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Based on a recertification survey, observation of delivery of care, review of medical records, policies and procedures, documents, and interviews from from 08/16/16 from 08/18/16 from 8:00 to 4:00 pm it was identified that Governing Body failed to carry out its responsibility for the operation and management of the hospital. The Governing Body failed to provide the necessary oversight and leadership as evidenced by the lack of compliance with: Medical Record Services (42 CFR 482. 24), which makes this condition Governing Body Condition (42 CFR 482.12), Not Met :(Cross reference Tags A0431, A0438, A0449, A0454 and A-0464).

During review of thirty-two out of fifty three clinical records (R.R #1 through #32) during the survey performed from 08/16/16 from 08/18/16 it was determine that the facility failed to ensure that clinical records contain complete information and documentation related to consults, nurses notes, physician progress notes, physician's orders included telephone order's, vital signs and physician discharge summary evaluation and other information and documents in the patient medical record and that are not accessible (Cross reference Tags A0438, A0449, A0454 and A-0464) All of which makes this condition "Not Met".

Based on the review of personnel credential files (C.F) for the nursing department and interview with Nursing supervisor (employee #26) it was determined that the facility failed to ensure that all personnel are licensed in accordance with State Law Number 254 of December 31, 2015 and federal requirements for 2 out of 2 Rehab Nursing Technicians credential files (RNT#1 and RNT#2).

Findings include:

On 08/18/16 at 9:20 am on interview with employee #26 stated " the Rehab Technicians do different things: They answer the patient call bells, Feed the patients, escort the patients to the different areas and give assistance to the patient. The letter R in the nursing work program is for the takeover if any of the License Practical Nurse did not show up at the next shift. I can use the Rehab Nursing Technicians as a floating " .

1. On 08/18/16 at 3:45 pm during the review of documents provided by Human Resource director (employee # 8) and two credential files Rehab Nursing Technicians (RNT# 1) and (RNT# 2), it was determined that the facility failed to ensure that the personnel who provide clinical interventions comply with the State Law Num. 254 of December 31, 2015 which regulates the nursing practice in Puerto Rico. The Rehab Nursing Technicians or Certified Nursing Assistance (CRN) are not contemplated in the Puerto Rico state law and did not have a valid certification or license for Puerto Rico.

Based on the review of documents and the admission packet, it was determined that the facility failed to ensure that patient's rights are promoted regarding complete disclosure in the admission packet related to whom they have to contact to file a grievance.

Findings include:

Admission packet that each patient receives during admission was reviewed on 8/17/16 at 8:50 am, it was identified that updated information of the phone number and address for lodging a grievance with the State agency and the Medicare hot line was not included.

Based on review of abuse and neglect protocol and interview with the administrator (employee #1), it was determinate that the facility failed to ensure that the results of abuse investigations must be reported to the administrator and to the State survey and certification agency within 5 working days of the incident.

Findings include:

1. During the review of the Policy and procedure of abuse, neglect and sexual harassment prevention on 8/17/16 at 9:00 am it was found that:

a. The policy establishes in the section Investigation and report, that the investigation of violation allegation that was subtended are to be notified to the Human Resource Department. If the employee where removed the Directors Board notified the Examining Board or Tribunal Examining. However it does not establish a time frame to notify all pertinent agencies.

b. The facility failed to ensure that all compliance of abuse and neglect investigation be notified to the state survey within 5 working days of the incident.

Based on records reviewed (R.R) and Policies and Procedures and interview, it was determined that the facility failed to ensure that peritoneal dialysis assessment and management are performed for patients receiving peritoneal dialysis in the facility for 1out of 53 record reviewed (R.R #52).

Findings include:

1. A mechanism to ensure peritoneal dialysis protocols and tools by which peritoneal dialysis is performed in a hospital was not promoted, nor followed according with the following findings discussed with the Manage Case employee #12 and Infection control coordinator (employee #5) on 8/17/16 at 9:30 am:

a. R.R #52 is a 64 years old female admitted on 07/06/16 with Neurological conditions as reviewed on 8/18/16 at 9:00 am. The patient was discharge on 7/16/2016 from the hospital. The patient is an End Stage Renal disease patient and she receives peritoneal dialysis. The patient was receiving care and rehabilitation at the facility and the hospital did not coordinate before accepting the patient with a facility that will provide peritoneal dialysis. The patients was discharge from the Hospital on 7/5/2016 and admitted to the rehabilitation hospital on 7/6/16 no evidence was found of conversation or coordination performed with the patients end stage renal disease facility for the service to be received in the rehabilitation hospital. The patient's caregiver brought the patients peritoneal dialysis machine and the patient ' s sister connected and disconnect the patient from the machine. However no documentation was found about assessment performed before and after the treatment.

The employee #12 was asked on 8/18/16 at 9:51 am that in case of admission to patients with peritoneal dialysis, what kind of orientation the patient and the caregiver received by them. She stated " there is not any orientation provided by the social workers and also this area does not have any integration with the dialysis center. We just call the renal center when there hemodialysis patients but not when we admit a peritoneal dialysis patient " .

The Infection control coordinator (employee #5) was asked on 8/21/12 at 9:30 am if nursing personnel performed the peritoneal dialysis assessment and management daily and where they documented the information and she stated " Nursing staff do not have protocols for assessment and management of the peritoneal dialysis with machine. Also the facility does not have protocol for infection control for patients with peritoneal dialysis staying in the isolation room " .

2. R.R. #42 is an 88 year old female admitted on 8/15/16 with a diagnosis of Left hip replacement. Accordance to the record review performed on 8/17/16 at 11:15 am, on 8/15/16 at 8:30 am an infectology consult was place and the patient was evaluate by the infectologist on 8/6/17 at 10:00 am and recommended and order Contact isolation, Acyclovir 800 milligram (mg) per mouth (PO) every 6 hour and activated the isolation Protocol due to Herpes Zoster.

However, no evidence was found on the nurse ' s note of patient and relative orientation related to the contact isolation measure.

During interview with the patient on 8/17/16 at 11:30 am patient state that the nurse said to her that she was going to be move to a better room but did not said why.

3. R.R. #44 is a 74 year old female admitted on 8/12/16 with a diagnosis of Cerebro Vascular Accident (CVA). Accordance to the record review performed on 8/17/16 at 1:30 am, on 8/12/16 at 10:07 pm an Abdominal wound culture was performance, Laboratory report the result on 8/16/16 at 12:40 pm with Methicillin-resistant Staphylococcus Aureus (MRSA) and be notified to the registered nurse.

On 8/16/16 at 12:40 pm the physician place an order for Infectology consult and the patient was evaluate by the infectologist on 8/16/16 at 2:00 pm. The infectology recommended and ordered place on Contact isolation started on Septra DS 2 tablets PO twice daily (BID) and performance a Nasal culture for MRSA.

The registered Nurses note performed on 8/16/16 at 12:40 pm reveal that patient physician was notified related to positive culture to MRSA, however no evidence was found in the nurse note related to patient and family orientation related to contact isolation measure and culture result.

4. No evidence was found in patient medical record related to patient participates in the development and implementation of her plan of care about isolation.


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Based on record reviewed (R.R), it was determined that the facility failed to ensure that patients participate in the implementation of care plans and physician recommendations of care plans for 3 out of 53 patients records reviewed for patient's rights (R.R #42, #44 and #52).

Findings include:

1. During the record review performed on 8/17/16 at 8:45 am the (R.R #52) evidence about educations being given to the patient and her relative about infection control inside the isolation room and the assessment and management of the peritoneal dialysis and machine during the patient ' s stay at the hospital.

Based on record review of fifty two, interview and documents, it was determined that the facility failed to ensure that assessment care planning and monitoring of patients' needs are met in order to prevent situations which might lead to lack of coordination in the management and care of patients who receive care in this facility for 2 out of 53 records reviewed (R.R #31 and #52).

Findings include:

1. R.R #52 is a 64 years old female admitted on 07/06/16 with Neurological conditions as reviewed on 8/18/16 at 9:00 am. The patient was discharge on 8/6/2016 from the hospital. The patient is an End Stage Renal disease patient and she receives Peritoneal Dialysis (PD). During the record review the following was found:

a. The medical record did not include documentation related to the PD like time of start of the dialysis, duration of the dialysis, the facility who is giving the service of PD, model of the machine that the patient uses.

b. No documentation was found on nurse's notes related with the patient ' s dialysis and care of the patient after she was connect or disconnect to the machine by her sister.

c. No nursing documentation was found related to the status of the patient after being moved to the isolation room with her dialysis machine. No documentation was found about the disinfection of the machine before and after having been inside the isolation room. (Cross reference Tag 0749)

d. A physician order dated 7/7/2016 at 10:00 am was found and indicates Peritoneal Dialysis 7:00 am 2000cc 2.5%, 11:00am 2000cc 1.5%, 3:00pm 2000 cc 2.5%, 7:00 pm 2000 cc 2.5%, 11:00 pm 2000 CC 1.5% no more information or nurse notes was found about the solution and the hours of dialysis.

e. No vital signs were found on the nursing progress notes documented before and after the treatment.

f. The patient was discharged home on 7/16/16 at 1:00 pm, however no nursing documentation was found related to the exact hour that the patient left the hospital or special instructions given to the patient during the discharge process.

g. Assessments and care of this patient with special needs based on her condition was not promoted, not followed nor performed. This record was reviewed and discussed with the Director of Nursing on 8/18/16 at 2:15 pm and Infection control coordinator and they stated and showed facility protocols developed in order to offer care and manage patients with dialysis peritoneal. However, these policies were not operationalized during the management of this patient. (Cross reference Tag A0749)

h. Review of the record provided evidence that this patient was recuperating from a surgical procedure and received physical therapy and she is a peritoneal dialysis patient, however no evidence was found of nursing care received in accordance with her special needs, if the patient is received nursing care it was not documented or evidenced in the medical record.

i. The facility failed to ensure that required nursing care and monitoring of patient's with specific needs are provided by nursing personnel for patients known with special needs for dialysis treatments and coordination of services.

Based on review of the Quality assessment and performance improvement program documents accompanied by the facility's quality assessment officer (employee #2), and interview with patients it was determined that the facility failed to consider all aspects of patient satisfaction surveys comments and related information to assess and improve processes of care, hospital service and operations.

Findings include:
1. A mechanism to ensure that facility performs and insightful analysis of patient satisfaction surveys comments to determine improvement need were not promoted. The following was identified during survey procedures 08/16/16 through 08/18/16 from 8:30 am through 3:30 pm:
a. Facility perform patient satisfaction surveys on monthly basis January/2016, February /2016, March/2016, April/2016, May/2016 and June/2016 in order to identify patient's perspective with care and services offered while receiving treatment for rehabilitation. Review of patient satisfaction surveys comments and related information evidence that they identify improvement needs or special attention on the cleanliness, dietary services and direct care offered by nursing personnel.
b. Facility's quality assessment officer (employee # 2), stated on 8/17/16 at 10:55 am that the patient satisfaction surveys comments and related information are discussed on committee meetings and informed to the administration on an ongoing basis. She stated that plans of action based on patient satisfaction surveys comments and related information were prepared by infection control services, dietary services and nursing services since January /2016 when patients and relatives begin to refer improvement needs on those areas. However improvement on those areas are not attained as expected by facility administration and related services.
c. Quality assurance activities and plans developed and implemented to improve cleanliness, dietary services and direct care offered by nursing personnel are implemented however failed to improve the efficiency and effectiveness of those services since the perspective of the patient experience while in the facility receiving services.


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2. A mechanism to ensure that facility nursing services answers the room calls and that the dietary services delivers the food in the proper temperature was not followed.
a. The RR #40 stated during interview performed on 8/17/16 at 10:20 am, the following: "The food comes late and cold, and the menu it is the same".
b. The RR #49 stated during interview performed on 8/17/16 at 11:30 am, the following: " The nursing service is slow, when you call to the counter for nursing assistance they say " I will be there in a second " they take too much time to send someone. "

Based on the review of nineteen medical staff credential files, it was determined that the facility failed to examine credential files (C.F) to ensure that medical staff have updated Health Certificates, Cardio-pulmonary Resuscitation Certificates (CPR), Hepatitis B vaccines and Influenza Vaccine for 15 out of 19 C.Fs (C.F #1, #2, #3, #5, #7, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19).

Findings include:

1. During the review of nineteen medical staff credential files on 8/16/16 from 1:30 p. m. till 2:00 p. m. the following was found:

a. One out of nineteen medical staff's credential files provided evidence of expired Health Certificates (C.F #5 (from 4/2016).

b. One out of nine-teen medical staff's credential files did not have evidence of CPR.

c. Five out of nine-teen medical staff's credential files did not have evidence of their hepatitis profiles or responsibility exoneration (C.Fs #1, #3, #10, #12, #13, #14, #15, #16, #17 and #19 ).

d. Eleven out of nineteen medical staff's credential files did not have evidence of their updated Influenza Vaccine or exoneration (C.F #2, #5, #7, #10, #11, #14, #15, #16, #17, #18 and #19).

h. During the policies/procedures reviewed and interview with Infection control coordinator employee #5 and Director of nursing employee #10 performed on 8/18/16 at 9:00 it was found that the facility do not have policies and procedure for the use peritoneal dialysis with the patients machine. The policy and procedure provide was a protocol manual dialysis only.
Interview with employee # 10 on 8/18/16 at 10:15 am reveals that the facility does not have a protocol to perform the peritoneal dialysis with machines. She refers that nurses were trained to give peritoneal dialysis manually. Each nurse has to record the interventions in the clinical record.
No evidence about competency to the personnel for this modality was found.


36632


Based on the review of the nursing administrative manual with the Director of Nursing (DON) (employee #10), it was found that the facility failed to ensure that nursing administrative manual is updated.

Findings include:
1. During the nursing administrative manual review on 8/18/16 at 2:30 pm it was found that the facility failed to have a mechanism to maintain the following policies updated and approved.
a. During the policy review for: Institutional Policy for room change, failed to have evidence of an updated policy revision date.
b. During the policy review for: The In the absence of the Nursing Director, it have a designated space to name the committee that approved this policy, however it was left in blank.
c. During the policy review for: The Patient Classification System, it have a designated space to name the committee that approved this policy, however it was left in blank.
d. During the policy review for: The Requirement for Recruitment and Retention for Nursing Personnel, it have a designated space to name the committee that approved this policy, however it was left in blank.
e. During the policy review for: The Competency of Nursing Personnel, the form has a designated space to name the committee that approved this policy; however it was left in blank.
f. During the policy review for: The Verification of the Emergency Cart, it have a designated space to name the committee that approved this policy, however it was left in blank..
g. During the policy review for: Usage of the Speaker System, it have a designated space to name the committee that approved this policy, the revision date, and next revision date, however there were left in blank

Based on observations perform on the rehabilitation ward, discussion with Director of Nursing (employee #10), and interview with patients it was determined that the facility failed to ensure nursing care and services as provided to patients as needed.

Findings include:
1. A mechanism to assure that there are supervisory and staff personnel for each nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient were not promoted. The following was identified during survey procedures 08/16/16 through 08/18/16 from 8:30 am through 3:30 pm:

a. On 8/17/16 at 9:54 am it was observed three register nurses documenting on the nurses station located on the rehabilitation ward on the second floor. It was observed that the nurses call system receive calls who are answering on the nurses station by the ward clerk. When the ward clerk answer to the patient via intercom she report to one rehabilitation assistant instead of refer the situation to the nurse for whom are assigned the patient, who was in charge of the area (room ) were the patient made the call.

b. On the monthly patient satisfaction surveys from January/2016,February /2016,March/2016,April/2016,May/2016 and June/2016, patients surveyed comments and related information evidence that them identify improvement needs and suggests that special attention are required to the services offered by nursing personnel. In many instances patients comments are related with the delay of attention to them when use the call system to request assistance. As observed on 8/17/16 at 9:54 am no supervisory rounds or evaluation are perfomed to assure immediate availability of a registered nurse for bedside care of any patient. Nurse responsiveness to the nurse call or how often patients or family visitors who had unmet needs and require assistance received; was not observed assessed.


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2. A mechanism to ensure that facility nursing services answers the nurses calls and that the dietary services delivers the food in the proper temperature.
a. The RR #40 stated during interview performed on 8/17/16 at 10:20 am, the following: "The food comes late and cold, and the menu it is the same".
b. The RR #49 stated during interview performed on 8/17/16 at 11:30 am, the following: " The nursing service is slow, when you call to the counter for nursing assistance they say " I will be there in a second " they take too much time to send someone. "
3. It was observed on 8/17/16 at 9:47 am that the license practical nurse (LPN) (employee #19) discards the content of the urine collector; however no evidence was found of the measure of the patient' s liquid output on the RR #53.
The LPN (employee #19) stated during interview performed on 8/18/16 at 2:00 pm, the following: "I did not document or notify to the registered nurse in charge the liquid output " .
The Director of nursing (employee #10) stated during interview performed on 8/18/16 at 2:05 pm, "The practical nursing personnel must document output every time that they discard or dispose the content of the urine collector. We document the output of our entire census. "
4. It was observed on 8/17/16 at 11:32 am that the rehab technician discarded the content of the urine collector; however no evidence was found of the measure of the patient ' s liquid output on the RR #49.
The Director of nursing (employee #10) stated during interview performed on 8/18/16 at 2:05 pm, " The rehab personnel can discard or dispose the urine from the collector but must notify the LPN and they must document. Any authorize personnel that performs an intervention with the patient must document or notify, so the authorize personnel document".
5. It was observed on 8/17/16 at 10:20 am that the LPN (employee #16) performed an ulcer care to RR #40. The LPN did not know how to classify an ulcer.
The LPN (employee #16) stated during interview performed on 8/17/16 at 10:30 am, " it would be better if someone with more knowledge or specialized in wound care provided this service, someone that knows the terminology of ulcer care and classification. "
6. It was observed on 8/17/16 at 10:37 am that the LPN (employee #16) performed a central line care to RR #40. The central line is located in the sub-clavia vein.
According to review of the facility policies and procedures manual on 8/17/16 at 1:15 pm this procedure is establish as a Registered Nurse (RN) procedure. In the review of the Basic Duties and Responsibilities of the LPN states the following in item #2.1 Manage this treatments with the BSN/AND orientation: Vital signs, intake/output, urine/fecal collection, weight, elimination, alimentation, application/removal of simple splints, ulcer/wound care, intermittent catheterization, and one on one supervision.
However it does not include the central line care. No evidence was found of the central line care orientation and competence with the Director of Nursing (employee #10), Nursing educator (employee #15), Nursing Supervisor (employee #26), and the Wound Care Nurse (employee #28).

Based on the review of clinical records and policies/procedures, it was found that the facility failed to ensure that 1 out of 53 records reviewed R. R (R.R. #52) have developed updated and implemented nursing care plans.

Findings include:

1. One out of fifty-three records reviewed for care plans development and implementation for patients according to the patient's needs provided evidence that care plans do not have written evidence of developed, updated, revisions and are implemented during the patients' hospital stay related to their needs:

a. R.R #52 is a 64 years old female who was admitted on 07/06/16 with a diagnosis of Neurological conditions. During the record review performed on 8/18/16 at 9:00 am no evidence was found that the registered nurse developed and implemented the plan of care for the patient according to the patient's needs of peritoneal dialysis.

5. A mechanism to ensure that paper-based medical record are maintained in good condition and is legible was not promoted accordingly with the following findings identified during survey procedures 08/16/16 through 08/18/16 from 8:30 am through 3:30 pm:
a. Eleven medical records were review as part of the evaluation of appropriateness of services offered by rehabilitation services and respiratory therapy, all of the records were observed in poor condition pages were ripped out, wrinkled and torn.

b. Five medical records were review as part of the evaluation of appropriateness of services offered by respiratory therapy department. For the Respiratory Care Clinic Assessment clinicians used a template with very tiny letters, who was illegible.





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Based on observations, review of close and open clinical records during the survey performed from 08/16/16 from 08/18/16 from 8:30 am through 3:30 pm during survey procedures, it was determined that the facility failed to ensure that medical records are maintain in good condition, accurately written and legible for 4 out of 53 records reviewed (RR) (RR #6, #29, #32 to #52)

Findings include:

1. RR #6 was reviewed on 8/16/16 patient with 80 years old female who was admitted post status post fall with resulting right intertrochantheric fracture and status post intramedullary nailing. The record was reviewed and provide evidence that the identification label of the two pages of ' ' Consultation ' ' performed on 5/29/16 at 7:13 p. m. per the physician (employee #36) did not correspond to this patient it corresponded to another patient admitted on 5/25/16. The first and the second pages were identified with a label of another patient however the information related to the consult corresponded to this patient. The second page of this consulting was performed by the physician (employee #36) and lacks of the physician signature, the date and the hour when performed the consult.

During the record review it was found additional situation related to the identification label the form used by the facility personnel to identified the '' Intergumentary System '' not corresponding to this patient the label corresponded to another patient admitted on 5/23/16 with other record number and other name. This form was signed per the register nurse on 5/23/16 however the nurse signature and the license number were illegible.

2. RR #29 was reviewed on 8/16/16 patient with 54 years old male who was admitted on 6/3/16 with diagnose of Right TKR Secondary Severe Right Knee. The record was reviewed and provides evidence that the identification label of this patient has a same medical record number of the patient #11 admitted on the same date with diagnosis of Left Femoral Neck Fracture.
The Medical Record Supervisor (employee #37) was interview at 10:30 a. m. related to this situation the information was reviewed on the system and provide evidence that the patient #11 and patient #29 of the surveyor patient roster according of the ''Face sheet form'' was admitted the same date on 6/3/16. The face sheet form of both patients revealed the correct medical number. However the patient #29 was discharge on 6/4/16 and was admitted again on 6/9/16.
The Director of the Admission Department (employee #7) was interview at 10:35 a. m related to this situation and she stated: '' All the information is enter manually and an error could have occur or the person that enter the information in the system could have made an error " '
3. RR #32 was reviewed on 8/16/16 patient with 85 years old male who was admitted on 09/12/15 due to a diagnose of Right Femur Intertrochanteric Pathologic Fracture, Status post- intramedullary nailing. The record was reviewed and no evidence of progress notes for 9/22/15, 9/28/15, 9/30/15 and 10/2/15.
The record was reviewed and provide evidence that the patient was admitted on 9/21/15 and discharge on 10/6/15 the daily Vital Signs register log revealed that the patient practical nurse did not weight the patient on admission and on weekly according of the policy and procedure reviewed on April 2016 of the agency that established '' All patient admitted at Health South Rehabilitation Hospital are weighted initially during the 48 hours of admission and then every week on Tuesday.

On progress note performed by the same physician (employee #34) on 9/24/15 on the '' Assessment the written by physician reads '' This is an 85 year old male with a right femur intertrochanteric pathologic fracture, status post intramedullary nailing.'' The team conference note provides evidence of the plan of treatment ordered to the patient during the rehabilitation program.

On progress note performed by the same physician (employee #34) on 9/25/15 on the '' Assessment the physician wrote '' This is a 46 year old male, status post left middle cerebral artery ischemic cerebral vascular accident, embolic.''

On progress note performed by the same physician (employee #34) on 9/27/15 on the '' Assessment the physician wrote '' This is an 80 year old male, status post left middle cerebral artery ischemic cerebral vascular accident, embolic.''

According of the consultation performed on 9/22/15 by the physician (employee #34) provide evidence that the patient has 85 years old and was admitted on 9/21/15 with a history of metastatic prostate cancer to the bone diagnosed with a right femur intertrochanteric pathological fracture status post intramedullary nailing on September 18/2015 and was admitted to received rehabilitation services.


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4. During the record review #52 performed on 8/18/16 at 9:00 am it was found a note with red ink on the treatment patient card. The note written on 07/12/2016 indicated (Register Personnel: Peritoneal dialysis 9:00 pm. Before: perform a blood sugar test with dextrostick (a quick test for glucose level) and took the vital signs. She must be bathed and changed diaper.
Interview with employee #10 (Director of nursing) on 8/18/16 at 1:30 pm reveals that she wrote the note with red ink and cited " I used that ink color to attract attention of nurses.
Interview with employee #6 on 8/18/16 at 11:20 am stated that all written documentation has to be with black ink.
Review of the policy/procedures on 8/18/16 at 11:25 am indicates on the " General Standard Documentation " in subsection h (Not allowed to use different ink pen, black ink only is allowed).

Based on closed and active clinical records reviewed (R.R), it was determined that the facility failed to ensure that the patient medical records contain complete information and documentation regarding to consults, nurses notes, physician progress notes, physician's orders included telephone order's, vital signs and physician discharge summary evaluation and other information and documents in the patient medical record that are not accessible for 19 out of 53 records reviewed (R.R #1, #2, #4, #6, #10, #11, #12, #13, #14, #15, #17, #20, #22, #23, #24, #25, #28, #32 and #39 ).

Findings included:

During performed the thirty two out of fifty three clinical records reviewed (R.R #1 through #32) reviewed during the survey performed from 08/16/16 from 08/18/16 from 8:00 am till 3:30 pm did not contain complete information and documentation related to consults, nurses notes, physician progress notes, physician's orders included telephone order's, vital signs and physician discharge summary evaluation and other information and documents in the patient medical record that are not accessible.

1. RR #1 was reviewed on 8/16/16 patient with 94 years old female who was admitted on 10/08/15 due to a diagnose of Right Hip Fracture, no evidence of a physician discharge progress note of 10/20/15. The treatment kardex for 10/08/15 provide evidence that the patient want the '' Influenza Vaccine '' and the nurse wrote '' pending '' however the patient stay at the hospital per 12 days and discharged home on 10/20/15 and no evidence if the Influenza Vaccine was administered before discharge.
2. RR #2 was reviewed on 8/16/16 patient with 92 years old female who was admitted on 9/29/15 due to a diagnose of Left ITT. The record was reviewed and no evidence of progress notes for 10/02/15, 10/05/15, 10/07/15, 10/09/15 and 10/12/15.

3. RR #4 was reviewed on 8/16/16 patient with 92 years old male who was admitted on 8/6/15 due to a diagnose of Left TKR Gait Dysfunction. The record was reviewed and provide evidence that the patient was admitted on 8/6/15 the daily Vital Signs register log revealed that the patients ' practical nurse did not weight the patient on admission and weekly according of the policy and procedure reviewed on April 2016 of the agency that established '' All patient admitted at Health South Rehabilitation Hospital is weighted initially 48 hours of admission and then every week on Tuesday '' however the daily Vital Signs register log revealed that the nurse weighted the patient on 8/11/15 at 4:00 p.m. and no evidence or other weight during the patient stay at the hospital.

On 8/6/15 at 3:00 p. m. the register nurse (employee #22) wrote '' Se entrega aseo personal al siguiente turno 3:00 p.m. to 11:00 p.m. '' The nurse note of shift 3:00 p.m. to 11:00 p.m. revealed that the patient did not received the bath because the nurse only wrote '' Patient was received on bed with side rails up, alert with good respiratory pattern at this moment no complaints of pain, vital signs stable, observed for changes.'' The facility policy and procedure for '' Bath on bed or shower '' reviewed on April 2016 provide evidence that the patient has the opportunity to received the bath on bed or shower and the patient choose the hour of preference when the nurse performs the admission. ''

4. RR #6 was reviewed on 8/16/16 patient with 80 years old female who was admitted post status post fall with resulting right intertrochantheric fracture and status post intramedullary nailing. The record was reviewed and provide evidence that the identification label of the two pages of ' ' Consultation ' ' performed on 5/29/16 at 7:13 p. m. per the physician (employee #36) did not belong to this patient it correspond to another patient admitted on 5/25/16. The first and the second pages were identified with a label of another patient however the information related to the consult corresponding to this patient. The second page of this consulting was performed by the physician (employee #36) and lacks of the physician signature, the date and the hour when performed the consult.

During the record review it was detected additional situation related to the identification label, the form used by the facility personnel to identified the '' Intergumentary System '' not corresponding to this patient the label correspond to another patient admitted on 5/23/16 with other record number and another name. This form was signed by the register nurse on 5/23/16 however the nurse signature and the license number were illegible.

5. RR #10 was reviewed on 8/16/16 patient with 62 years old male who was admitted on 5/3/16 due to a diagnose of Fracture of Left Femur. The record was reviewed and no evidence of progress notes for 5/10/16. No evidence of nurses notes for 5/6/16 and 5/7/16 on shift 7:00 a.m. till 3:00 p.m. and 5/11/16 on shift 11:00 p.m. till 7:00 a.m.

6. RR #11 was reviewed on 8/16/16 patient with 93 years old male who was admitted on 11/13/15 due to a diagnose of Left Femoral Neck Fracture. The daily registry of vital signs did not provide evidence of the patient weight on the admission only provide evidence of patient weight on 11/18/15 at 8:00 a.m. six days later.

The form designated to identify the intergumentary system lacks of the date and the hour when the register nurse performed the intergumentary assessment.

The skin local care note performed by the practical nurse on 11/14/15, 11/18/15 and 11/19/15 lacks of the register nurse signature and the license number.

No evidence of nurse note on 11/14/15 on shift 7:00 a.m. till 3:00 p.m. and 3::00 p.m. till 11:00 p.m.

7. RR #12 was reviewed on 8/16/16 patient with 71 years old male who was admitted on 8/12/15 due to a diagnose of Status post Lumbar Surgery. The record was reviewed and no evidence of nurses notes for 8/13/15, 8/14/15, 8/15/15, 8/16/15 and 8/17/15.

8. RR #13 was reviewed on 08/16/16 at 10:05 a. m. case of 74 years old female who was admitted on 11/06/15 due to a diagnose of Right Knee Osteoarthritis, it was found that the following order '' Transfer to HIMA Hospital '' on 11/9/15 at 6:00 however the order lacks to specify if a.m. or p.m. was signed by the physician however not taken by the register nurse.

9. RR #14 was reviewed on 8/16/16 patient with 77 years old female who was admitted on 9/5/15 due to a diagnose of Disease Myophaty. The record was reviewed and no evidence of progress notes for 09/06/15. No evidence of vital signs on shift 7:00 a.m. till 3:00 p.m. on the daily registry of vital signs for 9/10/15.

On the nurse note performed on 9/7/15 at 3:00 pm provides evidence on two lines written by the register nurse '' Entrega aseo personal turno 3:00 p.m. till 11:00 p.m. however no evidence on nurse note of shift 3:00 p.m. to 11:00 p.m. if the patient received the personal bath because the nurse note lacks of this information.

10. RR #15 was reviewed on 8/16/16 patient with 62 years old male who was admitted on 3/14/16 due to a diagnose of Status post Left Above Knee Amputation. The record was reviewed and no evidence of the date and the hour on five progress notes performed by the Endocrinology.
11. RR #17 was reviewed on 8/16/16 patient with 85 years old male who was admitted on 12/09/15 due to a diagnose of Unspecified Myophaty. The record was reviewed and no evidence of progress notes for 12/13/15 and 12/16/15. The daily registry of vital signs did not provide evidence of the patient weight on the admission only provide evidence of patient weight on 12/15/15 six days later.

No evidence of nurses notes for 12/11/15, 12/14/15, 12/15/15, 12/16/15, 12/16/15, 12/17/15, 12/18/15, 12/19/15 and 12/21/15 on shift 7:00 am till 3:00 p.m. On 12/12/15 the nurse note provide evidence that the patient has respiratory problems however no evidence of nurse intervention or when notified the physician related to the patient complaint and no evidence on the nurse note when the nurse reevaluated the patient. On 12/13/15 at 2:45 (the hour lacks if a.m or p.m.) the physician ordered by telephone Carafate 10 ml. p.o. stat per one dose and no evidence of when the nurse administered the medication and no evidence of the re-assessment.

12. RR #20 was reviewed on 8/16/16 patient with 82 years old male who was admitted on 4/15/16 due to a diagnose of Myopathy Unspecofied. The record was reviewed and no evidence of progress notes for 4/17/16 and 4/22/16. No evidence of the nursing daily assessment on 4/18/16. No evidence of the date and hour when the physician request a consult.
13. RR #22 was reviewed on 8/16/16 patient with 82 years old male who was admitted on 01/29/16 due to a diagnose of Right TKR due to DJD. The record was reviewed and no evidence of nurses notes for 1/30/16, 2/2/16, 2/3/16 and 2/4/16 on shift 7:00 a.m. till 3:00 p.m.
The skin local care note performed by the practical nurse on 1/31/16 lacks of the hour when the practical nurse performed the local care and the register nurse signature and license number.

14. RR #23 was reviewed on 8/16/16 patient with 68 years old female who was admitted on 2/16/16 due to a diagnose of Left TKR. The record was reviewed and no evidence of the date and the hour on two progress notes performed by the Endocrinology.
The skin local care notes performed by the practical nurse on 2/19/16 at 4:00 p.m., 2/24/16 at 2:00 p. m and on 2/22/16 ,lacks of the hour when the practical nurse performed the local care, lacks of the register nurse signature and the license number.

No evidence of physician progress notes on 2/21/16, 2/22/16 and 2/24/16.

15. RR #24 was reviewed on 8/16/16 patient with 6 years old female who was admitted on 7/21/15 due to a diagnose of Right Hip Suthrosotheric Fracture. The record was reviewed and no evidence of progress notes on 7/26/15.
No evidence of nurses notes on 7/23/15 and 7/24/15.
16. RR #25 was reviewed on 8/16/16 patient with 85 years old male who was admitted on 6/23/15 due to a diagnose of Right ITT with Subtrochanteric Extension. The record was reviewed and no evidence of progress notes for 6/27/15 and 6/29/15.

17. RR #28 was reviewed on 8/16/16 patient with 70 years old male who was admitted on 7/26/16 due to a diagnose of Acute Unspecified Myopathy. The record was reviewed and no evidence of progress notes for 7/30/16 and 8/4/16.

18. RR #32 was reviewed on 8/16/16 patient with 85 years old male who was admitted on 09/12/15 due to a diagnose of Right Femur Intertrochanteric Pathologic Fracture, Status post- intramedullary nailing. The record was reviewed and no evidence of progress notes for 9/22/15, 9/28/15, 9/30/15 and 10/2/15.
The record was reviewed and provide evidence that the patient was admitted on 9/21/15 and discharge on 10/6/15 the daily Vital Signs register log revealed that the patient practical nurse did not weight the patient on admission and weekly according of the policy and procedure reviewed on April 2016 of the agency that established '' All patient admitted at Health South Rehabilitation Hospital will be weighted initially on the 48 hours of admission and then every week on Tuesday.

On progress note performed by the same physician (employee #34) on 9/24/15 on the '' Assessment the physician wrote '' This is a 85 year old male with a right femur intertrochanteric pathologic fracture, status post intramedullary nailing.'' The team conference note provides evidence of the plan of treatment ordered to the patient during the rehabilitation program.

On progress note performed by the same physician (employee #34) on 9/25/15 on the '' Assessment the physician wrote '' This is a 46 year old male, status post left middle cerebral artery ischemic cerebral vascular accident, embolic.''

On progress note performed by the same physician (employee #34) on 9/27/15 on the '' Assessment the physician wrote '' This is an 80 year old male, status post left middle cerebral artery ischemic cerebral vascular accident, embolic.''

According of the consultation performed on 9/22/15 by the physician (employee #34) provide evidence that the patient has 85 years old and was admitted on 9/21/15 with a history of metastatic prostate cancer to the bone diagnosed with a right femur intertrochanteric pathological fracture status post intramedullary nailing on September 18/2015 and was admitted to received rehabilitation services.

The skin local care note performed by the practical nurse on 9/22/15 lacks of the hour when the practical nurse performed the local care and the register nurse signature and the license number.

The skin local care note performed by the practical nurse on 9/24/15, 9/25/15, 9/26/15, 10/2/15, 10/3/15, 10/4/15 and 10/6/15 lacks of the register nurse signature and the license number.

The skin local care note performed by the practical nurse on 9/26/15 and 9/27/15 lacks of the hour when the practical nurse performed the local care.

The skin local care note performed by the practical nurse on 9/29/15 lacks of the hour when the practical nurse performed the local care and the practical and register nurse signature and the license number.

The skin local care note performed by the practical nurse on 9/30/15 at 8:00 a. m. and 10/1/15 at 9:00 a.m. lacks of the practical and register nurse signature and the license number.


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19. During RR #39 performed on 08/16/16 at 10:50 pm, an 35 years old male who was admitted on 07/29/16 due to a diagnose of Cerebrovascular Accident (CVA), it was found that the Registry of Vital Signs lacks of the signature of the practical nurse (LPN) on the 8/8/16 8:00 am vitals that were documented.
During RR #39 performed on 08/16/16 at 10:50 pm, an 35 years old male who was admitted on 07/29/16 due to a diagnose of Cerebrovascular Accident (CVA), it was found that the progress note form 7/31/16 and 8/7/16 were not properly authenticated, there is no signature of the physician (employee #31).

8. RR #13 was reviewed on 08/16/16 at 10:05 a. m. case of 74 years old female who was admitted on 11/06/15 due to a diagnose of Right Knee Ostheoarthritis, it was found that the following order '' Transfer to HIMA Hospital '' on 11/9/15 at 6:00 however the order lacks hour specify if a.m or p.m ,was signed by the physician however not taken by the register nurse.

9. RR #17 was reviewed on 08/16/16 at 9:45 a. m. case of 85 years old male who was admitted on 12/09/15 due to a diagnose of Unspecified Myophaty, it was found that the following telephone order were countersigned by the prescribing physician within the first twenty-four hours after the telephone order was taken by the register nurse however no evidence of the read back per R.N. on 12/13/15 at 2:45 ( the nurse did not specified if a.m or p. m.)

a. Order from 12/13/15 at 2:45 '' Carafate 10 ml. p.o. stat per one taken by and no evidence of read back per R.N.

b. Order from 12/10/15 at 3:30 (the nurse did not specified if a.m. or p. m.)
'' Mom 30 ml. p.o. stat per one, Mineral oil 30 ml. p.o. stat per one, Dulcolax 10 mgs. Supp rectally stat per one, order was taken and reviewed by register nurse on 12/10/15 at 3:30 p.m. '' however the order lacks of who is the nurse that read back the order.

10. RR #18 was reviewed on 08/16/16 at 9:55 a. m. case of 79 years old female who was admitted on 03/24/16 due to a diagnose of Unspecified Myophaty, it was found that the following telephone order was prescribing by the physician on 3/29/16 at 6:20 (the order did not specified if a.m. or p.m.) to administer ''Acetaminophen 500 mgs. 2 tablets p.o. now'' the order did not provide the name of the physician who ordered the medication, was taken by the register nurse however it provide evidence of the read back per R.N. and near the order read ''omit '' and two vertical lines was observed above of the order however the order was not signed by the nurse.

11. RR #31 was reviewed on 8/16/16 at 9:10 a. m. case of 46 years old male who was admitted on 8/6/16 due to a diagnose of Critical Illness Neuropathy, it was found that the following telephone order were countersigned by the prescribing physician within the first twenty-four hours after the telephone order however lacks of the date when the physician signed the order.

12. RR #32 was reviewed on 08/16/16 at 9:20 a. m. case of 85 years old male who was admitted on 09/21/15 due to a diagnose of Right Femur Intertrochanteric Pathological Fracture, it was found that the following telephone order were countersigned by the prescribing physician within the first twenty-four hours after the telephone order however lacks of the hour when the physician signed the order.

a. Order from 10/04/15 9:30 a. m. '' Discontinue Guaifenisin with Codein 5 ml. p.o. every 8 hours, Phenergan with Codein 5 ml. p.o. every 8 hours p.r.n. order was taken and read back per R.N. (employee #24) on 10/4/15 at 9:30 a. m.


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Based on a recertification survey, review of policies and procedures (p&p's), six clinical records review(RR) for nursing services performed on 08/16/16 - 08/18/16 and interview with the Director of Nursing (employee #10), it was determined that the facility failed to ensure that the clinical records are countersigned by the physician within the first twenty-four hours after the telephone order is issued, as observed in 9 out of 53 records reviewed. (RR #13, #17, #18, #31, #32, #39, #40, #42, and #43).

Findings include:

1. During RR performed on 08/16/16 - 08/18/16 10:18 am it was identified incomplete physician's orders as follow:

According to interview with the Director of nursing (employee #10) performed on 08/16/16 at 3:30 pm, she stated: "The incomplete physician's orders have to be signed as soon as possible, no more than 24 hours should pass without being countersigned".

2. RR #39 performed on 08/16/16 at 10:50 pm, a 35 years old male who was admitted on 07/29/16 with a diagnose of Cerebrovascular Accident (CVA), it was found that the following telephone orders were not countersigned by the prescribing physician within the first twenty-four hours after the telephone order is issued:

a. Order from 07/29/16 at 9:40 pm - Condom Foley.
b. Order from 07/30/16 at 8:30 am - Wound Care.
c. Order from 7/30/16 at 2:26 pm - Change diet order to: 1900 Kcal, mashed and ground, all liquids, 4mg nut 2:2:2:1, Abintra 1 packet Orally (PO) Daily and 7 ounces (oz.) water, pre-protein 20 grams (gm) 30mililiters (ml) PO Daily.
d. Order from7/31/16 at 8:00 am - Kerilotion apply in legs daily.
e. Order from 7/31/16 at 12:00 pm- Mattress air.
f. Order from 7/31/16 at 10:30 pm - Percocet 5/325 1 tablet (Tab) PO every 4 hours (hrs.) and as needed (PRN). Order from 8/02/16 9:50 am - Septra 2 tabs PO two times a day (BID), Intestinex 1 tab BID, Infectology consult.
g. Order from 8/02/16 at 9:50 am - Septra 2 tabs PO two times a day (BID), Intestinex 1 tab BID, Infectology consult.
h. Order from8/02/16 at 2:15 pm - Ensure plus 8 oz. PO three times a day (TID).
i. Order from 8/03/16 at 9:00 am - Percocet 1 tab PO every 4 hrs. and PRN.
j. Order from 8/03/16 at 4:00 pm - Acetaminophen 500 mg 2 tabs PO now (stat).
k. Order from 8/04/16 at 10:30 pm - Vancomicyn 1gm Intravenous (IV) every 12 hrs. Discontinue Septra 320mg IV every 8 hrs.
l. Order from 8/07/16 at 11:30 am - Difulcan 100mg 2 tabs PO stat then 1 tab PO Daily for 7 days. Triple antibiotic on glande PRN.
m. Order from 8/08/16 at 7:00 pm - Percocet 2 tabs PO every 6 hrs. and PRN.
n. Order from 8/09/16 at 12:40 pm - Discharge (D/C) Percocet 5/325mg, Nucynta 50mg 1 tab PO every 4 hrs. and consult with Joglor, Torano.
o. Order from 8/11/16 at 1:30 pm Nucynta 50mg 1 tab PO every 4 hrs.
p. Order from 8/11/16 at 4:24 pm - Change diet consistency to: Regular with previous dietary restrictions.
q. Order from 8/15/16 at 9:00 am - PT- Electrical Stimulation (EE) for quadriceps and dorsiflexion ' s in LE ' s.
r. Order from 8/15/16 at 2 pm - Nucynta 50mg 1 tab PO every 4 hrs.

3. RR #40 performed on 08/16/16 at 1:20 pm, an 64 years old female who was admitted on 8/05/16 due to a diagnose of Left Dominant Hemiplegia due to Ischemic Stroke, it was found that the following telephone orders were not countersigned by the prescribing physician within the first twenty-four hours after the telephone order is issued:

a. Order from 8/11/16 at 4:15pm - Carafate 10ml PO stat then BID.
b. Order from 8/11/16 at 10:35pm - Ultracet 1 tab PO every 8 hrs. and PRN
c. Order from 8/12/16 at 10:05am - Change diet order to: 1800Kcal mechanical soft and ground meat, diabetic, renal, 83gm protein, 81 milliequivalent (mEq) Sodium (Na+), 60mEq Potassium (K+), 1000ml fluids 2:1:2:1:2:1
4. RR #42 performed on 08/16/16 at 2:07 pm, an 88 years old female who was admitted on 8/15/16 due to a diagnose of left femoral neck fracture (FNF), it was found that the following telephone orders were not countersigned by the prescribing physician within the first twenty-four hours after the telephone order is issued:

a. Order from 8/15/16 8:30 am - Bladders scan every 6hrs. > 250 ICP, Infectology consult.

5. RR #43 performed on 08/16/16 at 2:21 pm, an 86 years old male who was admitted on 7/22/16 due to a diagnose of Neurocognitive deficits, it was found that the following telephone orders were not countersigned by the prescribing physician within the first twenty-four hours after the telephone order is issued:

a. Order from 8/12/16 10:00 pm - Skull Occipital X-Ray and Cervical spine X-Ray.
b. Order from 8/15/15 10:40 am - Augmentin 500mg PO BID, Doxycicline 100mg PO BID, Intestinex 1 capsule PO BID, and Oral Hygiene with lemon swab BID.

6. During P& Ps' review provided by Director of nursing (employee #10) on 08/17/16 at 9:00am, the Policy of Making Telephone and Verbal Orders on item 6 states: The telephone orders must be countersigned by the physician that dictates it, within the first twenty-four hours (24 hours) of issued the order.

However the Facility failed to comply with the Making Telephone and Verbal Orders Policy.

7. The verbal orders and the orders made by telephone should be written with date, hour and physician's signature, the one who dictated the order, during the 24 hours that the order was issue.
The facility failed to comply with federal requirements and State Law Rules and Regulations Number 117 of December 1 of 2004, Chapter 12, Article 6, Section 6, step 2a.

Based on fisty three records reviewed (R.R), it was determined that the facility failed to ensure that 4 out of 53 records contain appropriate documentation related to consult evaluations and appropriate findings by clinical and others staff involved in the care of the patient (R.R #20, #39, #40, and #42).

Findings include:

1. R.R #20 was reviewed on 8/16/16 at 9:30 a. m. and failed to provide evidence of documentation of a consultation requested for the patient.


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2. RR #39 was reviewed on 8/16/16 at 10:50 am; a psychiatry consultation from 8/10/16 was found, however the document was not properly authenticated, there is no signature of the consulting physician (employee #30).
3. RR #40 was reviewed on 8/16/16 at 1:20 pm a consultation from 8/8/16 was found, however the document was not properly authenticated, there is no signature of the consulting physician (employee #31).
4. RR #42 was reviewed on 8/16/16 at 2:07 pm a consultation from 8/15/16 was found, however the document was not properly authenticated, there is no signature of the consulting physician (employee #32).

Based on observations, emergency carts check, medications carts verifications, medications storage check and interviews, 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 2 out of 4 medication cart (MC) (MC #1 and #2).

Findings include:

1. On 8/18/16 at 1:30 pm a tour was perform with the Nurse Supervisor (Employee #26) for the verification of proper storage of the drugs and biological
a. During the tour a medication cart (#1) was seen in the ward hallway without supervision. The surveyor proceeds to inspect the medication cart for rooms 209 through 215 with employee #26. The medication cart was unlocked. The surveyor ask employee #26 to close the cart but employee #26 cannot closed.
The facility failed to demonstrate that they have the cart keys for the proper store of the medications in a safe manner only accessible to authorized personnel.
b. On 8/18/16 at 1:37 pm accompany with employee #26 it was found that the medication cart (#2) for rooms 215 through 221 unlocked.
On 8/18/2016 at 1:38 pm during interview with the employee #26 state that the medication carts locks did not work but the medication carts will be changed went the new electronic medical record start.
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.
The facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized person.

Based on the Food trays temperature check with the administrative dietitian (employee #23), review of quality minutes, food code 2009 guidelines, registration temperatures, it was determined that the facility failed to have a procedures to ensure that food trays comply with the temperature establish by the food code, could affect all hospitalized patients.

Findings include:

1. On 08/17/2016 at 11:50 am during the food tray temperature check with employee #23 it was identified that the food trays were out of the safe zone temperature. The milk was on 48 degrees Fahrenheit, the Jelly on 58 degrees Fahrenheit and the vegetable on 68 degrees Fahrenheit, the cold food safe zone temperature have to be below 41 degrees Fahrenheit. The rice was on 105 degrees Fahrenheit and the ground beef on 109 degrees Fahrenheit, the hot food safe zone temperature have to be above 135 degrees Fahrenheit.

The facility failed to have a procedures to ensure that food trays comply with the temperature establish by the food code.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Physical Plant Manager, it was determined that the physical structure and care areas failed to ensure pull cords can be reached by patients, prevent leak from ceiling, wall and maintain log reports for the maintenance of beds alarm and call systems at patient's rooms for 21out of 21 patients rooms (PR) visit (PR #201 to #221)

Findings include:

1. Patient's night lights above their beds from all the rooms were observed on 8/16/16 from 9:00 am until 12:00 pm with pull cords that were too short to be reached by patients when lying in bed. Minimum requirements of "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) section 10.3.5.2 (1)(i) states that reading light controls shall be accessible to the patient without having to get out of bed.

2. During the visit to the second floor nursing ward on 8/16/16 at 10:10 am with the Physical Plant Manager (employee #3) observations were made of patient's room #205 bathroom and provided evidence that the wall near the head shower and ceiling has what appears to be water damage.

3. No evidence was found about a Log report for maintenance of the beds alarm, call system in the patient ' s room and jobs repairs order.

4. The twenty one patient ' s rooms were observed without towel rails. It was observed that all the patients put their wet towels behind the back board of the bed.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Physical Plant Manager (employee #3), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed from 8/16/16 from 9:00 am until 4:00 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form ( K0046, K0048 and K0130).

Based on tests and observations made during the survey for the physical environment with the facility's Physical Plant Manager (employee #3), it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related lacks of towel rails in patient ' s bathroom or sleeping rooms, broken tiles in patient ' s room (New room), rubber bases off the walls , broken , bathroom walls and floor tiles with dirt and scum, dirty and stained cubicles curtains in patient ' s sleeping room , visitor ' s cover chairs , loose hand sanitizer dispenser in patient ' s sleeping room, dirty and peeling of paint on walls, leak stains on patients sleeping rooms for 12 out of 21 patients rooms (PR) visit (PR# 201, #202, #203, #204, #205, #208, #209, #210, #211, #215, #218, and #221) .

Findings include:

1. During the observational tour of patient's room #201, 202, 209, 210, 211 and 221 with the Physical Plant Manager (employee #3) on 8/16/16 at 9:00 am until 11:30 am provided evidence that cubicle curtains have old stains and was observed dirty.

2. On room #204 it was observed on 8/16/16 at 10:16 am the window curtain with a hole in the middle of it.

3. During the observational tour of all patients ' room (twenty one rooms) it was observed the regular trash can and the biohazard trash can full.

4. Visitors chair cover on patient ' s rooms #201, #203,215 was observed ripped and broken.

5. Missing ceiling tiles on one of the roof edge was observed on room # 221.

6. The twenty one patient ' s room ' s walls were observed with peeling of paint and dirty.

7. On room #211 at 10:00 of 8/16/16 it was observed the patient dining table base was observed wrapped with a blue pad and tape.

8. Room #211 was observed without smoke detector.

9. Room #202 was observed with old pink stains over the floor tile.

10.Rubber base on patient ' s sleeping room # 204, #205, #208 and #209 off the walls.

11. Off loose floor tiles on patient ' s room # 218.

12. The twenty one patient ' s rooms were observed without towel rails. It was observed that all the patients put their wet towels behind the back board of the bed.

13. Patient ' s bathrooms were observed with old scum and dirt embedded on the last two tiles lines on the walls and the floor tiles located at the tub area.

14. The facility prepared a new patient room and this do not have a number. It was observed a missing floor tile and the hand sanitizer dispenser loose from the wall.

6. During the infection control tour on 8/17/16 from 9:15 am through 1:00 pm with the infection Control Officer (employee #5) it was observed the following:

a) Room #201 was observed with used gauze and alcohol swabs on the floor and a strong odor of urine.

b) Room #202 was observed with papers and used gauze on the floor, the walls ' paint peeled, and red spot on the floor near the biohazard trash.

c) Room #203 was observed with paper on the floor, patient spirometer (divice used to measure the amount of inhaled and exhaled air) equipment without a cover that protect from the environment on the night table

d) Room #204 was observed the patient spirometer equipment without a cover that protect from the environment on the night table. The walls ' paint peeled. The bathroom tile was observed with dark grout. Was observed a blue pads cover the toilet faucet.

e) Room #206 was observed with glove in the floor, the patient potty full of urine. Garbage from the breakfast above patient dining table. In the shower area a paper towel observed on the floor.

f) Room #207 was observed the bathroom tile with spot.

g) Room #208 was an Isolation room and was observed with paper on the floor.

h) Room #209 was observed with gauze with blood spot on patient bed, gauze on the floor. The wall between the bathroom and patient room was observed with the baseboards unglued and the paint was with bubbles. The room has a strong odor of urine.

i) Room #211-1 was observed with respiratory therapy equipment in a bag dated 8/11/16, the facility policy related to the respiratory therapy indicated discard after 72 hour of use, and the patient was not in respiratory therapy treatment.

Room 211-2 patient bi-pap mask was observed without cover that protect from environment in night tables desk.

j) Room #213 the wall between the bathroom and patient room was observed with the baseboards unglued

k) Room #214 the wall between the bathroom and patient room was observed with the baseboards unglued

l) Room #215 was observed with respiratory therapy equipment in a bag without a label with date hour and initial of the person that opened the equipment in the Oxymeter.

On the night table desk was observed a bottle of 250 milliliter (ml) of normal saline solution for irrigation and a bottle of 250 ml of sterile water opened without label an available to use. The manufactures recommendation is to discard after use.
In the shower was observed patient bath towel on the curtain tube.

m) Room #216 was observed paper under the sink and a package of towels cleaning up the sink.

n) Room #219 was observed with respiratory therapy equipment in a bag dated 8/11/16, the facility policy related to the respiratory therapy indicated discard after 72 hour of use, and the patient was not in respiratory therapy treatment.

o) Room #220 the wall between the bathroom and patient room was observed with the baseboards unglued.

p) The twenty one patient ' s rooms were observed without towel rails. It was observed that all the patients put their wet towels behind the back board of the bed.
7. R.R. #42 is an 88 year old female admitted on 8/15/16 with a diagnosis of Left hip replacement. Accordance to the record review performed on 8/17/16 at 11:15 am, on 8/15/16 at 8:30 am was place an infectology consult and the patient was evaluate by the infectologyst on 8/6/17 at 10:00 am an recommended and ordered Contact isolation, Acyclovir 800 milligram (mg) per mouth (PO) every 6 hour and activated the isolation Protocol due to Herpes Zoster.

However, no evidence was found on the nurse ' s note of patient and relative orientation related to the contact isolation measure.

During interview with the patient on 8/17/16 at 11:30 am patient state that the nurse said to her that she was going to be move to a better room but did not said why.

8. R.R. #44 is a 74 year old female admitted on 8/12/16 with a diagnosis of Cerebro Vascular Accident (CVA). Accordance to the record review performed on 8/17/16 at 1:30 am, on 8/12/16 at 10:07 pm an Abdominal wound culture was performance, Laboratory report the result on 8/16/16 at 12:40 pm with Methicillin-resistant Staphylococcus Aureus (MRSA) and be notified to the registered nurse.

On 8/16/16 at 12:40 pm the physician place an order for Infectology consult and the patient was evaluate by the infectology on 8/16/16 at 2:00 pm. The infectology recommended and ordered place on Contact isolation started on Septra DS 2 tablets PO twice daily (BID) and performance a Nasal culture for MRSA.

The registered Nurses note performed on 8/16/16 at 12:40 pm reveal that patient physician was notified related to positive culture to MRSA, however no evidence was found in the nurse note related to patient and family orientation related to contact isolation measure and culture result.


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9. During clinical record review performed on 8/18/2016 at 8:00 am thru 11:30 pm the following was found:

a. Record Review #52 is a 64 yrs. old female admitted on 07/06/2016 with a diagnostic of Neurological conditions. Secondary diagnostic of Diabetes, hypothyroidism, Congestive Heart Failure (CHF), Hypertension (HTN), Coronary Artery Disease (CAD), Parkinson, Seizures, Anemia, Charcoat right foot, Sleep Apnea, Polyneuropathy and Peritoneal Dialysis.
It was found that the patient at the moment of the admission have a follow up cultures pending from the hospital that she was discharge dated 06/30/2016 and the result was Serratia Marcescens/Enterococcus Faecalis.

The patient was admitted on a regular room without any isolation precautions until 07/11/2016.

b. It was not found an education to the relatives and patient about the results of the cultures.

c. It was found an incomplete order from the Physician dated 7/11/16. The order was found without be signed by the physician.

d. Patient receives peritoneal dialysis and no evidence of education of management and infection control for the patient's equipment and material during the patient's stay in hospital.

e. No evidence was found of infection control educations for entry of peritoneal dialysis machine property of the patient to the isolation room on 06/11/2016.

Interview with Infection Control Coordinator (employee #5) on 8/18/2016 at 9:50 am reveals that the facility does not have policies and procedures (P&P's) for patients who received peritoneal dialysis in their home and the facility admitted for rehabilitation. Employee #5 indicates that they do not receive a lot of patients with this modality and always the patient brings their equipment or they receive the manual dialysis not with the machine.

Interview with the Nursing educator (employee #15) on 8/17/2016 at 3:18 pm reveals that she gave an education for the BSN of peritoneal dialysis on May 2016. Only 7 register nurse of 27 register nurse receive the education. No training for a certificated dialysis nurse was found during the record review.

f. The facility failed to ensure the safe and proper handling of infection control for patients who are admitted and receiving peritoneal dialysis.


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10. On 08/16/16 at 2:27 pm during emergency cart inspection with the Pharmacist (employee #33) and Nursing Supervisor (employee # 26) at the facility 2nd floor nursing station the following was found:

3 Blue BD Vacutainer 2.7 ml tube expire on 07/2016
1 Suction catheter Amsio expire on 03/2016

10. On 08/16/16 at 2:27 pm during emergency cart inspection with the employee #33 and employee # 26 at the facility 1st floor therapy gym the following was found:

1 Package of Electrocardiogram electrode expire on 11/19/2013
1 Suction catheter Amsio expire on 09/2011
1 Non Conductive Connecting tubing expire on 12/2011

The facility fails to have the medical surgical material up to date to prevent risk of infections and communicable diseases.



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Based on review of policies and procedures (P&P 's) and observations performed from 8/16/16 to 8/18/2016, it was determine that the facility failed to ensure an effective infection control program that protects patients, families, visitors and hospital personnel by preventing and controlling infectious and contagious diseases, related to reduce possible transmission of infectious agents related to nursing personnel use shoe material who expose to blood, chemicals, and sharp needles, failed to maintain hand hygiene procedures accordingly with hand hygiene standards of practice, nursing personnel did not discard blood sample test tube that felt down to the floor, isolation patient orientation, expired medical surgical material and accepted guidelines for infection control which can affect all patients admitted.
Findings include:
1. Nursing personnel (employee #16, #24, #25, and #26) was observed on 8/17/16 at 10:00 am wearing canvas style sneakers, this type of shoe material expose the personnel to blood, chemicals, and sharp needles that could penetrate through.
Facility dress code policy reviewed on 8/17/16 at 11:40 am evidence that personnel must use appropriate footwear while providing direct care to patients. This policy stated that inappropriate footwear includes canvas sneakers which are non-closed shoes due to the potential exposure to hazardous chemicals, blood or other potentially infection material.
2. Nursing personnel (employee #16) was observed on 8/17/16 at 10:20 am performing hand washing. After she performed hand washing she proceeded to dry hands with a dry paper towel. However she dried from the elbow area through the finger and palm of the hand area. Facility failed to maintain hand hygiene procedures accordingly with hand hygiene standards of practice and accepted guidelines for infection control.
3. It was observed on 8/18/16 at 9:18 am that the license practical nurse (LPN) (employee #17) provide a perianal wash during the bath care failed to perform the hand washing after gloves have been worn and discard according to the hand washing protocol established by the Centers for Disease Control and Prevention (CDC)
4. It was observed on 8/17/16 at 9:15am that the nurse (employee #27) was taking a blood sample. The nurse dropped a sample test tube to the floor, immediately she picked up the blood sample tube, however instead of discarding the blood sample test tube she place it with the other tubes in the clean area.

5. It was observed on 8/17/16 at 9:40 am an used gauze, papers and a
plastic packaging on the floor of the room #202.