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Based on a validation survey, observational tour, review of sixty two records reviewed (RR) of policies/procedures and interviews, it was determined that the facility failed to demonstrate compliance with restriction protocol and physician orders during the management of a combative patient for 1 out of 62 records reviwed. (RR#52)

Findings include:

1. During review of facility compliance with patients' rights requirement with the nursing personnel (employee #3) on 10/24/18 at from 1:35 pm through 2:10 pm the following was identified:

a. RR #52 is a 79 years old male patient admitted on 10/22/18 at 7:00 am with a diagnosis of Status post Respiratory Failure. Patient was received disoriented confused and combative accordingly with nursing admission history as reviewed with nursing personnel (employee #3) on 10/24/18 at from 1:35 pm. As documented by nursing personnel patient attempt to remove treatment, equipment and continuously refuse care and interventions. Physician evaluate patient and order restriction on bilateral upper extremities at 11:50 am as evidence by physician order.

On the electronic medical record documentation of nursing personnel of shift of 10/22/18 -7-3 after order of restriction at 11:50 am, shift 3-11 and shift 11-7 it was documented on a full body picture on the patient it was restriction on the right upper extremity, left upper extremity and bilateral lower extremities.

On 10/23/18 at 10:30 am physician evaluate patient and after an assessment order on bilateral upper extremities. On the electronic medical record documentation of nursing personnel of shift of 10/23/18 after order of restriction at 10:30 am shift 7-3, shift 3-11 and shift 11-7 it was documented on a full body picture on the patient it was restriction on the right upper extremity, left upper extremity and bilateral lower extremities.

During interview on 10/24/18 at 3:30 pm Director of Nursing (employee #1) while providing a copy of the facility physical restriction protocol, stated that facility usually did not apply restrictions on four extremities. She stated that probably nursing personnel wrongly document on the full body picture of the electronic record that patient was on restriction on four extremities due to failure to understand physician order on the restriction protocols who was available only in English. She stated that this is a situation that nursing services department already identified in other cases with restriction and facility is in the process of planning how to develop and implement electronic medical record physical restraint aids in order to assist staff in compliance with the restraint Policy.

Based on a validation survey, eighteen closed medical record reviewed (RR) and 30 active medical record Review R.R. , it was determined that the facility failed to ensure that all medical record are legible and complete consistent with hospital policies and procedures for 2 out of 18 closed records reviewed. (RR# 18 and #60)

Findings include:

During the review of 18 close medical record review R.R with the Medical Record Director employee #12 on 10/25/18 from 10:00 am through 4:00 pm it was found the following:

1. One out of eighteen close medical record the operation and procedure consent was found in blank, only have the date, hour patient relative signature and surgeon signature. The document lack who the patient relative authorized to perform the procedure, the procedure to be performed, other alternative to treat their condition, and the risk of the procedure. (R.R. #18).

2 One out of eighteen close medical record the operation and procedure consent was found illegible. (R.R. #60).

Based on a validation survey, eighteen closed medical record reviewed and thirty active medical record reviewed ( R.R.) , it was determined that the facility failed to ensure that all informed consent forms are properly executed, legible and complete consistent with hospital policies and procedures. for 2 out of 18 closed records reviewed. (RR# 18 and #60)

Findings include:

During the review of 18 close medical record review R.R with the Medical Record Director employee #12 on 10/25/18 from 10:00 am through 4:00 pm it was found the following:

1. One out of eighteen close medical record the operation and procedure consent was found in blank, only has the date, hour patient relative signature and surgeon signature. The document lack of who the patient relative authorized to perform the procedure, the procedure to be performed, other alternative to treat their condition, and the risk of the procedure.( R.R. #18).

2. One out of eighteen close medical record the operation and procedure consent was found illegible.( R.R. #60)

Based on a validation survey, kitchen observational tour, review of policies/procedures and interviews, it was determined that the facility failed to maintain kitchen and entire environment in good condition, to operationalize procedures to ensure chemicals used to clean contains labels who identify them with important information and maintain safe procedures during preparation of phyllo dough pastry to prevent bacterial contamination.

Findings include:

1. During the kitchen observational tour performed with the dietitian (employee #2) on 10/24/18 at from 8:20 am through 9:50 am, the following was observed:

In the food production area close to a hand washing station it was observed a spray bottle with a reddish color liquid. The spray bottle did not content a label who indicates chemical name, date or information related with chemical dilution if any before rebottled.

Dietitian (employee #2) stated on interview on 10/24/18 at 8:29 am that the spray bottle contents is degreaser, she also indicates that the chemical was not diluted before rebottled.

Facility failed to manage correctly hazardous chemicals to prevent risks to health and safety.

2. In the women bathroom located near to the kitchen area used by kitchen personnel it was observed a spray bottle with a yellowish color liquid. The spray bottle did not contain a label who indicates chemical name date or information related with chemical dilution if any before rebottled.

Dietitian (employee #2) stated on interview on 10/24/18 at 8:45 am that the spray bottle contents is a cleaner named all clean used to clean different areas from the kitchen she also indicates that the chemical was not diluted before rebottled.

Facility failed to manage correctly hazardous chemicals to prevent risks to health and safety.

3. Facility had in place a policy titled " Rotulación y Movimiento de Productos Químicos " last revised January/2018 who indicates procedures to be followed by personnel on daily basis to ensure labeling chemical products used on the kitchen. However accordingly with findings identified during kitchen observational tour performed with the dietitian (employee #2) on 10/24/18 at from 8:20 am through 9:50 am personnel failed to follow established procedures.

4. In the refrigerator located near the food production area it was observed a plastic spray bottle located over one of the shelves. The spray bottle did not contain a label who indicates the contents or date were the contents were bottled.
Dietitian (employee #2) stated on interview on 10/24/18 at 8:27 am that the spray bottle content water to be used to moist phyllo dough crust before reheat in the oven.
Facility failed to maintain procedures to prevent cross contamination of items to be used with frozen pastry dough.


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5. During the kitchen observational tour performed with the dietitian (employee #2) on 10/24/18 at from 8:20 am through 9:50 am, the following was observed:

a.Multiples kitchen floor tiles are missing or broken. Some areas of the kitchen floor were observed uneven.

b.The facility failed to maintain the kitchen floors in good condition.

Based on a validation survey, the observational tour, review of policies/procedures and observation of procedures, it was determined that the facility failed to ensure that all procedures are perform with the standard precautions which can affect all admitted patients.

Findings include:

1.On 10/24/18 at 2:59 pm during a blood draw it was observed the (RN#4) changing her gloves during the procedure without a proper hand hygiene.

The facility fail to follow a proper standard of practice for gloves change.

2. On 10/25/18 at 8:57 am during a left lower extremity stump ulcer care it was observed the (RN#5) changing her gloves during the procedure without a proper hand hygiene in two occasion.

The facility fail to follow a proper standard of practice for gloves change.

Based on a validation survey observational tour, review of policies/procedures, it was determined that the facility failed to ensure that the surgical services maintains a high standard of medical practice for patient care.

Findings include:

During the initial tours performed on 10/23/18 from 9:00 am through 1:00 pm in the operation room area, with the Nurse Manger (employee #6 ) and Nurse Supervisor (employee #7) it was found the following:

1. At 9:30 am the patient bathroom nurses call was reviewed and it was found that did not function. The holding area have 3 cubicle with 7 patient waiting to be call to the operation room suite. The three cubicle have one nurses call each one and the line was in the oxygen meter and any of three nurses call function.

The monitor of the nurses call was in the recovery room area the nurse supervisor employee #7 review if it functions and it was found not functioning. The nurses call of the nine cubicle of the recovery room was found tied or in the oxygen meter or in the back of the garbage and not functioning.

The nurse manager (employee #7) calls the biomedical personnel and at 9:45 am the biomedical personal and the electrical technician review the nurses call system.

The patient bathroom used for patient s' to change clothe was review and this area has 1 bathroom with nurse call that do not function and 3 cubicle for patient s' to change their cloths and 1 shower that not have a nurses call system.

The phase 2 area have 6 cubicle and any six nurses call of this area function.

The patient bathroom of the phase 2 area the nurse's call not function and the cable was too short.

Any personnel in the recovery room area noticed that the nurses' call do not function.

At 10:30 am the nurses call system was reviewed and was functioning and the cable of the nurse's call of the patient bathroom of the phase 2 area were replace.

According to the biomedical personnel and electrical technician the nurses system work with electricity and battery in this case the nurses call system have exhausted batteries and when this occur the system do not function.

2. Observation of the Pre-operative area (Holding area) it was found the following:

a. In the front of the patient bathroom it was observed a cart with material to canulizated patient and take blood sample, it was observed a 1000 milliliter bag of 0.9% of normal saline solution with the Intravenous line inserted ready to use without labeling. The employee #10 discard them.

3. Operation Suite #4 it was observed the following:

a. At 9:35 am during the observation of patient preparation it was observed that the circulating nurse employee #9 prepared the patient to insert a catheter to drain the urine, during the process the employee #9 change non sterile glove to sterile glove and did not wash his hand according to the Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. When finish the procedure he discard all used material and his glove, did not wash his hand, then takes a blue pads that was in the operation stretcher and return the blue pads to the area where are the clean material.

b. This operation suite #4 was observed with cracked tiles, stain and detached from the wall.

c. The surgery lamp was observed with pail paint.

4. Operation Suite #2 it was observed the following:

a. At 10: 55 am the nitrogen tank cart was observed with peeling paint.

b. The floor tile was observe detached and the tile not link with the wall.

c. It was observed that the housekeeping employee #10 was cleaning the suite and was sweeping with a broom. The operation suite technician employee #11 have the tray for the next case on the table previous the suite was completely cleaned by the house kipping.

d. In the table near the left wall was observed a bottle of 1,500 milliliter of Irrigation saline open available to use. The manufactured recommended discard unused portion. It was observed an open 16 ounce bottle of alcohol 70% with 1/4 of the bottle available to use and without label with date, hour and initial of the person that opened.

5. Operation Suite #3 it was observed the following:

a. The tile was observed with cracks

b. A clock was observed in the left wall with rust.

c. An Archive was observed near the sharp container with peeled paint.

d. In the wall near to the air condition was observed with a square approximate 12 inches by 12 inches without the monolithic material that not permit the adequate cleaning.

e. The air conditioning console is observed with sticky adhesive of color slightly darkened.

f. The surgery lamp was observed with pail paint.

6. Operation Suite #5 it was observed the following:

a. Tile broken near the wall.

7. Operation Suite #6 it was observed the following:

a. Cracks in the floor slabs.

8. Operation Suite #7 it was observed the following:

a. A suction cable attached to the wall with adhesive tape.

b. The walls was observed with adhesive tape waste.

c. The operation room metal shelves was observed closed with adhesive tape due to was over supply with sterile material and not maintain closed.

d. An Intravenous stand was observed with and gauze and tape in the tube and peeled paint in the foot.

Based on a validation survey, seven record reviewed (RR), it was determined that the facility failed to ensure that surgeon operation report be written with complete information including the post-operative diagnosis for 7 out of 7 records reviewed. (RR# 24, #25, #26, #27, #28, #29 and #30).

Findings include:

During the seven record review (R.R.) performed on 10/23/18 from 3:00 pm through 4:00 pm and on 10/24/18 from 8:00 am through 11:00 am with the operation room nurse manager employee #6 and nurse supervisor employee #7 it was found the following:

1. R.R. #24 it a 28 years old female that was admitted to the operation room on 9/4/18 with a diagnosis of Left Nephrolithiasis. During the record review performed on 10/23/18 at 3:27 pm with the operation room nurse manager employee #6 and nurse supervisor employee #7, it was found that the surgeon perform the operation report and writes in the post-operative diagnosis "SAME". The surgeon failed to write the complete post-operative diagnosis.

2. R.R. #25 it an 80 years old female that was admitted to the operation room on 9/25/18 with a diagnosis of Left Breast Cancer. During the record review performed on 10/23/18 at 4:00 pm with the operation room nurse manager employee #6 and nurse supervisor employee #7, it was found that the surgeon perform the operation report and write in the post-operative diagnosis "SAME". The surgeon failed to write the complete post-operative diagnosis.

3. R.R. #26 it a 72 years old male that was admitted to the operation room on 9/29/18 with a diagnosis of Resection Tranurethral obstructive prostate. During the record review performed on 10/24/18 at 10:30 am with the operation room nurse supervisor employee #7, it was found that the surgeon perform the operation report and writes in the post-operative diagnosis "SAME". The surgeon failed to write the complete post-operative diagnosis.

4. R.R. #27 it a 58 years old female that was admitted to the operation room on 9/20/18 with a diagnosis of Right Knee Medial Meniscal Tear degenerative join disease. During the record review performed on 10/24/18 at 11:00 am with the operation room nurse supervisor employee #7, it was found that the surgeon perform the operation report and writes in the post-operative diagnosis "SAME". The surgeon failed to write the complete post-operative diagnosis.

5. R.R. #28 it a 34 years old male that was admitted to the operation room on 9/11/18 with a diagnosis of Bilateral Breast Mass. During the record review performed on 10/24/18 at 9:05 am with the operation room nurse supervisor employee #7, it was found that the surgeon perform the operation report and write in the post-operative diagnosis "SAME". The surgeon failed to write the complete post-operative diagnosis.

6. R.R. #29 it a 70 years old male that was admitted to the operation room on 10/2/18 with a diagnosis of Sick Sinus Syndrome. During the record review performed on 10/24/18 at 9:00 am with the operation room nurse supervisor employee #7, it was found that the surgeon perform the operation report and writes in the post-operative diagnosis "SAME". The surgeon failed to write the complete post-operative diagnosis.

7. R.R. #30 it a 72 years old female that was admitted to the operation room on 9/22/18 with a diagnosis of Chronic Cholecystitis. During the record review performed on 10/24/18 at 8:00 am with the operation room nurse supervisor employee #7, it was found that the surgeon perform the operation report and writes in the post-operative diagnosis "SAME". The surgeon failed to write the complete post-operative diagnosis.

Based on a validation survey, seven medical records reviewed (R.R) for respiratory therapy services, policies/procedures, it was determined that the facility failed to ensure that the organization of respiratory therapy services is appropriate to the scope and complexity of the services provided for 5 out of 7 clinical records reviewed (R.R #17, #20, #21, #22 and #23).

Findings include:

1.Seven medical records were reviewed on 10/23/18 from 8:30 am till 4:00 pm and 10/24/18 from 8:30 am till 3:30 pm 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 #17, #20, #21, #22 and #23. Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis (some received treatment four hour before the scheduled time and others received treatment from fifty five (55) hours after the scheduled establish treatment hours.

a. R.R #17 is a 42 years old female who was admitted on 10/20/18 with a diagnosis of Acute Bronchitis and Acute Bronchospam. The record review was performed on 10/23/18 at 1:00 pm, with the respiratory therapist supervisor (employee # 12) and provided evidence that on 10/21/16 at 11:00 am the physician ordered Atrovent 0.2% by power nebulizer every 4 hour x 15 minutes. On 10/21/18 at 3:00 pm the respiratory therapist ( employee #13) provides patient orientation related to treatment and performed an assessment and started first respiratory therapy treatment four (4) hours later and no evidence was found that the physician was notified and justification for not administrating the treatment.

b. R.R #20 is an 83 years old male who was admitted on 10/10/18 with a diagnosis of Right Femur Fracture. The record review was performed on 10/23/16 at 2:30 pm, with the respiratory therapist supervisor (employee # 12) and provided evidence that the patient was transfer to Intensive Unit Care (ICU) on 10/18/18. On 10/21/18 at 7:00 pm the physician ordered Atrovent 0.2% by power nebulizer every 6 hours. On 10/21/18 at 7:00 pm the respiratory therapist provides patient orientation related to treatment and performed an assessment and started the respiratory therapy treatment. However, the second treatment was not given on 10/22/18 at 1:00 am and it is not reported in the treatment sheet. The next treatment was given at 7:00 am however the patient received the respiratory therapy treatment twelve (12) hours later and no evidence was found that the physician was notified and justification for not administrating the treatment.

c. R.R #21 is a 75 years old female who was admitted on 10/18/18 with a diagnosis of Asthma Exacerbation Suspected BKP. The record review was performed on 10/24/18 at 8:55 am, with the respiratory therapist supervisor (employee #12) and provided evidence that on 10/17/18 at 7:30 pm the physician (employee #14) ordered Albuterol ( Proventyl 0.083% ) every ½ hour per 3 doses. The first therapy was given at 8:00 pm, the second therapy was given at 8:30 pm and the third therapy was given at 9:54 pm by the respiratory therapist (employee #17) however the third treatment was given twenty six (26) minutes later not accordance with the physician order. Then on 10/17/18 at 7:45 pm a new order was placed by the physician Albuterol (Proventyl) 0.083% (2.5 mgs) however this order was not completed by the physician and at 7:46 pm one minute later the physician discontinue this therapy order. Then on 10/17/18 at 9:00 pm a new order was placed by the physician (employee #14) to administered Albuterol 1 ampule per 15 minutes every 2 hours x 6 doses. The first dose of this respiratory therapy treatment was given at 9:26 pm by the respiratory therapist (employee #15) accordance of the respiratory patient treatment sheet
the patient received two treatments of the same respiratory treatment medication per two different therapist because the physician ordered a new treatment at the same hour (9:00 pm) at this hour ended the anterior treatment of Proventyl 0.83% every 1/2 hour x 3 doses and the last dose of this order was given by the therapist at 9:54 pm. However this new medical order conflige with previous order. No evidence of re-evaluation performed by the physician when the patient ended the last respiratory treatment.

The patient record provided evidence that the patient received the respiratory therapies of the last order of six treatments however patient received double therapies at the same time per two different therapists. However the therapist provided the treatments but did not review the last physician order and if the physician re-evaluated the patient previous to place the next treatment.

No evidence was found that the physician was notified related to the two respiratory treatments administrated at the same hour by different respiratory therapist and no evidence when the patient was re-evaluated by the physician post this situation.

During the record review it was identified that the physician placed various orders of respiratory treatments but the orders conflige with previous order treatment and no evidence of respiratory assessment when the patient complete previous treatment.

On 10/19/18 the patient received a respiratory treatment at 11:00 am the next treatment was given at 2:06 pm 24 minutes before. Then was given at 7:00 pm thirty (30 minutes) later.

On 10/21/18 the patient received a respiratory therapy at 3:02 am, them at 6:30 am the next treatment was given at 11:56 am (56 minutes later).


d. R.R #22 is a 79 years old male who was admitted on 10/21/18 with a diagnosis of Respiratory Acidosis. The record review was performed on 10/24/18 at 10:50 am, with the respiratory therapist supervisor (employee #12) and provided evidence that on 10/21/18 at 6:30 pm the physician ordered Atrovent 0.02% every 4 hours. The first therapy was given at 7:00 pm and the second therapy was given at 11:00 pm. On 10/22/18 the third therapy was given at 3:05 am, however the next treatment was given at 7:00 am but the respiratory therapist note (employee #18) revealed that the patient refuse the treatment but no evidence of the reason of this refuse and no evidence when the respiratory therapist notify the physician related to this situation.

The next therapy was given at 11:00 am eight hours later (8) not accordance with the physician order.

d. R.R #23 is a 53 years old male who was admitted on 10/16/18 with a diagnosis of COPD v/s BKP. The record review was performed on 10/24/18 at 2:15 pm, with the respiratory therapist supervisor (employee #12) and respiratory therapist of medicine IV (employee #19) and provided evidence that patient received respiratory therapy at the emergency room with Levarbutherol (Xopenex) 1.25 mgs. Power nebulizer every 20 minutes per 3 doses and Atrovent 0.02 % every 20 minutes per 3 doses and discontinue on 10/16/18 at 10:42 am. The patient was admitted on 10/16/18 at medicine ward IV. On 10/21/18 at 4:05 pm the physician ordered Atrovent 0.02% every 4 hours stating at 7:00 pm. and Zopenex 1.25 mgs every 4 hours starting at 7:00 pm. The patient record provides evidence that the patient received the Atrovent treatment at 7:00 pm and then continues every 4 hours until 10/22/18 at 11:00 pm.

On 10/23/18 at 3:08 am the respiratory therapist note reveled the following: '' Not administer patient refuse.'' The next therapy of Atrovent was given on 10/23/18 at 7:00 am and the next therapy is not given at 11:00 am because the patient staid at the radiology department. However no evidence of documentation related to the reason why the patient refuses the treatment and no evidence if the therapist notified the physician related to this situation.

On 10/21/18 at 7:00 pm according of the physician the patient is starting with Xopenex 1.25 mgs every 4 hours however no evidence on the patient respiratory treatment sheet of this treatment.

At 11:20 pm a respiratory therapist note reveled the following: '' Not given reason: medication not available in the area.'' On 10/22/18 at 3:06 am, at 7:00 am, 11:00 am, 2:30 pm, 6:39 pm and 11:00 pm the patient did not received the respiratory therapy with Xopenex because according of the therapist note reveled: '' Not administered not available in the area.''

On 10/23/18 at 3:00 am no evidence of therapist documentation if the patient received or not received the treatment. On 10/23/18 at 7:00 am the patient received the first therapy of Xopenex.

On 10/23/18 at 8:55 am a nurse note revealed that the patient was transferred to the Cardiovascular Intervention Institute '' to performed a procedure "TEE Ablation'' per the electrophysiologist physician.

The patient return at the medicine ward IV at 2:40 pm according of sequence the next treatment was at 3:00 pm, then at 7:00 pm however the therapist notes reveled '' Not administered '' and did not write the reason that the patient did not received the Xopenex therapy.

On 10/23/18 at 11:00 pm the therapy was given by the respiratory therapist. On 10/24/18 the therapy was given at 3:00 am, 6:30 am and 11:00 am according of the physician order and the patient needs.

The respiratory therapist supervisor (employee #12) was interview related to this case and he stated: '' The medication Xopenex was supplied per pharmacy department on10/22/18 during the shift from 7:00 am to 3:00 pm. The patient was transfer from medicine I to medicine IV on 10/22/18 at 10:16 pm but did not transfer the medications to the medicine IV. ''

The respiratory therapist of medicine ward IV (employee #20) was interview at 2:50 pm and he stated: "The medication was not available at this time when as needed."

During performed the respiratory therapy patient records evaluation on different departments the nurse supervisors of Medicine I, Medicine IV, Pediatric and Maternal Child, Surgery was interview related to if they know that patients have respiratory therapy service, oxygen or other therapeutic service and stated: '' I did not know that the patient have respiratory therapy service, only for the treatment on medication kardex. ''