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Based on complaint investigation Acts intake PR00000626, review of policies and procedures, incidents review with the Emergency room Manager (employees #5), it was determined that facility failed to ensure that patient or patient relative sign the treatment inform consent regarding of patient treatment. This deficient practice was identified on 2 out of 50 cases review (RR. #12 and #21).

Findings include:

1. A mechanism to ensure that facility follow the facility treatment consent policies and procedure when patient was receiving ER treatment were not performed accordingly with information provided on survey procedures from 9/4/19 through 9/5/19:

a.R.R. #12 is a 2 years old male who visited the Emergency Room on 8/16/19 at 4:22 pm (16:22) with a Diagnosis of Burn of second degree of left foot and forearm. During review of the case it was identified that after screening and physician evaluation of the case it was admitted to the third floor on the burn unit area.

However, the Treatment Consent was left in blank. The Physician Disposition Note lack of patient relative sign.

b. R.R. #21 is a 12 years old male who visited the Emergency Room on 5/6/19 at 12:28 pm with a Diagnosis of Burn of second degree of Right lower leg and right ankle. During review of the case it was identified that after screening and physician evaluation of the case it was transfer to the pediatric Hospital.
However, the Treatment Consent was left in blank. The Physician Disposition Note lack of patient relative sign.

Based on complaint investigation Acts intake PR00000626, review of policies and procedures, incidents and interview with Emergency room medical director (employees #10), emergency room manager (employees #5) and Surgery Ward Coordinator (employee #14) it was determined that facility failed to provide evidence of an appropriate system to storage patient's body parts images and follow policies established when taking images as part of patient skin assessment. This deficient practice was identified on 2 out of 50 cases review (RR #29 and #36).

Findings include:

1. A mechanism to ensure that facility follow privacy of information policies in place when produce patient's body parts images to be used as part of patient assessment and evolution of skin lesions were not performed accordingly with information provided on survey procedures from 9/4/19 through 9/5/19:

a. RR. # 29 is a 53 years old male, who visited the Emergency Room on 3/11/19 at 11:09 pm. The patient referred burn with hot water on left foot. During review of the case it was identified that after screening and physician evaluation of the case it was admitted to the third floor on the burn unit area. Patient begun to receive care who include cleansing debridement hyperbaric chamber treatment and skin graft procedures.

It was identified that on 5/14/19, 5/18/19 and 5/24/19 photos of left foot was taken and filed on the medical record.

No evidence was found of patient consent for the procedure of taken photos (images) as established on Corporate policies "Confidentiality and disclosure of information" last review 8/24/18 and "Consents for Medical Treatment" last review 8/24/18.

This medical record was evaluated and discussed with emergency room manager (employees #5) and Surgery Ward Coordinator (employee #14) on 9/5/19 at 10:30 am. However no evidence was found of patient consent for the procedure of taken photos (images) of left foot to evaluate evolution of the lesion.

Surgery Ward Coordinator (employee #14) stated on interview on 9/5/19 at 11:43 am that every patient from which personnel took photos of lesions must have an informed consent to explain enough about the procedure in order to request patient agreement or permission.

b. RR. # 36 is a 41 years old male, who visited the Emergency Room on 6/29/19 at 11:28 am. The patient referred burn with hot water (from the car hot radiator) on left forearm.

Physician evaluate patient on 6/29/19 at 2:15 pm and document on clinical impression of the medical evaluation form that images of the burn area that was taken and sent to the personnel of the burn unit area.

However he did not receive response. He then proceed to provide local care with Silver Sulfadiazide cream prescribe oral antibiotics and discharge patient home giving instructions to return to the emergency room if present complications. Patient final diagnosis was 2nd degree burn on the anterior forearm.

During the review of this case on 9/4/19 at 11:34 am no evidence was found of the patient consent for the procedure of taken photos ( images ) as established on Corporate policies " Confidentiality and disclosure of information " last review 8/24/18 and " Consents for Medical Treatment " last review 8/24/18.

No evidence was found of the images taken on 6/29/19 sent to the personnel of the burn unit area. This medical record was evaluated and discussed with emergency room manager (employees #5) and Emergency room Medical Director (employee #10) on 9/4/19 at 11:45 am.

During interview emergency room manager and Medical Director stated that if a healthcare personnel took photos or images of any patient body part in order to be used for assessment purposes it must comply with the facility privacy of information policies in place.

Based on complaint investigation Acts intake PR00000626, review of policies and procedures, incidents review with Emergency room Manager (employees #5), it was determined that facility failed to ensure that patient medical record was completed with patient or patient relative sign, with date and hour. This deficient practice was identified on 14 out of 50 cases review (RR #1, #2, #4, #5, #6, #7, #9, #10, #12, #15, #18, #20, #21and #38).

Findings include:

1. During 50 medical record review on survey procedures from 9/4/19 through 9/5/19 it was found the following:

a. R.R. #2 is a 36 years old female who visited the Emergency Room on 7/29/19 at 12:42 pm with a Diagnosis of Residual Foreign Body in Soft Tissue. During review of the case on 9/4/19 at 11:00 am, it was identified that the nurse Initial intervention and Note from the adult emergency room , The nurse failed to write the patient vital sign at the moment of the admission, sign, license number date and hour.

b. R.R. #6 is a 4 years old male who visited the Emergency Room on 7/26/19 at 8:27 pm (20:27) with a Diagnosis of Balanoposthitis. During review of the case on 9/4/19 at 1:58 pm, it was identified that the nurse Pediatric Triage, lack of the nurse sign and the Nurse Disposition Note lack of the nurse sign.

c. R.R. #9 is a 66 years old male who visited the Emergency Room on 5/28/19 at 2:11 pm with a Diagnosis of Burn of Second Degree of Left Thigh and male genital region. During review of the case on 9/4/19 at 1:30 pm, it was identified that the Nursing Adult Triage Assessment lack of the patient current medication. The Nursing Initial Intervention and Note of the adult emergency room lack of the patient vital sign at the moment of the admission and lack of the nurses sign, license number, date and hour.

d. R.R. #10 is a 68 years old male who visited the Emergency Room on 5/25/19 at 5:50 pm with a Diagnosis of Burn of Second Degree of Left hand, head, face and neck and Diabetes Mellitus Type II. During review of the case on 9/4/19 at 12:53 pm, it was identified that the Nursing Adult Triage Assessment lack of the patient Dextrostic, Physical Status, current medication and Immunization and lack of the nurses sign, license number, date and hour. The Nursing Initial Intervention and Note of the adult emergency room lack of the patient vital sign at the moment of the admission and lack of the nurses sign, license number, date and hour.

e. R.R. #12 is a 2 years old male who visited the Emergency Room on 8/16/19 at 4:22 pm with a Diagnosis of Burn of Second Degree of Left foot and forearm. During review of the case on 9/5/19 at 9:20 am, it was identified that the Treatment Consent was left in blank and without the patient relative sign. The nursing Disposition lack of the nurse sign. The Physician Disposition lack of patient relative sign.

f. R.R. #20 is a 63 years old male who visited the Emergency Room on 4/17/19 at 11:26 pm with a Diagnosis of Hemorrhagic Stroke. During review of the case on 9/5/19 at 10:37 am, it was identified that the Nursing Initial Intervention and Note of the adult emergency room lack of the patient disposition, vital sign at the moment of the admission and lack of the nurses sign, license number, date and hour.

g. R.R. #21 is a 12 years old male who visited the Emergency Room on 5/6/19 at 12:28 pm with a Diagnosis of Burn of second degree of Right lower leg and right ankle. During review of the case it was identified that after screening and physician evaluation of the case it was transfer to the pediatric Hospital. However, the Treatment Consent was left in blank. The Physician Disposition Note lack of patient relative sign.


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h. R.R. #1 is a 64 years old male who visited the Emergency Room on 7/30/19 at 4:44 am with a Diagnosis of Burn of second degree of left foot. During review of the case on 9/4/19 at 1:15 pm, it was identified that the patient was evaluated in emergency room by physician at 10:36 pm and then was admitted at the burn unit however, the nurse failed to take the patient vital sign at the moment of the admission at the burn unit and failed to write the disposition at the moment when the patient was admitted at this unit.

i. R.R. #4 is a 38 years old female who visited the Emergency Room on 8/27/19 at 3:10 pm with a Diagnosis of Bilateral Legs of Second Degree Burns. During review of the case on 9/4/19 at 3:10 pm, it was identified that the Physician Assessment lacks of the patient vital signs, medication history, the hour when the patient arrival, the name of the physician who performed the history, no final diagnosis and no disposition. The general consent for admission and treatment did not have the identification label and lacks of the physician name.

j. R.R. #5 is a 1 years old male who visited the Emergency Room on 7/28/19 at 6:33 pm (18:33) with a Diagnosis of Burn of Second degree of Right and Left foot. During review of the case on 9/4/19 at 2:05 pm, it was identified that the disposition medical form was not signed by the patient mother.

k. R.R. #7 is a pediatric patient 2 years old male who visited the Emergency Room with his mother on 7/20/19 at 11:46 pm with a Diagnosis of Burn of Second Degree of Right foot. During review of the case on 9/4/19 at 2:40 pm, it was identified that the discharge instructions form lacks of the physician signature.

l. R.R. #15 is a 25 years old female who visited the Emergency Room on 8/26/19 at 3:45 pm with a Diagnosis of Burn of Second Degree of Left foot. During review of the case on 9/5/19 at 9:40 am, it was identified that the Triage form lacks of nursing observation. Treatment authorization form lacks of the physician sign.

m. R.R. #18 is a 5 years old pediatric female who visited the Emergency Room on 4/14/19 at 14:25 with a Diagnosis of Burn of second degree of chest. During review of the case on 9/5/19 at 10:15 am, it was identified that the patient was admitted at Pediatric Department Burn Unit. The consent for Admission and Treatment of Emergency did not apply for pediatric patients. It is designated for adult patients because indicate the following: '' I so and so I understand that I have a health condition that requires medical treatment. During my hospitalization or hospital stay I authorize the following...'' The anesthesia consult performed on 4/15/19 at 11:30 am lacks of patient vital signs. Post anesthesia assessment related to complications post 24 hours did not indicated yes or no. The discharge summary lacks of information.

n. R.R. #38 is a 58 years old female who visited the Emergency Room on 6/23/19 at 11:42 am with a Diagnosis of Burn of third and fourth finger of Right hand. During review of the case on 9/4/19 at 12:45 pm it was identified that after screening and physician evaluation of the case it was discharge to home but the nurse note lacks of pain reevaluation.