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Based on the validation survey, review of the State Law License regulations and the review of physicians credential files (C.F.), it was determined that the facility failed to updated personnel credential files for lack of Hepatitis B vaccine and Influenza Vaccine for 9 out of 29 credential files, (Medical staff C.F. #5, #6, #8, #10, #12, #13, #20, #21 and #24)

Findings include:

1. On 06/29/2018 at 10:00 am during the review of the physician credential file the following was found:

a.Five of twenty-nine physicians 'personal credentials files did not contain evidence of their Hepatitis B vaccine (CF#5, #8, #13, #20 and #24).

b. Four of twenty-nine physicians 'personal credentials files did not contain evidence of their Influenza vaccine (CF#6, #10, #12, and #21).

2. The facility failed to updated personnel credential files for lack of Hepatitis B vaccine and Influenza Vaccine.

Based on a validation survey, medical record review and interview with the medicine ward nursing supervisor ( employee # 9 ) and admission personnel ( employee #11 ) it was determined that the facility failed to document date were Medicare recipients receive "An Important Message from Medicare" (IM) during admission process. This deficient practice was identified in 2 out of 10 records reviewed for compliance with the IM requirements. (RR) (RR. # 8 and RR. # 15).

Findings include:

1. A mechanism to ensure that facility promote complete documentation of information provided to Medicare patients of their rights to appeal facility ' s discharge was not performed accordingly with the following findings identified during survey procedures on 6/26/18 from 9:35 am till 3:30 pm:

a. RR. # 8 patient admitted on 6/25/18 with a diagnosis of Left Hand Abscess. The record was review on 6/26/18 at 11:00 am with the medicine ward nursing supervisor (employee #9). The Important Message from Medicare was provided upon admission to the patient however it was not dated. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be signed and dated by the patient to acknowledge receipt as per requirement.

b. RR. # 15 is a 92 years old male patient admitted on 6/11/18 with a diagnosis of Respiratory Failure and bilateral Bronchopneumonia. The record was review on 6/26/18 at 9:50 am with the medicine ward nursing supervisor (employee #12). The Important Message from Medicare was provided upon admission to a patient relative however it was not dated. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be signed and dated by the patient to acknowledge receipt as per requirement.

Medicine ward nursing supervisor (employee #9) stated on interview on 6/26/18 at 10:07 am that information is always provided during admission process by admission department personnel.

Admission personnel (employee # 11) stated on interview on 6/26/18 at 1:58 pm that "when admission personnel provide patient and relative information about the right of patient to appeal facility's discharge and sign "An Important Message from Medicare" form, sometimes consider the date included in the label who has admission information of the patient as the date were the patient or relatives sign the form".

However, An Important Message from Medicare form CMS-R-193(07/10)/CR clearly establish on the bottom of the page "please provide signature and date were this information is provided.

Based on a validation survey, observations, record review and interview with medicine ward nursing supervisor (employee # 9) on 6/26/18 from 9:20 am through 2:00 pm, it was determined that facility failed to obtain an informed consent prior to take photos to patients; when used in wound care, as an adjunct to assessment documentation and to serve only to support the written wound documentation. This deficient practice is identified on 2 out of 3 records reviewed with skin ulcers and wounds. (RR # 5 RR # 7).

Findings include:

1. A mechanism to ensure that facility promote the right of each patient to privacy and confidentiality of his/her body was not followed accordingly with these findings identified during survey procedures from 6/26/18 through 6/29/18:

a. RR.# 5 is a 88 years old male patient admitted on 6/17/18 with a diagnosis of Sacral Ulcer. The record was review on 6/26/18 at 10:30 am with the medicine ward nursing supervisor (employee #9). During record review it was identified that to this patient wound care team took photos of sacral ulcer area on 6/26/18. Review of cognitive status of this patient evidence that patient is disoriented in person, place and time. Inform consent to take photos was not signed by patient relative or surrogate.

b. RR.# 7 is a 68 years old male patient admitted on 6/14/18 with a diagnosis of Right Heel Infected Ulcer and Diabetes Mellitus. The record was review on 6/26/18 at 10:00 am with the medicine ward nursing supervisor employee #9. During record review it was identified that to this patient wound care team took photos of right heel ulcer on 6/18/18 and on 6/25/18. Review of cognitive status of this patient evidence that patient is disoriented in person, place and time. Inform consent to take photos was not signed by patient relative or surrogate.

Based on a validation survey, observations, record review with medicine ward nursing supervisor ( employee # 9 and employee #12 ) on 6/26/18 and 6/27/18 from 10:25 am through 3:00 pm and interview with the medical director ( employee # 5) it was determined that facility failed to promote patient's right to refuse treatment . This deficient practice is identified on 3 out of 3 records reviewed (RR) for compliance with advance directives ( RR # 6,RR # 15 and RR # 21 ) .

Findings include:

1. A mechanism to assure that facility personnel promote patients and surrogates (decision makers) rights and adhere to their patients' advance directives was not followed accordingly with these findings identified during survey procedures from 6/26/18 through 6/29/18:

a. RR # 6 is an 84 years old male patient admitted on 6/19/18 with a diagnosis of Rectal Bleeding. The record was review on 6/26/18 at 10:00 am with the medicine ward nursing supervisor (employee #9). During record review it was identified that on 6/2018 at 1:05 am a physician took an inform consent to this patient. On this informed consent patient refuse endotracheal intubation (Do Not Intubate) in the event of a cardiorespiratory arrest. A physician prescription/order to operationalize this patient advance directive was not evidenced after review medical record as part of this case documentation.

During review of facility Advance Directives policy who was last reviewed on May/2018 it was found that policy establish that patient must be educated about his/her advance directive.

However no documentation of education to this patient in relation with his advance directive decision were found documented. Facility failed to evidence that patient was fully informed about and consented to the DNI advance directive.

b. RR. # 15 is a 92 years old male patient admitted on 6/11/18 with a diagnosis of Respiratory Failure and bilateral Bronchopneumonia. The record was review on 6/27/18 at 9:10 am with the medicine ward nursing supervisor (employee # 12). During record review it was identified that on 6/25/2018 at 1:45 pm a physician took an inform consent to this patient relative .On this informed consent patient relative establish as an advance directive a DNR (Do not Resuscitate).
With this DNR; relative establish their wish to do not perform Cardiopulmonary Resuscitation (CPR) to patient in the event of a cardiac arrest.

During review of facility Advance Directives policy who was last reviewed on May/2018 it was found that policy establish that patient or patient relatives (surrogate) must be educated about advance directives.

No information was found documented on medical record related with discussion with patient relative and information about the DNR advance directive. Facility failed to evidence that patient relatives (surrogate) was fully informed about and consented to the DNR advance directive.

c. RR. # 21 is an 87 years old male patient admitted on 6/13/18 with a diagnosis of Respiratory Failure. The record was review on 6/27/18 at 9:10 am with the medicine ward nursing supervisor (employee # 12). During record review it was identified that on 6/15/2018 at 5:00 pm a physician took an inform consent to this patient relative. On this informed consent patient relative establish as an advance directive refusing endotracheal intubation (Do Not Intubate- DNI) in the event of a cardiorespiratory arrest. A physician prescription/order to operationalize this patient relative (surrogate) advance directive was not evidenced after review medical record.

During review of facility Advance Directives policy who was last reviewed on May/2018 it was found that policy establish that patient must be educated about his/her advance directive.

However no documentation of education to this patient relative (surrogate) in relation with his advance directive decision were found documented. Facility failed to evidence that patient was fully informed about and consented to the DNI advance directive.

During interview with the Medical director (employee # 5), stated on 6/29/18 at 10:50 am that it is facility policy accordingly with advance directives protocols that on every case that patient or surrogate establish an advance directive education in relation with his advance directive decision must be provided and documented on the medical record. He also stated that on every case from which an advance directive is requested, a physician prescription/order to operationalize this patient relative (surrogate) advance directive must be prescribed and included in the medical record.

Based on the observational tour on the pediatric emergency room with the Physical Plant Director (Employee #1), it was determined that the facility failed to promote the right of each patient to receive care in a safe setting.

Findings include:

1. During the observational tour performed during survey process on 06/28/2018 at 9:25 am the following was identified: in the pediatric triage room a neonatal weighing scale on top of a hospital bedside tray table, ready to be use.

a. The facility failed to promote the right of each patient to receive care in a safe setting.

Based on a validations survey, observations, record reviewed (RR) with medicine ward nursing supervisor (employee # 9 and employee #12) on 6/27/18 from 9:20 am through 2:00 pm it was determined that facility failed to ensure that patient restriction is only use in circumstances were patient has medical symptoms that warrant the use of them and maintain evidence of care provided to supply direct care and needs every two hour or more frequent accordingly with patient needs. This deficient practice is identified on 2 out of 3 record reviewed for physical restriction (RR. # 7 and RR. # 15).

Findings include:

1. A mechanism to ensure that facility promote the right of each patient to be free from physical restraints and supply direct care and needs accordingly with patient needs was not followed accordingly with these findings identified during survey procedures from 6/26/18 through 6/29/18:

a.RR.# 7 is a 68 years old male patient admitted on 6/14/18 with a diagnosis of Right Heel Infected Ulcer and Diabetes Mellitus. The record was review on 6/26/18 at 10:00 am with the medicine ward nursing supervisor (employee #9). During record review it was identified that this patient had a physical restraint order dated 6/15/18 at 9:30 pm. Since 6/15/18 patient had been on physical restriction accordingly with physician order prescription due to disorientation and episodes where he try to interrupt treatment.

However documentation performed by health care professionals (daily comprehensive assessments & progress notes) who include information description patient cognitive status or medical symptoms that warrant the use of physical restriction was not found documented. On this case also on 6/25/18 shift 3-11 no information was found documented related with services provided to supply direct care and needs every two hour or more frequent accordingly with facility physical restriction protocols.

b. RR.# 15 is a 92 years old male patient admitted on 6/11/18 with a diagnosis of Respiratory Failure and bilateral Bronchopneumonia. The record was review on 6/26/18 at 9:50 am with the medicine ward nursing supervisor (employee #12). During record review it was identified that this patient had a physical restraint order since 6/14/18 patient had been on physical restriction accordingly with physician order prescription due to disorientation and episodes where he try to interrupt treatment.

On 6/15/18 it was found documented that during 7-3, 3-11 and 11-7 shifts services provided to supply direct care and needs every two hour was provided to the patient accordingly with facility physical restriction protocols.

However no physical restraint order was found prescribed by physician for 6/15/18.
Documentation performed by health care professionals (daily comprehensive assessments & progress notes) who include information description patient cognitive status or medical symptoms that warrant the use of physical restriction was not found documented since 6/14/18 when patient began on physical restriction.

Based on a validation survey, fifty (50) active and close record review (R.R.), with the Medical Record Director (employee # 17), it was determined that the facility failed to ensure that all medical record must be promptly completed accordance with State law and hospital policy no later than 30 days after discharge.

Findings include:

1. During the medical record review with the medical record director employee #17 on 6/28/18 and 6/29/18 from 8:30 am through 3:50 pm, it was determined that the facility lack of a mechanism to ensure that facility's medical Staff and other professional prompt complete the delinquent medical records.

a. The Medical Record director employee #17 provide evidence of report that include the exact number of incomplete and delinquent files. The incomplete medical record report received on June 26, 2018 revealed that the total of medical record incomplete and delinquent was 4,594 by the medical staff. Four Physician of Medicine department have 534, 436, 417 and 305 incomplete and delinquent medical record.

b. The incomplete medical record statistic report did not provide evidence of incomplete or delinquent files by nursing staff or other disciplines but at the request by the surveyor the medical record director employee #17 provide a table of incomplete medical record by professional with a total of 5,530 incomplete medical record and delinquent by profession.

The Medical Record director employee #17 state on interview on 6/28/18 at 2:30 pm that the facility performed Marathon to complete medical record during the year but the physician that have more amount of incomplete medical records did not assist.

Based on a validation Survey, observation and medical record reviewed (R.R.) performed on 6/27/18, 6/28/18 and 6/29/18 from 8:30 am through 3:50 pm with the Medical Record Director (employee #17), it was determined that the facility failed to ensure that all patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form, as observed in 9 out of 50 records reviewed (RR). (RR #24, #28, #30, #32, #33, #34, #35, #36, and #39).

Findings include:

1. During review of fifty active and close medical records perform from 6/27/17 thru 6/29/17 with the Medical Record Director (Employee #17) was found the following:

a. The Medical Order was found without the physician signature, Registered Nurse signature, date, time, illegible, telephone and verbal orders without the physician countersignature or countersigned before the 24 hour period on 6 out of 50 medical records. (RR #30, #32, #33, #34, #36 and #39)

b. The Consult was found without signature, date, time, illegible, and without the regarding information on 1 out of 50 medical records. (RR #33)

c. The Discharge Summary was found in blank and without the physician signature, left in Blank incomplete without level of Consciousness, Prognosis, Condition at discharge 3 out of 50 medical records. (RR #32, #33, and #34).

d. The Anesthesia consent lack of the anesthesiologist that is going to administrated the anesthesia 1 out of 50. (R.R #24, #35, #36),

e. The Photo Consent lack of patient or relative signature that authorized the photography 1 out of 50 records reviewed. (R.R #36),

f. The Physician progress note lack of physician signature 1 out of 50 RR. (R.R #33).

g. The Medication Reconciliation lack of the physician Signature 1 out of 50 RR. (R.R #33).

h. The History and Physical was incomplete due to lack of vital sign and weight 1 out of 50 R.R. (R.R #24).

i. The Nursing Health History of Ambulatory Services was left in blank 2 out of 50 R.R. (R.R #24, #28).

j. The Pre admissions Pre and post-operative orientation was left in blank 2 out of 50 R.R. (R.R #24).

k. The Operating room Discharge instructions and possible post-operative reactions lack of the date and hour when patient or relative sign the document 1 out of 50 R.R. (R.R #24).

l. The operative report the surgeon write "same in the post-operative diagnosis 1 out of 50 R.R. (R.R #28).

m. The Surgical Services and Anesthesia Recovery Room File lack of the hour when patient was discharge home 2 out of 50 R.R. (R.R #28 and #29).

Based on a validation survey, observation and medical record reviewed (R.R.) performed on 6/27/18 through 6/29/18 with Medical Record Director (employee #17), it was determined that the facility failed to ensure that the physician Verbal Telephonic order are countersigned by the physician (MD) within the first twenty-four hours after the telephone order is issued, as observed in 3 out of 50 records reviewed. (RR #32, #33 and #36).

Findings include:

1. R.R. #32 is a 50 year old female admitted to the facility on 1/25/18 with a diagnosis of Acute Kidney Disease. During the record review performed on 6/28/18 at 1:00 pm it was found:

a. A telephone medical order was place on 1/26/18 at 11:00 am and on 1/27/18 at 3:00 pm and were not countersign by the MD.

2. R.R. #33 is a 77 year old male admitted to the facility on 1/17/18 with a diagnosis of Acute Post Hemorrhagic Anemia. During the record review performed on 6/28/18 at 1:30 pm, it was found:

a. A telephone medical order was place on 1/18/18 at 2:30 pm and 1/19/18 at 2:00 pm and were not countersign by the MD.

3. R.R. #36 is a 17 year old male admitted to the facility on 1/1/18 with a diagnosis of Burn Second degree multiple site. During the record review performed on 6/28/18 at 3:15 pm it was found:

a. A telephone medical order was place on 1/2/18 at 1220 am, on 1/8/18 at 2:30 pm, on 1/8/18 at 2:30 pm were not countersign by the MD.

Based on a validation survey, observation and medical record reviewed (R.R.) performed on 6/27/18 through 6/29/18, it was determined that the facility failed to ensure that all medical record document the results of all consultative evaluations of the patient by clinical and other staff involved in the care of the patient for 1 out of 50 record review (R.R. #33).

Findings include:

1. R.R. #33 is a 77 year old male admitted to the facility on 1/17/18 with a diagnosis of Acute Post Hemorrhagic Anemia. During the record review performed on 6/28/18 at 1:00 pm it was found:

a. The Report of the Consult place on 1/17/18 at 12:25 pm, was not completed and did not reflect the attending physician reason for consult, and the physician signature.

Base on validation survey and fifty records reviewed (RR) with medical record Director (employee #17), on 6/28/18 and 6/29/18, it was determined that the facility failed to ensure that medical record document properly executed informed consent forms for procedures and treatments for 4 out of 50 records reviewed (R.R. #24, #25, #35 and #36)

Findings include:

1. R.R. #24 is a 61 years old female admitted on 6/18/18 with a diagnosis of Cholelitiasis, during the record review performed on 6/27/18 at 1:45 pm it was found the following:

a. The anesthesia consent performed on 6/18/18 at 7:00 am, lack of the anesthesiologist that is going to administrate the anesthesia.

2. R.R. #25 is a 87 years old female admitted on 6/14/18 with a diagnosis of Displaced left distal radius fracture, during the record review performed on 6/27/18 at 3:30 pm it was found the following:

a. The anesthesia consent performed on 6/13/18 at 4:00 pm, lack of the anesthesiologist that going to administrate the anesthesia.

3. R.R. #35 is a 9 years old female admitted on 1/15/18 with a diagnosis of Bell's Palsy, during the record review performed on 6/28/18 at 3:00 pm it was found the following:

a. The anesthesia consent performed on 2/1/18 at 1:00 pm, lack of the anesthesiologist that is going to administrate the anesthesia.

4. R.R. #36 is a 17 years old male admitted on 1/1/18 with a diagnosis of Burn Second Degree multiple site, during the record review performed on 6/28/18 at 3:30 pm it was found the following:

a. The anesthesia consent performed on 1/5/18 at 7:00 am, lack of the anesthesiologist that is going to administrate the anesthesia.

Based on validation survey, fifty active and close medical records reviewed (R.R), it was determined that the facility failed to ensure that discharge or death summaries are performed with all pertinent information for 1 out of 50 records reviewed (R.R #34).

Findings include:

R.R #34 is a male patient who was admitted to the hospital on 1/5/18 with a diagnosis of Acute Respiratory Distress. The record review was performed on 6/28/18 at 2:30 pm and provided evidence that the discharge summary was incomplete due to lack of Level of conscious at discharge, Prognosis, Condition at discharge, diet and follow up appointment, Physical activities orientation to patient or relative, if understood.

Based on a validation survey, observations, emergency carts check, medications carts verifications, medications storage check and interview with Nursing director DON (employee # 2) , it was determined that the facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel in a 2 out of 2 medication carts on East Medicine and 1 out of 1 treatment carts on East Medicine.

Findings include:

1. During the observation tour from 6/27/2018 to 6/29/2018 with the Physical Plant Director (employee #1) it was identified that all medication and treatment carts locks did not work properly and the nursing personnel did not closed the respective carts.

On interview with the Nursing Director (employee #2) on 06/29/2018 at 1:30 pm refer that the facility have new medications carts for the replacement of the old carts.

a. The facility failed to demonstrate that they have the carts keys for the proper store of the medications in a safe manner only accessible to authorized personnel.

b. The facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel in all medication carts and treatment carts.

Based on a validation survey, observations, and interview with administrative dietitian (employee #7) on 6/28/18 at 9:48 am it was determined that facility failed to maintain safe clean and in good condition kitchen environment. Coolers and refrigerators was observed in need of repair, storage room were observed without door with equipment used to provide maintenance exposed to the kitchen environment.

Findings include:

1. During the kitchen observational tour performed with the dietitian (employee # 7) on 8/7/12 from 10:30 am till 11:50 am, the following was observed:

a. Coolers and refrigerators located in the kitchen were observed with rust in bad condition and in need of repair.

Accordingly with information provided by administrative dietitian during interview on 6/28/18 at 9:48 am, this deficiency was cited by state health surveyors during a visit to the facility on March/2018. Accordingly with information provided during interview due to the bad condition of coolers and refrigerators to correct this deficiency, all coolers and refrigerators must be replaced. Administrative dietitian stated that as part of plan to correct this deficiency three different quotes are request to three different companies. Kitchen services pertain to a contractor company named "Excell Nutritional Care ". Facility is in the process of dealing with the contractor company of the kitchen in order to determine obligations of the contractor and facility to pay for the project.

2. Room located in the same hallway where ice machine room is located was observed without door. Inside the room it was observed two pails and a gallon of paint and a floor machine to polish floors.

Based on a validation survey, observations and tests made during the survey for the physical environment with the facility's Physical Plant Director (employee #1), it was determined that the structure and care of this areas failed to allow staff to provide care in a safe manner ensuring the well-being of patients receiving services.

Findings include:

1.During the round to observe and evaluated the Operating Room Department on 6/26/18 at 1:55 p. m. the following was observed:

a.On the operating room ''A'' was observed with all of the walls with ceramic tiles.

The floor and all around the room was observed with dust.

Floor, walls spaces between tiles with much dirty.

Raw cement in the area where the surgery table is located and dirty area was observed.

Small Anesthesia room located in this room dirty, mush dust, paint detached, door with detachment of wood, has no bulb and has no cover of protection, and floor is of vinyl and lacks of sockets ''socalos''.

Equipment with rust

The clock did not function the nurse supervisor stated: ''It fill on the floor and was placed again to cover the hole.

b. Fourth wash surgical material.

Stainless steel table located to the right of the dirty entrance was observed dirty, with dust, particles of surgical and health care hand antiseptic, was observed mask box, surgical scrubs, hand antiseptic, gloves box all were opened.

At 2:00 p.m. office material (papers) was observed inside a hole in the wall where electric pipeline.

The temperature at 2:05 p.m. stay on 72.0 grades Fahrenheit and Humidity was on 65 percent (%) on the storage #1. The humidity exceeds the established parameters 30% to 60%.

c. On the operating room ''B'' was observed with all of the walls with ceramic tiles.

The floor and all around the room was observed with dust and dirty.

Floor, walls spaces between tiles with much dirt.

Raw cement in the ceiling areas was observed.

The clock did not function.

Wooden door inside of this room deteriorate with detachment of pieces of wood, this small room is not in use as referred by the nurse supervisor.

The lights in this operating room does not have a plastic cover.

d. The operating room ''scrub area'' localized at the left side of the hall was observed with three handwash scrubs at the left side and two at the right side, the five handwash scrubs were observed with water spots, dirty, did not have hot water and the second hand sink of five does not work.

At the right side of the two '' handwash scrubs '' a biohazard trash disposal was observed dirty and white spots on the top of the plastic cover.

e. At 2:30 p.m. the '' Sterile Room '' was visit and was observed:

This room was located in the hall at the right side near the operating room identified with letter '' D '' this operating room was observed with a black plastic curtain and the nurse supervisor stated that this operating room was closed because is in remodeling.

However, near this room was observed the '' Sterile Room '' used to maintain all of the sterile trays and other materials used for surgical interventions, it was observed a commercial humidifier.

The Physical Plant Director (employee #1) stated: '' This room did not have humidifier system to control the humidity. ''

The room felt hot the temperature was 73 grades Fahrenheit but the Humidity was on 65 percent (%).

f. The designated area for '' Sterile Supplies '' was visit at 2:40 p.m. and was observed the following:

Dirty and black dusty acoustics, all of the walls and floor has tiles and was observed dirty, deteriorate and absence of slabs and sockets.

Metal tower of Straight Care machines located in the main entrance was observed with much stain.
Wooden sockets located at both ends of the corridor that reaches the autoclaves were observed with dirt and deteriorated.

A fire extinguisher was observe in this hallway without protective cover and it is only fastened with a screw and small metal hook.

Biohazards trash disposal was observed dirty and with white spots in the top of the plastic cover.

A lot of dust accumulation was observed in anchors where material is placed and then sterilized.

The sterile supply technician employee #16 removed the dust from all of the shelves with the same towel and did not use gloves to clean.

g. The following was observed in Anesthesia room:

Deteriorate door absence of small pieces of wood

Has no lock

Has no bulb on the ceiling

No plastic cover of protection switch for turning on the light

Dirty floor, dust, the floor did not have sockets.

h. At 2:45 p.m. the following was observed in the Housekeeping room

Three compartments shelf and wooden board was observed in a crass deterioration with pieces of loose wood and humidity

Lamp has no cover, cables exposed

Edges around blind cover located in the ceiling lacks cement.

i. Nurse's dressing room has a shower out of service, drain area was covered with four large pieces of adhesive tape, the area was observed dirty and with peeling paint.

2. During the round to observe the fourth (4) floor department on 6/26/18 at 10:30 a. m. the following was observed:

Biohazard room it was found open

Bathroom curtains for patients with no hooks

Privacy dividers curtains broken

Patient rooms and beds with no touch-up of paint

Night table with fallen door

Curtains of patient bathtubs touch the floor
Room for preparation of pediatric formulas maintains temperatures in 68 grades Fahrenheit the acceptable temperatures was maintain enter 70 to 75 grades. The humidity was maintain in 84% the Humidity acceptable parameters is to be maintain between 30 % to 60 %.

3. During the round to observe the third floor department on 6/27/18 at 10:00 a. m. the following was observed:

In the pantry area a dirty, dusty and white spots around the ice machine was observed.

Physical plant supervisor stated: Is given maintenance in the interior by physical plant personnel.''

No external cleaning record was evidenced.

Patient rooms and beds with no touch-up of paint

Curtains of patient bathtubs touch the floor

In the room designated to keep dirty clothes was observed acoustics with humidity and dust.

4. During the round to observed the Pediatric Emergency Room Department on 6/28/18 at 9:30 a. m. the following was observed:

Privacy dividers curtains missing hooks

Broken and detached tiles was observed in front of the nurses counter

Nursing counter has absence of laminate material expose wood

All of the area did not have hot water

Mattress of the treatment bed and triage area are broken

Black powder was observed in acoustics of the treatment room.

Pediatric area does not have a housekeeping room.

The nurse supervisor (employee #3) was interview related to this and she stated: '' The housekeeping employee picks up the regular garbage and biohazard garbage and takes it to the adult's emergency room area. The housekeeping employee cleans the pediatric unit every day he or she has a cleaning cart to service the pediatric unit then go to the adult pool collets clean water then goes to the pediatric unit cleaning and when finishes returns to the adults housekeeping room discard the dirty water washes the mop in that area and was maintain on the cleaning cart then the clean cart is taken to the basement.''

5. During the round to the '' Morgue" located on the basement on 6/28/18 at 10:15 a. m. the following was observed:

This room has two freezers to keep the bodies while they are taken to the funeral home.

At right side of this room it was observed two commercial freezers one of the freezers is designed to keep the extremities of the patient's post-surgical interventions and the other to maintain the placentas.

The housekeeping employee stated: '' Cleaning staff are in charge of the maintenance Morgue and to keep the temperature record of the three freezers.''

However the '' Morgue Room '' does not have air conditioning.

At 10:20 a.m. the temperature registered inside the '' Morgue Room '' was 76.9 grades Fahrenheit temperatures was maintain between 70 to 75 grades Fahrenheit and the humidity registered inside the morgue room was 27 % the acceptable parameters is maintain between 30 % to 60 %.

The facility personnel did not provide evidence of the daily record of temperatures and humidity.

6. During the round to the '' Basement" on 6/28/18 at 10:25 a. m. the following was observed:

Throughout the hallway that leads to the exit door is observed plastic cans for roof treatment, a refrigerator, a freezer, desk, chairs, cartoons and other equipment. The entire area of the basement lacks cleanliness and painting including the areas of stairs and the exterior.

6. During the round to the area designated to maintain the '' cleaning scrubs used on the operating room, the clean bed sheets and the clean room curtains " on 6/28/18 at 10: 30 a. m. the following was observed:

Cardboards
Blocks 4x6 for construction
Wood
Hooks used for curtains
Bedside table of patient's room broken
Three cardboard boxes on one of the three shelves
On the left side of the room was observed a transparent plastic packaging with curtains the same were observed open and some curtains exposes.

On the right side there was a rag, where the cleaning scrubs is placed, that are going to be used in the operating room, all of which are located on the first level, the plastic touches the floor and some were observed with the loose trousers ties making contact with the floor.

This room has no tiles is raw cement, was observed dirty, with dust, no air conditioning. In the main entrance was observed engineering materials and equipment.
A desk was observed in the main entrance at right side it is used by the maintenance supervisor to do their daily work.

A blue plastic cart used to transport clean sheets was observed uncovered near to engineering materials and equipment.

The room door was observed without paint and poor condition.

7. During the round to observe the '' Central Supply '' on 6/28/18 at 10:50 a. m. the following was observed:

On the left side of the main entrance metal table was observed on the first shelf it was observed a '' Fire Extinguisher '' the same is without security not placed on the wall and has no security cover.

A metal shelf was observed with pilled and cracked paint and mold on this shelf was observed with sterile material and trays with sterile packing of Bone Marrow Lumbar Puncture adults and pediatrics, sterile strips, colostomy bags and others.

Floor does not have tiles, is polished but some areas have raw cement and blue paint.

Plug located on the main entrance has no safety plastic cover.

The facility personnel employee #33 provide evidence of the daily record of temperatures and humidity. At 11:03 a.m. the temperature registered inside the Central Supply was 73.6 grades Fahrenheit and the humidity registered inside was 73 %.

According of the daily log for temperature and humidity for year 2017 and 2018 for this area designated for '' Medical Surgical Materials '' the acceptable temperatures was maintain between the 65 to 78 grades Fahrenheit and the humidity was maintain between 30 % to 60 %.

The document provides evidence that during year 2017 the temperature was maintain in various days under the range (63grades Fahrenheit) and the humidity was maintain between 61% to 97% and during the present year 2018 temperature was maintain in various days under the range (68 grades Fahrenheit ) and the humidity was maintain between 63% to 89%.

No evidence on the daily register log when changes are detected on temperature and humidity if to notify the person on charge related to this situation to resolve the problem.

8. During the round to observe the '' Dialysis Unit '' on 6/27/18 at 11:15 a. m. the following was observed:

Acoustics with humidity

Dirty floor was observed on all of the unit

Area under the sink was dirty, dust and moisture

Absence of tiles in the bath

The fire extinguisher without protection cover

The temperature and humidity was taken at 11:25 a.m. on the treatment area and reveled that Temp was on 74.5 grades Fahrenheit and the humidity was 82 %. The acceptable humidity parameters is to be maintain between 30 % to 60 %.

Based on a recertification survey, the observational tour with the Physical Plant Director (employee #1), review of policies/procedures, it was determined that the facility failed to ensure that appropriate standards of practice are followed for infection control practice for expire medical surgical material on the crash cart, dirty laundry room without extractor, Ceiling tiles with dark spots, floor tiles broken, treatment chairs broken, medical equipment with dark spots, walls with the peeling paint, floors with dark spots, medical surgical material directly to the floor and Curtains touching the floor which can affect ### of ### admitted patients (PTE) (PTE ## to ##).

Findings include:

1. On 06/27/18 at 10:30 am during the observational tour on third floor medicine east with the Physical Plant Director (employee # 1) it was found: the handrails in front of room 372 pealing, room 361 and 365 with the walls with peeling paint, floor tiles in front of Social Worker office and in front of room 362 broken. On the electrical panel room one ceiling tile missing, at the a/c handler room 7 ceiling tiles missing, on room 352 one ceiling tile with dark spots and the cleaning supply storage have dark spots on the floor.

2. On 6/27/2018 at 10:55 am during the emergency cart inspection it was found: three hi-lo oral/nasal tube cuffed 8.0 mm expire on 05/2017 and one package of electrodes 3M red dot expire on 05/2018.

In the same floor at the dialysis unit it was found the floor with multiples darks spots and in front of the restroom door was a dark red spot.

3. On 6/27/2018 at 1:26 pm during the intensive care unit observational tour it was found on cubicle 8 the courting touching the floor, cubicle 1 with floor tiles broken and peeling paint on the walls.

On the intensive care unit emergency cart it was found four butterfly Vacutainer needle expire on 05/2018.

4. On 06/27/2018 at 1:50 pm at Neonatal Intensive Care Unit It was fond a ceiling tile with dark spot and the walls with peeling paint.

5. On 6/27/2018 at 2:06 on the delivery room emergency cart it was found three hi-lo oral/nasal tube cuffed 6.5 mm expire on 11/2016, three hi-lo oral/nasal tube cuffed 7.0 mm expire on 03/2017 and three hi-lo oral/nasal tube cuffed 7.5 mm expire on 03/2017.

6. On 6/27/ 2018 at 2:43 at the emergency room it was found on cubicle 9 a stretcher with peeling paint and dark spots, and two ceiling tiles with dark spots. On the minor surgery room it was found the cabinets with dark spots.

7. On 6/28/2018 at 8:57 am on the cardiac catheterization laboratory it was found the Innova Machine and the stainless steel table with dark spots.

8. On 6/28/2018 at 9:25 am on the Pediatric emergency room it was found one treatment chair cushion broken floor tiles on front of the nurse station broken. On the pediatric triage room it was found one ceiling tile with dark spots.

9. On 06/28/2018 at 10:59 am on the general storage it was fond more than 50 boxes with medical surgical material one on top of each other directly to the floor and 5 wood pallets with medical surgical material.

10. On 06/28/2018 at 1:30 pm it was found the basement dirty laundry room with no air extraction.

11. The facility failed to ensure that appropriate standards of practice are followed for infection control practice for expire medical surgical material on the crash cart, dirty laundry room without extractor, Ceiling tiles with dark spots, floor tiles broken, treatment chairs broken, medical equipment with dark spots, walls with the paint peeling, floors with dark spots, medical surgical material directly to the floor and Curtains touching the floor.


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12. During the emergency room initial observational tour performed with the nursing supervisor (employee # 3) on 6/26/18 from 10:30 am till 11:30 am, it was identified medical surgical storage located near observation area where ceiling tiles are missing. Medical surgical materials and items were observed exposed to ceiling air conditioning celing tubes and connections.


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13. During the round to observe and evaluated the Operating Room Department on 6/26/18 at 1:55 p. m. the following was observed:

a. On the operating room ''A'' was observed with all of the walls with ceramic tiles.

The floor and all around the room was observed with dust.

Floor, walls spaces between tiles with much dirty.

Raw cement in the area where the surgery table is located and dirty area was observed.

Small Anesthesia room located in this room dirty, mush dust, paint detached, door with detachment of wood, has no bulb and has no cover of protection, floor is of vinyl and lacks of sockets ''socalos''

Equipment with rust

The clock did not function the nurse supervisor stated: ''It fell down to the floor and was placed again to cover the hole.

b. Fourth wash surgical material

Stainless steel table located to the right of the dirty entrance was observed dirty, with dust, particles of surgical and health care hand antiseptic, was observed mask box, surgical scrubs, hand antiseptic, gloves box all were opened.

At 2:00 p.m. office material (papers) was observed inside a hole on the wall where electric pipeline are.

The temperature at 2:05 p.m. stay on 72.0 grades Fahrenheit and Humidity was on 65 percent (%) on the storage #1.

The humidity exceeds the established parameters 30% to 60%.

c. On the operating room ''B'' it was observed with all of the walls with ceramic tiles.

The floor and all around the room was observed with dust and dirty.

Floor, walls spaces between tiles with much dirt.

Raw cement in the ceiling areas was observed.

The clock did not function.

The lights in this operating room does not have a plastic cover.

d. The operating room ''scrub area'' located at the left side of the hall was observed with three hand wash scrubs at the left side and two at the right side, the five hand wash scrubs were observed with water spots, dirty, did not have hot water and the second hand sink of five does not work. At the right side of the two '' hand wash scrubs '' a biohazards trash disposal was observed dirty and write spots in the top of the plastic cover.

e. At 2:30 p.m. the '' Sterile Room '' was visit and was observed:

This room was located in the hall at the right side near the operating room identified with letter '' D '' this operating room was observed with a black plastic curtain and the nurse supervisor stated that this operating room was closed because is in remodeling.

However, near this room was observed the '' Sterile Room '' used to maintain all of the sterile trays and other materials used for surgical interventions, it was observed a commercial humidifier.

The Physical Plant Director stated: '' This room did not have humidifier system to control the humidity. ''

The room felt hot the temperature was in 73 grades Fahrenheit but the Humidity was on 65 percent (%).

f. The designated area for '' Sterile Supplies '' was visit at 2:40 p.m. and was observed the following:

Dirty and black dusty acoustics, all of the walls and floor has tiles and was observed dirty, deteriorate and absence of slabs and sockets.

Metal tower of Straight Care machines located in the main entrance was observed with much stain. Wooden sockets located at both ends of the corridor that reaches the autoclaves were observed with dirty and deteriorated.

A fire extinguisher was observe in this hallway without protective cover and it is only fastened with a crew and small metal hook.

Biohazard trash disposal was observed dirty and with white spots on the top of the plastic cover.

A lot of dust accumulation was observed in anchors where material is placed and then sterilized.

The sterile supply technician employee #16 removed the dust from all of the shelves with the same towel and did not use gloves to clean.

g. The following was observed in Anesthesia room:

Deteriorate door absence of small pieces of wood

Has no lock

Has no bulb on the ceiling

No plastic cover of protection switch of turning on the light

Dirty floor, dust, the floor did not have sockets

h. At 2:45 p.m. the following was observed in the Housekeeping room

Three compartments shelf and wooden board was observed in a crass deterioration with pieces of loose wood and humidity

There is no mop for infected cases

Lamp has no cover cables exposed

Edges around blind cover located in the ceiling lacks cement.

i. Nurse's dressing room has a shower out of service drain area was covered with four large pieces of adhesive tape, the area was observed dirty and with peeling paint.

B. During the round to observe the fourth floor department (4) on 6/26/18 at 10:30 a. m. the following was observed:

Biohazard room it was found open

Sharps containers with expired date placed on cleaning patients rooms.

Bathroom curtains for patients with no hooks

Privacy dividers curtains broken

Patient rooms and beds with no touch-up of paint

Night table with fallen door

Curtains of patient bathtubs touch the floor

Room of preparation of pediatric formulas maintains temperatures in 68 grades Fahrenheit the acceptable temperatures is maintain between 70 to 75 grades.

The humidity was maintain in 84% the Humidity acceptable parameters is maintain between 30 % to 60 %.

C. During the round to observe the third floor department on 6/27/18 at 10:00 a. m. the following was observed:

In the pantry area a dirty, dusty and white spots around the ice machine was observed.

Physical plant supervisor stated: Is given maintenance in the interior by physical plant personnel.''

No external cleaning record was evidenced.

Patient rooms and beds with no touch-up of paint

Curtains of patient bathtubs touch the floor

In the room designated to keep dirty clothes was observed acoustics with humidity and dust.

D. During the round to observed the Pediatric Emergency Room Department on 6/28/18 at 9:30 a. m. the following was observed:

Privacy dividers curtains missing hooks

Broken and detached tiles was observed in front of the nurses counter

Nursing counter has absence of laminate material expose wood

All of the area did not have hot water

Mattress of the treatment bed and triage area are broken

Black powder was observed in acoustics of the treatment room

Pediatric area does not have a housekeeping room

The nurse supervisor (employee #3) was interview related to this and she stated: '' The housekeeping employee picks up the regular garbage and biohazard garbage and takes it to the adult's emergency room area. The housekeeping employee cleans the pediatric unit every day he/she has a cleaning cart to service the pediatric unit, then goes to the adult pool, collets clean water then go to the pediatric unit cleans and when finishes returns to the adults housekeeping room discard the dirty water washes the mop in that area and is maintain on the cleaning cart then the cleaning cart is taken to the basement.''

E. During the round to the '' Morgue" located in the basement on 6/28/18 at 10:15 a. m. the following was observed:

This room has two freezers to keep the bodies in, while they are taken to the funeral home. At right side of this room it was observed two commercial freezers, one of the freezers is designated to keep the extremities of the patient's post-surgical interventions and the other to maintain the placentas.

The housekeeping employee stated: '' Cleaning staff are in charge of the maintenance of the Morgue and to keep the temperature record of the three freezers.''

However the '' Morgue Room '' does not have air conditioning.

At 10:20 a.m. the temperature registered inside the '' Morgue Room '' was 76.9 grades Fahrenheit, the acceptable temperatures is maintain between 70 to 75 grades Fahrenheit and the humidity registered inside the morgue room was 27 % the acceptable parameters is maintain between 30 % to 60 %.

The facility personnel did not provide evidence of the daily record of temperatures and humidity.

F. During the round to the '' Basement" on 6/28/18 at 10:25 a. m. the following was observed:

Throughout the hallway that leads to the escape door is observed plastic cans for roof treatment, a refrigerator, a freezer, desk, chairs, cartoons and other equipment. The entire area of the basement lacks cleanliness and painting including the areas of stairs and the exterior.

G. During the round to the area designated to maintain the '' cleaning scrubs used on the operating room, the clean bed sheets and the clean room curtains " on 6/28/18 at 10: 30 a. m. the following was observed:

Cardboard, blocks 4x6 for construction, wood, Easter basket, hooks used for curtains, bedside table of patients room broken, three cardboard boxes on one of the three shelves.

On the left side of the room was observed a transparent plastic packaging with curtains the same were observed open and some curtains exposes.

On the right side there was a rag where cleaning scrubs are placed, that are going to be used in the operating room, all of which are located on the first level, the plastic touches the floor and some were observed with the loose trousers ties making contact with the floor.

This room has no tiles, is raw cement, and was observed dirty, with dust, no air conditioning.

In the main entrance was observed engineering materials and equipment.

A desk was observed in the main entrance at right side it is used by the maintenance supervisor to do their daily work.

A blue plastic cart used to transport clean sheets was observed uncovered near to engineering materials and equipment.

The room door was observed without paint and poor condition.

H. During the round to observe the '' Central Supply '' on 6/28/18 at 10:50 a. m. the following was observed:

On the left side of the main entrance metal table was observed on the first shelf a Fire Extinguisher the same is without security not placed on the wall and has no security cover.

On the second tablet was observed specimen containers bottles of blood cultures, multiple boxes with different materials including stationery.

A metal shelf was observed with pilled and cracked paint and mold on this shelf was observed with sterile material and trays with sterile packing of Bone Marrow Lumbar Puncture adults and pediatrics, sterile strips, colostomy bags and others.

Floor does not have tiles is polished but some areas have raw cement and blue paint.

A plug located on the main entrance has no safety plastic cover.

The facility personnel employee #33 provide evidence of the daily record of temperatures and humidity.

At 11:03 a.m. the temperature registered inside the Central Supply was 73.6 grades Fahrenheit and the humidity registered inside was 73 %.

According of the daily log for temperature and humidity for year 2017 and 2018 for this area designated for '' Medical Surgical Materials '' the acceptable temperatures is maintain between the 65 to 78 grades Fahrenheit and the humidity was maintain between 30 % to 60 %.

The document provides evidence that during year 2017 the temperature was maintain in various days under the range (63grades Fahrenheit ) and the humidity was maintain between 61% to 97% and during the present year 2018 temperature was maintain in various days under the range (68 grades Fahrenheit ) and the humidity was maintain between 63% to 89%.

No evidence on the daily register log when changes are detected on temperature and humidity if to notify the person in charge related to this situation to resolve the problem.

I. During the round to observe the '' Dialysis Unit '' on 6/27/18 at 11:15 a. m. the following was observed:

Acoustics with humidity

Dirty floor was observed on all of the unit

Area under the sink was dirty, dust and moisture

Absence of tiles in the bath
The fire extinguishing without protection cover

The temperature and humidity was taken at 11:25 a.m. on the treatment area and reveled that Temp was on 74.5 grades Fahrenheit and the humidity was 82 %.
The acceptable humidity parameters is maintain between 30 % to 60 %.

Based on a validation survey, observations and records reviewed (RR) for discharge planning, performed on 6/28/18 from 9:00 am thru 12:00 md and accompanied by the discharge planning (employee #8), it was identified that facility failed to reassess patient's discharge plan. This deficient practice was identified on 3 out of 10 records evaluated for discharge planning. (RR # 6, RR # 7 and RR. # 15).

Findings include:

1. A mechanism to ensure that facility assess and reassess patient's discharge plan when there is factors that may affect continuing care needs, was not performed, accordingly with the following findings identified during survey procedures on 6/28/18 from 9:00 am thru 12:00 md:

a. RR.# 6 is a 84 years old male patient admitted on 6/19/18 with a diagnosis of Rectal Bleeding and Abdominal Mass. The record was review on 6/28/18 at 10:20 am with discharge planning (employee # 8). Discharge planning services evaluate patient on 6/19/18. This patient decline in his condition and on 6/20/18 patient presents Pleural effusion and a chest tube was inserted on right side. On 6/20/18 patient sign a consent and establish an advance directive, on this patient refuse endotracheal intubation (Do Not Intubate) in the event of a cardiorespiratory arrest. Discharge planning services did not reassess patient discharge plan to include factors as respiratory status and terminal illness status as factors that may affect continuing care needs.

b.RR.# 7 is a 68 years old male patient admitted on 6/14/18 with a diagnosis of Right Heel Infected Ulcer and Diabetes Mellitus. The record was review on 6/28/18 at 10:50 am with discharge planning (employee # 8). This patient had a physical restraint order since 6/15/18 due to disorientation and episodes where try to interrupt treatment. Patient was also located on contact isolation precaution since 6/18/18 due to the identification that was positive to rectal Kebsiella Pneumonia.

Discharge planning services did not assess patient discharge needs after admission to include factors as cognitive status needs and isolation precautions as factors that may affect continuing care needs. Discharge planning services evaluate patient on 6/25/18.

c. RR.# 15 R.R. # 15 is a 92 years old male patient admitted on 6/11/18 with a diagnosis of Respiratory Failure and bilateral Bronchopneumonia. The record was review on 6/28/18 at 9:10 am with discharge planning (employee # 8). Discharge planning services evaluate patient on 6/11/18. This patient decline in his condition and a Percutaneous Endoscopic Gastrostomy (PEG) tube to provide feeding by gastrostomy was inserted on 6/27/18, patient also was disoriented, trying to interrupt treatment and due to this he was on physical restriction since 6/14/18.

Discharge planning services did not reassess patient discharge plan to include factors as specialized nutrition needs and cognitive status needs as factors that may affect continuing care needs.

During interview with discharge planning personnel ( employee # 8 ) on 6/28/18 at 11:55 am, she stated accordingly with facility policy for discharge planning every patient admitted to the hospital was evaluated in order to determine factors that may affect continuing care needs when was discharge home. After this evaluation every 72 hours a reassessment must be performed in order to determine patient decline or changes in psychosocial events who may interfere or affects continuing care needs.

Based on a validation survey conducted on 6/27/18 thru 6/28/18, the observational tour, interview and review of policies/procedures in the operation room department, it was determined that the facility failed to ensure that surgical services maintain a high standards of medical practice and patients' care for 3 out of 4 operating suites (Stes). (Stes. #A, #B and #C)

Findings include:

1. The following was observed during the visual inspection for compliance of standards of medical practice and patient care on 6/27/18 and 6/28/18 from 9:30 a. m. till 4:00 pm at the Operating Room Department:

a. The operating suites #D was out of service due to remodeling however, the isolation plastic to assess to the operation suite #D was observed the adhesive tape is detached from the top. Not isolating the area from the rest of the operation rooms Department.

b. Dust and sand particles were observed in the plastic floor that isolates the operation room #D that was remodeling in the front of operation room #B.

c. The operating suites #A, #B and #C was observed with floors grown and dull.

Interview with the nurse supervisor on 6/27/18 at 11:00 am state that the floor was cleaned after each procedure and on 2/15/18 and 4/12/18 the floor was washed and wax. She indicated to the personnel that performed the work that she's not satisfied with the work performed on the floor.

d. The Operation Suite #B was observed with rust in the metal shelve near the floor and a slab of broken wall

e. The facility nurse supervisor (employee #19) provided evidence of the operating rooms daily temperature and humidity of the operating room suites #A, #B, C, D, Intravenous Fluid Room, Central Room, Storage Room, Recovery room, Sterile Bandage room and Orthopedic Room.

According of the operating room the parameters of temperature was maintain between 65 ºF and 78 ºF and humidity between 30% and 60 %.

The daily temperatures and humidity documents revealed that during January 2018, February 2018, March 2018, April 2018, May 2018 and June 2018 the temperatures of all of the areas were maintain on 57 ºF to 77 ºF and humidity was maintain up to 60 % not according of the establish parameters.

The daily temperatures and humidity forms in some days was documented that the facility physical plant personnel was notified, however no evidence was found related to interventions and actions the facility personnel took to maintain the establish parameters.

f. The facility failed to ensure that appropriate standards of practice are followed for infection control practice and expose the patients to contamination during the procedure due to variance in temperature and humidity range.

Based on a validation survey conducted on 6/27/18 thru 6/28/18, the observational tour, interview and review of policies/procedures in the operation room department, it was determined that the facility failed to ensure that the call-in system equipment was available to the operating room suites (Stes). (Stes. #A, #B, # C and #D)

Findings include:

1. The following was observed during the visual inspection for of compliance of equipment available on the Operating Room suite on 6/27/18 from 9:30 a. m. till 1:00 pm:

a. No evidence was found related to a functional call system in the four operation suite.

Interview with the nurse supervisor on 6/27/18 at 12:00 pm state that the intercom was damage , the facility provide and hand up telephone but was removed, at this time if an emergency arises in the operating room, a staff goes out into the hall and gives notice. As always there is someone in the counter to answers the call.

b. The facility failed to have an operative hand free call system in case that an emergency arise in the operation suite during a procedure.

Based on a validation survey conducted on 6/27/18 thru 6/28/18, review of six record reviewed (R.R) in the operation room department wit nurse supervisor (employee # 19) , it was determined that the facility failed to ensure that operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon for 2 out of 6 records reviewed (R.R. #24 and #28).

Findings include:

1. The following was observed during the six record review with the nurse supervisor employee #19 on 6/27/18 from 1:45 pm till 4:00 pm on the Operating Room Department:

a. R.R. #24 is a 61 years old female admitted to operation room with a diagnosis of Cholelithiasis to performer a cholecystectomy, it was found that in the operative report the surgeon writes "same" in the post-operative diagnosis.

b. R.R. #28 is a 59 years old male admitted to operation room with a diagnosis of umbilical Hernia to performer a Umbilical Hernia Repair, it was found that in the operative report the surgeon writes "same" in the post-operative diagnosis.

Base on validation survey and six records reviewed (RR) with nurse supervisor (employee #19), on 6/27/18 from 1:45 pm thru 4:00 pm, it was determined that the facility failed to ensure that medical record document properly executed anesthesia informed consent forms for anesthesia service for 3 out of 6 record reviewed (R.R. #24, #25 and #35)

Findings include:

1. R.R. #24 is a 61 years old female admitted on 6/18/18 with a diagnosis of Cholelithiasis, during the record review performed on 6/27/18 at 1:45 pm it was found the following:

a. The anesthesia consent performed on 6/18/18 at 7:00 am, lack of the anesthesiologist that is going to administrate the anesthesia.

2. R.R. #25 is a 87 years old female admitted on 6/14/18 with a diagnosis of Displaced left distal radius fracture, during the record review performed on 6/27/18 at 3:30 pm it was found the following:

a. The anesthesia consent performed on 6/13/18 at 4:00 pm, lack of the anesthesiologist that going to administrate the anesthesia.

3. R.R. #35 is a 9 years old female admitted on 1/15/18 with a diagnosis of Bell's Palsy, during the record review performed on 6/28/18 at 3:00 pm it was found the following:

a. The anesthesia consent performed on 2/1/18 at 1:00 pm, lack of the anesthesiologist that is going to administrate the anesthesia.

Based on a validation survey, observations, and interview with nursing supervisor ( employee #3) on 6/26/18 at 10:48 am it was determined that facility failed to comply with requirement to maintain sign posting as required by the Emergency Medical Treatment and Labor Act ( EMTALA ) federal law.

Findings include:

During the emergency room initial observational tour performed with the nursing supervisor (employee # 3) on 6/26/18 from 10:30 am till 11:30 am, it was identified that facility did not have posted EMTALA sign on the emergency room entrance area,waiting area,treatment area and admitting area to provide the rights for orientation to all patients that visits the emergency room.

Based on a Validation survey, 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 (employee #22), 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 4 out of 4 clinical records reviewed (R.R #47, #48, #49 and #50).

Findings include:

During the Validation Survey of the Respiratory Therapy Services on 6/29/2018 at 8:45 a.m. till 12:00 p.m. the supervisor of the Respiratory Therapy Department (employee #22) stated during an interview on 6/29/18 at 10:30 a.m, "The facility has a contract with a private company; I am the only hospital employee as a supervisor and I am the link between the private company and the hospital. The Respiratory Therapy Department has seventeen respiratory therapists all under contract with rotating shifts from 6:00 am to 2:00 pm, 2:00 pm to 10:00 pm and 10:00 pm to 6:00 am. The respiratory company provides all the employees and performs the schedule every week. If someone is absence with notification or without notification or any changes on the program it is notified to the supervisor. The company is available 24 hours a day, 7 days a week. Everything related to materials is supplied by the hospital. We have eight ventilators owned by the hospital. Any situation with the hospital ventilators, the hospital resolves it including the preventive maintenance. All supplies used by the respiratory therapist to provide the respiratory care is provided by the hospital.''

1. The Respiratory Therapy Department Manual for policies and procedures was request on 6/25/18 and provide evidence of the respiratory policy to verify the respiratory therapy hour of administration and establish the following: '' All respiratory therapy personnel will comply with the schedule established for the administration of nebulization therapies and the purpose is to ensure that every patient receives the treatment according to the ordered frequency.'' However, the facility failed to find a mechanism that ensures that all patients receive their treatments according to the order and based on the respiratory patients' needs.

2. The form used by the respiratory therapist to document the name of therapist for each shift, patient information, room number, treatment ordered, frequency date of the order, treatment time and comments lacks relevant information related to the name of the therapist on the three shifts, date of the order and hour of treatment.

3. Four patient medical records were reviewed on 6/29/18 from 8:45 a.m till 12:00 p.m 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 #47, #48, #49 and #50. Records reviewed provided evidence that patients did not receive respiratory treatment in a timely manner:

a.R.R #47 is one year old male admitted on 6/25/18 at 4:12 p.m. at Pediatric Department located on the fourth floor with a diagnosis of Bronchitis. The record review was performed on 6/29/18 at 8:45 a.m. and provided evidence that the physician ordered oxygen therapy at 40 percent (%) on hood, chest tapping per 10 minutes two times daily and Albutherol 1.25 mgs c/4 hours and Atrovent 0.5 mgs. every 6 hours on 6/25/18 at 5:50 p.m. was signed by the nurse and the therapist at 5:50 p.m.

The initial assessment by the respiratory therapist (employee #27) was performed on 6/25/18 at 6:00 p.m. The patient received the first respiratory therapy of Albuterol and Atrovent on 6/25/18 at 5:51 p.m per 15 minutes at 7 liters /minutes and the first chest tapping and continue with the respiratory care however on 6/27/18 the respiratory therapy of Albuterol was given at 6:00 a.m. not according with the respiratory therapy administration schedule, the therapy was to be given at 2:00 a.m. and was given at 6:00 a.m. eight hours later there is no written evidence for the reason why it was not administered in the corresponding hour.

On 6/27/18 the Albuterol and the Atrovent therapy it was to be given at 5:30 p.m. however was given by the therapist 20 minutes later. On 6/28/18 the Albuterol therapy it was to be given at 2:00 a.m. however, no treatment time appears in the progress note for the therapist employee #29.

On 6/28/18 the Atrovent therapy it was to be given at 4:00 p.m. however was given by the therapist employee #30 at 6:25 p.m. one hour and fifty five minutes later.

The record revealed that the physician re-evaluated the patient on 6/27/12 at 3:00 p.m and ordered Oxyhood with high humidity at 40% the order was signed by the respiratory therapist employee #31 at 3:15 p.m and no evidence of documentation on the therapist progress note.

The patient record reveled on 6/29/18 at 8:45 a.m. that the patient did not received the respiratory treatments in accordance with the physicians' orders and his respiratory needs.

b. R.R #48 is a 38 years old female admitted on 6/24/18 at 3:00 p.m with a diagnosis of Percutaneous Nephrostomy Left Kidney. The record review was performed on 6/29/18 at 1:15 p.m and provided evidence that the patient physician ordered on 6/27/18 intensive spirometry.

The initial assessment was performed by the respiratory therapist on 6/27/18 at 11:58 a.m. but the respiratory progress note was performed on 6/27/18 at 9:40 p.m. (nine hours and forty minutes later) than the initial assessment and revealed that the respiratory therapist oriented the patient to perform the exercise twice a day tolerated and reach up to 730 ml. air for two seconds while this sustained.

On 6/29/18 the intensive spirometry therapy was performed at 9:30 a.m. and the therapist take the vital sign before the spirometry, however no evidence on the progress notes of the vital signs post spirometry. The patient record revealed that the patient did not received the treatment according of the physician's orders and patient needs.

c. R.R #49 is an 82 years old female admitted on 6/25/18 at 8:32 p.m. with diagnosis of Pleural Effusion of the Right Lung. The record review was reviewed on 6/29/18 at 9:30 a.m and provided evidence that the patient physician ordered on a pneumologist consult on the admission and ordered therapy of oxygen by nasal cannula at 2 liters/minutes.
On 6/26/18 at 1:25 p.m. ordered Atrvent theray 0.02 by PN every 6 hours, therapy of oxygen at 1/2 liter/minute and Pulmicort therapy 1 mg. by power nebulizer two times daily per 3 days and was taken by the nurse on 6/26/18 at 1:30 p.m.

The order was signed by the respiratory therapist employee #32 but no evidence was found of the hour when the therapist signed the order. The patient record revealed that the respiratory therapist did not performed the initial assessment.

The patient record revealed that the patient received the respiratory treatment not according with the physician orders and patient needs.

On 6/27/18 the respiratory therapy it was to be administrated at 2:00 a.m. however was administered at 12:00 a.m. two hours before (2 hours before) by the employee #28.

The respiratory therapy of Pulmicort it was it was be administered on 6/28/18 at 2:45 a.m. however was given on 6/28/18 at 6:25 a.m. (3 hours and fifteen minutes later). The therapies offered but were not administer according to the physician's orders and patient needs.

d. R.R # 50 is a 24 years old female admitted at medicine north on 6/26/18 at 7:12 a.m. with diagnosis of Asthma Exacerbation. The record review was performed on 6/29/18 at 11:10 a.m and provided evidence that the patient was admitted from the emergency room to medicine ward and physician ordered on 6/26/12 at 4:02 a.m. respiratory therapy by nasal cannula with Albuterol 0.83 % and Atrovent 0.02 % by power nebulizer every 30 minutes per 3 times signed by the emergency nurse at 4:15 a.m.

The first respiratory therapy was given on 6/26/18 at 4:40 am., at 5:10 a.m. and 5:40 a.m. then was admitted at medicine ward to continue the respiratory treatment.

On 6/26/18 at 4:55 p.m. a new respiratory therapy was placed by the physician, Pulmicort 1 mg. by power nebulizer (PN) two times daily per 3 days. The therapy was initiated on 6/26/18 at 6:30 p.m., the second therapy it was to be administered 6:30 a.m., however was given by the therapist 10 minutes later. The therapies were given but did not administer according to the physician's orders and patient needs.