's on-call list, interview and the observational tour with the emergency room nursing supervisor, it was determined that the facility failed to comply with EMTALA regulations related to on-call surgeons roster to cover the emergency room in the event that this specialty is needed.

Findings include:

The facility provided evidence on 3/24/10 at 10:30 am of an on-call surgeon roster to cover the Emergency Room in the event that this specialty is needed. However, from the months of February and March of 2010 no surgeon were on-call for Thursday of the entire months of February and March. Also, on March 26, 27 and 28 (Friday, Saturday and Sunday) no surgeons were on the on-call roster. The Emergency Room Medical Director (employee #10) stated during an interview on 3/24/10 at 12:15 pm that surgeons are not on-call for Thursdays, but if there is a case that requires a surgeon's evaluation, the emergency room physician calls any of the physician that are on the surgeon roster. The medical director of the facility (employee #11) stated on 3/24/10 at 2:15 pm that since he arrived on 12/15/09 the on-call program has not changed. The facility failed to ensure that the on-call roster is complete for each day of the month related to surgeon coverage and failed to provide evidence of the first call and second call options in the event that they can not get in touch with the on-call surgeon designated for that day.

Based on four medical records reviewed (R.R), the lack of documents provided, the lack of policies/procedures and interview with the supervisor of the Respiratory Therapy Department, it was determined that the facility failed to ensure that the organization of the respiratory care services is appropriate to the scope and complexity of the services for two out of two clinical records reviewed (R.R #1 and #2).

Findings include:

1. During the survey of the respiratory therapy services on 3/25/10 at 1:00 pm, the supervisor of the Respiratory Therapy Department (employee #1) stated during an interview on 3/25/10 at 1:10 pm that there are only four respiratory therapy personnel and two other personnel that work per diem who perform the 11-7 shifts because one of his employees quit the 11-7 shift on 3/22/10.

2. No evidence was found on 3/25/10 at 2:00 pm of in-service training for the year of 2010. The last offered in-service was in October of 2009.

3. Respiratory therapy services has not submitted a quality assurance plan or activities for improvement since August of 2010 as reviewed on 3/25/10 at 1:30 pm.

4. Two medical records were reviewed on 3/24/10 from 9:30 am till 11:30 am of patients who received respiratory therapy and provided evidence that respiratory therapists did not administer respiratory therapy treatment in accordance with physician orders for R.R #1 and #2. Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis:

a. R.R #1 is a 69 years old female admitted on 3/19/10 with a diagnosis of Bronchopneumonia. The record review was performed on 3/24/10 at 9:45 am and provided evidence that the physician ordered Proventil 0.3/3ml of NSS every 4 hours. The patient received respiratory therapy on 3/22/10 at 12:00 am, the respiratory therapy technician writes that the patient was observed disoriented, the next therapy was given at 7:20 am (four hours and 20 minute late), the next therapy was given at 11:10 am the respiratory therapy technician writes that the patient was observed disoriented, the next therapy was given at 7:00 pm (four hours late). On 3/23/10 respiratory therapy was given at 12:00 am (half an hour late), the next therapy was given at 3:00 am (half an hour before), the next therapy was given at 9:30 am (two hours and 30 minutes late), the next therapy was given at 12:30 pm, the next therapy was given at 4:00 pm and the next therapy was given at 8:30 pm. On 3/24/10 respiratory therapy was given at 12:00 am, the next therapy was given at 4:40 am and the next therapy was given at 7:57 am. The record revealed that the patient did not receive respiratory therapies in accordance with the physicians' orders and her respiratory needs.

b. R.R #2 is a 94 years old male admitted on 3/21/10 at 1:30 pm with a diagnosis of Congestive Heart Failure (CHF). The record review was performed on 3/24/10 at 10:00 am and provided evidence that the physician ordered Atrovent 2.5 ml, Proventil 0.25/3ml and 3ml NSS every 4 hours. The patient received respiratory therapy on 3/21/10 till 3/24/10 for Atrovent 2.5ml and Proventil 0.25ml. Respiratory therapies offered did not administer 3ml of NSS according to the physician's orders. On 3/22/10 at 12:00 am, the next therapy was given at 4:00 am, the next therapy was given at 11:04 am and the next therapy was given at 7:00 pm (four hours late).

Based on the review of medical records, documents, policies/procedures and interview with the supervisor of the Respiratory Therapy Department, it was determined that the facility failed to ensure that there an adequate number of respiratory therapists and other personnel to meet qualifications specified by the medical staff and consistent with State law.

Findings include:

1. During the survey of the respiratory therapy services on 3/25/10 at 1:00 pm, the supervisor of the Respiratory Therapy Department (employee #1) stated during an interview on 3/25/10 at 1:10 pm that there are only four respiratory therapy personnel and two other personnel that work per diem who perform the 11-7 shifts because one of his employees quit the 11-7 shift on 3/22/10.

2. The facility does not have sufficient personnel available to respond to respiratory care needs of its patient's population as reviewed on 3/25/10 at 1:30 pm.

3. Review of the monthly program of respiratory therapy services with the supervisor of the Respiratory Therapy Department (employee #1) on 3/24/10 at 2:00 pm provided evidence that on 3/1/10 for the 11-7 shift only one respiratory therapist was working for 33 patients receiving respiratory therapy as ordered by the physician. On 3/2/10 for the 11-7 shift only one respiratory therapist was working for 14 patients receiving respiratory therapy as ordered by the physician. On 3/3/10 for the 11-7 shift only one respiratory therapist was working for 28 patients receiving respiratory therapy as ordered by the physician. On 3/4/10 for the 11-7 shift only one respiratory therapist was working for 30 patients receiving treatment as ordered by the physician. On 3/6/10 for the 7-3, 3-11 and 11-7 shifts only one a respiratory therapist was working for 22 patients receiving respiratory therapy as ordered by the physician. On 3/7/10 for the 7-3, 3-11 and 11-7 shifts only one a respiratory therapist was working for 26 patients receiving respiratory therapy as ordered by the physician. On 3/8/10 for the 11-7 shift only one respiratory therapist was working for 27 patients receiving respiratory therapy as ordered by the physician. On 3/9/10 for the 11-7 shift only one respiratory therapist was working for 21 patients receiving respiratory therapy as ordered by the physician. On 3/10/10 for the 11-7 shift only one respiratory therapist was working for 38 patients receiving respiratory therapy as ordered by the physician. On 3/11/10 for the 11-7 shift only one respiratory therapist was working for 28 patients receiving respiratory therapy as ordered by the physician. On 3/13/10 for the 7-3, 3-11 and 11-7 shifts only one respiratory therapist was working for 29 patients receiving respiratory therapy order by the physician. On 3/14/10 for the 7-3, 3-11 and 11-7 shifts only one respiratory therapist was working for 19 patients receiving respiratory therapy as ordered by the physician. On 3/15/10 for the 11-7 shift only one respiratory therapist was working for 17 patients receiving respiratory therapy as ordered by the physician. On 3/16/10 for the 11-7 shift only one respiratory therapist was working for 29 patients receiving respiratory therapy as ordered by the physician. On 3/17/10 for the 11-7 shift only one respiratory therapist was working for 28 patients receiving respiratory therapy as ordered by the physician. On 3/18/10 for the 11-7 shift only one respiratory therapist was working for 28 patients receiving respiratory therapy as ordered by the physician. On 3/19/10 for the 7-3, 3-11 and 11-7 shifts only one respiratory therapist was working for 35 patients receiving respiratory therapy as ordered by the physician. On 3/20/10 for the 7-3, 3-11 and 11-7 shifts only one respiratory therapist was working for 21 patients receiving respiratory therapy as ordered by the physician. On 3/21/10 for the 7-3, 3-11 and 11-7 shifts only one respiratory therapist was working for 21 patients receiving respiratory therapy as ordered by the physician. On 3/22/10 for the 7-3, 3-11 and 11-7 shifts only one respiratory therapist was working for 25 patients receiving respiratory therapy as ordered by the physician. On 3/23/10 for the 7-3 only one respiratory therapist was working for 20 patients receiving respiratory therapy as ordered by the physician.

4. The facility does not have sufficient personnel available to respond to the respiratory care needs of its patient population as determined on 3/25/10 at 3:00 pm. Two medical records were reviewed on 3/24/10 from 9:30 am till 11:30 am and provided evidence that patients are receiving respiratory therapy services but they did not receive respiratory therapies in accordance with the physicians' orders and their respiratory needs (R.R #1 and #2).

Based on the review of policies and procedures and observations with the supervisor of the Respiratory Therapy Department, it was determined that the facility failed to ensure that services are provided in accordance with acceptable standards of practice related to respiratory equipment not labeled with the date and hour when started on the equipment in five out of five patient's rooms using respiratory equipment (in patient's rooms #117A, #120A, #127A, #128A and #128B) and failed to follow policies and procedures related to respiratory equipment changes.

Findings include:

1. No evidence was provided from the supervisor of the Respiratory Therapy Department
(Employee #1) on 3/24/10 at 1:40 pm of written policies for the delivery of respiratory care services, which are developed and approved by the medical staff related with posting of signs and gas line identification.

2. During the observational tour with the respiratory therapy technician (employee #2) on 3/24/10 at 11:15 am in three out of five patient's rooms did not have evidence of sign posting for those patient's using oxygen (patient's rooms #117A, #120A and #128B).

3. During the observational tour on 3/24/10 from 11:30 am till 12:00 pm with a respiratory therapy technician (Employee #2), patient's sleeping rooms #120A, #127A, #128A and
#128B were visited and provided evidence that the patient's respiratory equipment were found in plastic bags on the patient's night tables. However, evidence was found of the respiratory equipment in plastic bags for more than 72 hours without changing them. According to the facility's policies and procedures, respiratory equipment once started is to be replaced every 72 hours. Also, the facility must verify current guidelines related to respiratory equipment and the frequency of changes to ensure that they adhere to infection control standards.

4. The Respiratory Therapy Department was visited with the respiratory therapist supervisor (Employee #2) and the space used to disinfect and store clean mechanical ventilators was observed on 3/24/10 at 1:45 pm. The area was observed with a box of disposable pediatric breathing circuits and one box of airlife universal volume ventilator circuits with manifold nebulizer on the floor and the door between the dirty and clean area did not close completely.

5. In the area of the emergency room in the room of minor surgery, it was observed on 3/25/10 at 11:00 am a clean ventilator without a cover.

Based on the review of seven respiratory therapists credential files (C.F) with the supervisor of the Respiratory Therapy Department (employee #1), it was determined that the facility failed to ensure that four out of seven respiratory therapists personnel meet the qualification specified and consistent with State laws related to annual evaluations and certificate of health (C.F #1, #3, #4 and #7).

Findings include:

1. Three out of seven respiratory therapist's credential files reviewed on 3/25/10 at 9:20 am did not provide evidence of updated annual evaluations (C.F #1 since 3/7/07, C.F #3 since 3/9/07 and C.F #4 does not have an annual evaluation).

2. One out of seven respiratory therapist's credential files reviewed on 3/25/10 at 9:20 am did not provide evidence of a health certificate (C.F #6).

Based on four medical records reviewed (R.R) for respiratory therapy services, policies/procedures with respiratory therapy technician, it was determined that the facility failed to ensure that services are provided in accordance with the physician's orders for two out of four clinical records reviewed (R.R #1 and #2).

Findings include:

1. Two medical records were reviewed on 3/24/10 from 9:30 am till 11:30 am, with a respiratory therapy technician (Employee #2), of patients who received respiratory therapy and provided evidence that respiratory therapists did not administer respiratory therapy treatment in accordance with physician orders for R.R #1 and #2. Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis:

a. R.R #1 is a 69 years old female admitted on 3/19/10 with a diagnosis of Bronchopneumonia. The record review was performed on 3/24/10 at 9:45 am and provided evidence that the physician ordered Proventil 0.3/3ml of NSS every 4 hours. The patient received respiratory therapy on 3/22/10 at 12:00 am, the respiratory therapy technician writes that the patient was observed disoriented, the next therapy was given at 7:20 am (four hours and 20 minute late), the next therapy was given at 11:10 am the respiratory therapy technician writes that the patient was observed disoriented, the next therapy was given at 7:00 pm (four hours late). On 3/23/10 respiratory therapy was given at 12:00 am (half an hour minutes late), the next therapy was given at 3:00 am (half an hour before), the next therapy was given at 9:30 am (two hours and 30 minutes late), the next therapy was given at 12:30 pm, the next therapy was given at 4:00 pm and the next therapy was given at 8:30 pm. On 3/24/10 respiratory therapy was given at 12:00 am, the next therapy was given at 4:40 am and the next therapy was given at 7:57 am. The record revealed that the patient did not receive respiratory therapies in accordance with the physicians' orders and her respiratory needs.

b. R.R #2 is a 94 years old male admitted on 3/21/10 at 1:30 pm with a diagnosis of Congestive Heart Failure (CHF). The record review was performed on 3/24/10 at 10:00 am and provided evidence that the physician ordered Atrovent 2.5 ml, Proventil 0.25/3ml and 3ml NSS every 4 hours. The patient received respiratory therapy on 3/21/10 till 3/24/10 for Atrovent 2.5ml and Proventil 0.25ml. Respiratory therapies offered did not administer 3ml of NSS according to the physician's orders. On 3/22/10 at 12:00 am, the next therapy was given at 4:00 am, the next therapy was given at 11:04 am and the next therapy was given at 7:00 pm (four hours late).

Based on observations and review of quality assurance activities with the Quality Assurance Officer, it was determined that the facility failed to act upon indicators for which there is evidence that it will improve patient health outcomes.

Findings include:

The facility is downloading the Hospital Compare Quality Indicators information of patients treated for heart attacks, heart failure, pneumonia or having surgery of the period from December/2009 through March 18, 2010 as reviewed on 3/25/10 at 11:00 am. On this report the facility has indicators with a lower percentage related with Surgical Improvement Project and Pneumonia Project when compared with a national database and other hospitals in the geographical area. No discussion or analysis of reasons or plans to improve were evidenced and the facility failed to focus attention on these quality issues.

Based on the review of quality reports with the Facility's Quality Improvement Officer, it was determined that the facility failed to measure, analyze and track quality indicators, including adverse patients' events and other aspects of performance that assess processes of care, hospital services and operations.

Findings include:

1. Anesthesia is a contracted service that has not submitted a quality assurance plan or activities for improvement for the natural year of 2009 and the months of January and February 2010 as reviewed on 3/25/10 at 11:30 am.

2. Respiratory services has not submitted a quality assurance plan or activities for improvement since August/2009 as reviewed on 3/25/10 at 11:45 am.

3. During the trimester of May-June and July 2009 the Quality Improvement Program does not meet to discuss quality indicators, including adverse patient events and other aspects of performance that assess processes of care, hospital services and operations. No reports were found of the services of the hospital related with surveillance and quality improvement activities for this period as reviewed on 3/25/10 at 11:55 am.

4. The last two quality assurance committee meetings were on January 21, 2010 and in October 2010, however the minutes were not available in the Quality assurance meeting minutes folder as reviewed on 3/25/10 at 11:48 am.

5. Quality assurance activities indicators information of the appropriateness of Do Not Resuscitate protocols operation were not provided on an ongoing basis by hospital services as required. Only Intensive Care Unit (ICU) and Medicine Services were sending this information to the quality assurance program as reviewed on 3/25/10 at 3:00 pm.
The monitoring of compliance with Do Not Resuscitate protocols were started in January of 2010 as reviewed on 3/25/10 at 3:27 pm. Monitoring of appropriateness of advance directives procedures at the facility were not followed.

Based on observations and the review of policies and procedures and interview with the supervisor of the X-Ray department at Santa Rosa I and Santa Rosa II, it was determined that the facility failed to maintain copies of reports and printouts, films, scans and other image records as appropriate for at least five years.

Findings include:

During the observational tour of the X-Ray Department on 3/25/10 at 1:00 pm located at Santa Rosa I with the Infection Control Officer (employee #26) and interview with the X-Ray Department Supervisor (employee #21) on 3/25/10 at 1:00 pm, he stated "the facility has an "actual digital reviewer", however the facility maintains copies of these reports and printouts, films, scans and other image records in a storage area outside of the hospital because it does not have an agreement to eliminate records for at least five years".

Based on interviews with the nurse in charge of Infection Control, it was determined that the facility failed to ensure that a log of incidents related to infections and communicable diseases is maintained and failed to ensure that the infection control program gathers and is part of the Quality Assessment and Performance Improvement program.

Findings include:

1. During the Infection Control survey with the nurse in charge of infection control (employee #6) on 3/24/10 from 9:00 am till 3:00 pm the following was found:

a. No evidence was provided related to quality assurance reports.

b. No evidence was provided related to the Infection Control Committee participation of the Housekipping maintainance supervisor and pharmacy department.

c. No evidence was provided related to a program to detect, manage and to prevent nosocomial infections.

d. The infection control officer did not provide evidence of a log of incidents related to infections and communicable diseases.

e. No evidence was provided related to periodic reports performed by the infection control program.

f. The infection control officer (employee #26) did not provide evidence of an Infection Control Manual and organizational chart of the infection control program.

g. No evidence was provided related to the Material Safety Data Sheets (MSDS) orientation directed toward housekeeping and other personnel.

h. No evidence was provided related to the orientation given to new personnel about infection control measures.

i. No evidence was provided related to the infection control surveillance program.

j. No evidence was provided related to the monitoring and reporting system.