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Based on complaint investigation ACTS Intake PR00000574 review of sixteen active records reviewed (R.R), policies/procedures manual with the respiratory intensive care unit manager ( employee #9 ) ,director of nursing ( employee # 1) and director of institutional programs (employee #2 ) it was determined that facility failed to ensure that an accurate documentation of patient ' s integumentary status were performed of every patient who receive services. This deficient practice were identified on 4 out of 13 cases reviewed ( # 1, #13, #14 and #16 ).

Findings include:
1.A mechanism to ensure that personnel maintain appropriate and accurate documentation of patient ' s integumentary status of cases that receive services at the facility was not promoted or followed. The following findings were identified during survey procedures on 11/22/16 & 11/23/16 from 8:00 am through 3:00 pm and discussed with respiratory intensive care unit manager ( employee #9 ), director of institutional programs (employee #2 ) and director of nursing ( employee #1 ) on 11/23/16 at 11:57 am:
a. Case # 1 is an 83 years old female visit the emergency room on October 14, 2016 with a diagnosis of Congestive Heart Failure. While was on the emergency room skin management team professionals evaluate the patient and document that patient had a lesion on left and right buttock. Case was admitted to the hospital respiratory intensive unit on October 14, 2016 with a diagnosis of Congestive Heart Failure. On October 15, 2016 at 11:00 am nursing personnel document on the skin status assessment that patient had a lesion Stage II on left buttock. On October 16, 2016 at 10:00 am nurse document that this patient had a lesion on left buttock stage I and a lesion on right buttock stage I. On October 17, 2016 a nurse document that patient had lesions on both buttocks and they were cleansing the lesions with antiseptic and locate the patient on air mattress. On October 18, 2016 nurse document that patient had a lesion on right buttock stage II. During interview respiratory intensive care unit manager ( employee # 9) and director of institutional programs (employee #2 ) on 11/23/16 at 9:45 am stated that this patient had lesions on buttocks when was admitted to receive services at the hospital but nursing personnel failed to accurate document skin status of patient. It was evident that nursing personnel classify lesions with stage as if there were ulcers and reverse staging during the assessment. This does not promote standards of practice recommended for skin assessment; and difficult that healthcare personnel must take appropriate decisions about treatment based on circumstances presented by any individual patient
b. Case # 13 is a 85 years old male admitted to the hospital on July 2, 2016 with a diagnosis of Pancytopenia due to Chemotherapy, Urine Bladder Cancer with metastasis to lumbar L 2 Vertebrae. On the nursing initial assessment of medical surgical ward it was document that patient had ulcer and laceration and the body diagram had a mark on the sacral area. On July 2, 2016 at 8 pm in the documentation of the skin reassessment nursing personnel stated that patient had lacerations on both buttocks and Vaseline gauze was applied to the area. On the internal medicine physician progress notes dated July 3, 2016 stated that patient had sacral ulcers. Since admission to receive services in the hospital there is incongruence in the patient skin assessment and documentation of skin status. As evidence on the " Initial Assessment of skin, reassessment of skin status and daily assessment " personnel who took care and offer services to him refers and document skin status sometimes describing laceration on both buttocks, as ulcers on both buttocks other days and when document that skin integrity loss as ulcers reversing staging from Stage III, to Stage II or Stage I and vice versa. Information of local care products used when local care is provided and prevention strategies and activities performed to avoid the development of new skin loss of integrity is not well described and documentation performed by facility wide skin care team sometimes are illegible or unable to understand. Lack of characteristics that describe skin status evolution to decline or improve could not be determined by the information documented on the medical record. This case was discussed with director of institutional programs (employee #2 ) and director of nursing ( employee #1 ) on 11/23/16 at 11:57 am. This deficient practice was evidence through patient prolonged stay on hospital while was receiving services from 7/2/16 through 11/23/16 when survey was performed. This does not promote standards of practice recommended for skin assessment; and difficult that healthcare personnel must take appropriate decisions about treatment based on circumstances presented by any individual patient.


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c. Case #16 is an 71 years old female visit the emergency room on November 11, 2016 with a diagnosis of Aspiration Bronchopneumonia and secondary diagnosis of Alzheimer Disease End Stage, Diabetes Mellitus II, Bed Ridden, Oxygenatory Respiratory Failure, Endoscopy Gastrostomy was admitted at Medicine Ward on eight floor. The patient record was evaluated on 11/22/16 at 2:00 p. m. and reveled the following:
a. On 11/11/16 at 12:30 p. m. a physician ordered a nutritionist evaluation because the patient has intake problems, reflux, difficulty to chew, muscle loss and the patient was evaluated on 11/12/16 at 11:15 a. m. placed on 1600 Kcals diabetic blanderized diet and Juven b.i.d. per percutaneus endoscopic gastrostomy tube (PEG).
b. According of the nurse initial assessment performed on 11/11/16 at 4:15 p. m. the patient last hospitalization was one month ago October 16/16 related to a gastrostomy and ulcers. On 11/11/16 at 11:30 a. m. a wound culture was taken on Emergency Room and a final report was received on 11/13/16 at 8:50 a. m. by Fax at Epidemiology nurse (employee #4) and on 11/14/16 at 9:05 a. m. at Epidemiology nurse (employee #5) and revealed that the patient has four (4) microorganism: Isolate Number: 1 Klebsiella pneumoniae (Moderate), Isolate Number: 2 Providencia stuartii (Moderate), Isolate Number: 3 Acinetobacter baumannii (moderate) and Isolate Number: 4 Pseudomonas Aeruginosa (Abundant).
On 11/13/16 at 10:17 a. m. the physician ordered a '' Contact Isolation,'' discontinue antibiotics and start on Menren 1 gram I.V. every 12 hours. The record reveled that on 11/11/16 two referrals were placed for the skin coordinator and identified that the patient has ulcers on sacral and trochanter area and needs a team professional ' s evaluation. However, the initial estimated performed per the skin care nurse (employee #20) was performed on 11/14/16 at 1:30 p. m. and reveled the patient has six (6) Ulcer #1 on sacral area with measures was L 8.5 cms. x A 11.0 cms x P 1.0 cms, Ulcer #2 on back area with measures was L 2.0 cms. x A 3.0 cms x P 0.0 cms, Ulcer #3 on sacral area with measures was L 16.0 cms. x A 17.0 cms. x P 1.0 cms, Ulcer #4 left gluteo with measures was L 1.5 cms. x A 1.0 cms x P 0.0 cms, Ulcer #5 left isqueal area not classifiable, Ulcer #6 on right talus with measures was L 1.0 cms. x A 1.0 cms x P 0.0 cms. The skin care nurse documented on comments that the patient local care was performed daily with '' EPC (Extra Protein Cream)and antimicrobial,'' Infectology and Social Worker evaluation, case was discuss with the physician and orientation to patient family and nurse patient.'' However, the patient record did not provide evidence of patient family and nurse ' s orientation.
On November 18, 2016 at 2:00 p. m. two days post the initial skin nurse evaluation the license practical nurse (LPN) personnel (employee #17) document on the skin care assessment that patient had a Ulcer #1 was localized on the Left trochanter with red tissue of granulation and rose epithelial tissue with macerated circundant tissue, with pain on level #3, treatment with antiseptic and vaselinated gauze. Ulcer #2 was localized on right superior back, with red tissue of granulation and rose epithelial tissue, esfacelo with pain on level #3 with antiseptic and vaselinated gauze. Ulcer #3 was localized on the sacral area with red tissue of granulation and rose epithelial tissue with pain on scale #3 with vaselinated gauze and Ulcer #4 was localized on the Left trochanter not classifiable, necrotic, treatment antiseptic and cleaning with sterile gauze.
The nurse documentation was not according with the initial skin evaluation performed on November 14/16 and did not identified the ulcers on the same order of the initial evaluation and did not referred the others two ulcers.
On November 20/2016 at 9:00 a. m. four days post the initial skin nurse evaluation the practical nurse personnel (LPN) (employee #18) document on the skin care assessment that patient had a Ulcer #1 was localized on the Left trochanter with red tissue, granulation, rose epithelial tissue with macerated circundant tissue, esfacelo, tunnels, treatment with antiseptic and vaselinated gauze. Ulcer #2 was localized on right trochanter, with red tissue of granulation and rose epithelial tissue, esfacelo, treatment with antiseptic and Alginato. The nurse documentation was not according with the initial skin evaluation performed on November 14/16 and did not identified the ulcers on the same order of the initial evaluation and did not referred the others four ulcers.
During performed the patient record review on November 22/16 at 2:00 p. m. reveled that all of the register nurses notes performed on November 11/2016 till November 21/2016 lacked information related to the patient skin care, the nurses notes only provide information related to the daily patient re-estimated but did not provided documentation related to the six patient ulcers local care, treatment ordered per the physician, precautions measures related to the contact isolation and nursing intervention.
During interview with the nurse supervisor (employee #16) on 11/22/16 at 2:20 p. m. stated: '' When the patient was admitted on 11/11/16 was placed on contact isolation without physician order because this patient was admitted on others occasions and has a recurrent admissions related to the infected ulcers.'' Related to the positive cultures of the four microorganism Klebsiella pneumoniae, Providencia stuartii, Acinetobacter baumannii and Pseudomonas aeruginosa she stated: '' The patient was covered with antibiotics and continue on contact isolation. ''
However, the nursing personnel failed to document accurate skin status of patient, what kind of treatment was used to perform the ulcers local care and family orientation related to the precautions for contact isolation. During reviewed the license practical nurses notes (LPN) it was evident that nursing personnel was incongruence with information related to the classifications of lesions, did not classify lesions with stage as if there were ulcers and reverse staging during the assessment. This does not promote standards of practice recommended for skin assessment; and difficult that healthcare personnel must take appropriate decisions about treatment based on circumstances presented by any individual patient.
d. Case # 14 is an 81 years old female admitted at floor #8 on November 16, 2016 with a diagnosis of Symptomatic Anemia. The patient placed on protective isolation on 11/17/16 according of physician order. The initial nurse assessment was performed on 11/17/16 at 7:00 a. m. and provide evidence that the nurse referred at discharge planning services however, during the record reviewed on 11/23/16 at 8:55 a. m. seven days (7) post - admission no evidence of discharge planning initial evaluation. According of the hospital policies / procedures the initial discharge planning was performed per the social worker on the first 24 hours of the admission and then the social worker re-evaluated the patient per two times a week or according of needs. However, this case lacked of initial discharge planning evaluation.
The social worker (employee #11) was interviewed related to this case and she stated: '' I did not evaluated this case, but according of the hospital the social worker should evaluated all Medicare patients on the first 24 hours responds per consult and per priorities. However, the hospital had many patients admitted with many situations and only had two social workers.''

Based on a Complaint Investigation Survey, observation, p & p reviewed and interviews with the Nursing Director (DON) (employee # 1) and Epidemiologist Nurse ( employee #5) on 11/22/16 at 8:15 a. m. till 11:55 a. m. it was determined that the facility failed maintain a sanitary environment and ensure monitoring that personnel compliance with all policies, procedures, protocols and other infection control program requirements for Infection Control.

Findings include:
1. The Medicine and Surgery Department on the eight floor was visit and the following was observed:

a. The acoustics located on ceiling of the corridor between the patient's room #803 and #804 was observed with brown spots apparently mold related to water filtration.

b. The area designated to " pantry area '' was observed the ice machine, the ceiling was observed with humid and black spots.

c. The canalization car was observed on the corridor at all time, this canalization car was used per the nursing personnel on the side A, was observed with broken shelves and all the materials was exposed and did not provided security to the medical surgical material.

2. The Medicine and Surgery Department on the seven floor was visit and the following was observed:

a. The acoustics located on ceiling of the corridor enter the patient's room #703 and #704 was observed with brown spots apparently mold related to water filtration.

b. A used patient sheet was observed placed on the interior of the closet.

c. A corrugated line used to respiratory treatment was observed outside of the regular trash can on patient room #701.

d. At 9:50 a. m. on the small storage located on the corridor a commode was observed and over the commode electric bulb cover was observed. The ceiling lacked of acoustics, a plastic bulb cover was observed on the top of the chair. The area lacked of illumination.

e. At 9:55 a. m. the patient room #714 lacked of hand paper. The housekeeping (employee #19) was observed with gloves on both hands she treated to removed a glove stay over the door of the storage located on the corridor then she entering at the patient room #714 with the same gloves she removed a small plastic cover then with the same gloves management the roll of the hand paper and put on the patient room dispenser.

f. The IV stand located on back of the wall and the acoustics of the patient room #715 were observed loose.

g. On the main entrance at left side of the column on patient room #716 was observed a circular hollow. Brown spots and humid were observed on the acoustics of the main entrance. The main electrical panel located on back of the patient bed lacked of security cover.

h. In the designated area for the ice machine the floor was observed dirty, the wall lacked of ''socalos'' sockets and the cement wall was exposed and broken and deteriorate tiles were observed.

i. One opened bag of Sodium Chloride .9% 500 ml. was observed on the top of the hand washing on the bathroom designated for the visits. The bathroom lacked hand paper, sanitary paper and the hand paper dispenser was observed loose.

3. The Multidisciplinary Intensive Care Unit located on the six floor was visit and the following was observed:

a. The Emergency Crash Car was observed with much mold and deteriorate condition.

b. The floor and the table on patient room #607 was observed with white spots.

c. One bag of Sodium Chloride 9% of 50 ml., one bag of Albumin and Invance 500 mgs were observed on the top of the space located on back of the patient bed at 10:30 a. m., the medications bags was reviewed and provide evidence of the hour 9:00 a. m., according to the nurse supervisor (employee #12) the medications not administered, however the patient did not received the medication according of the physician order, it pass one hour and 30 minutes post the medication was prepared. The medications bags was placed and maintain on the area exposed to dust not according of infection control measures.

The foley catheter and the nephrostomy tube lacked of identification label.

The patient bed was observed with mold on the head area and was observed with damage.

4. The Intensive Care Unit (Telemety) located on the six floor was visit and the following was observed:

a. Mucomist used for respiratory therapy and Cozar 25 mgs were observed over the plastic materials cart on the medication room.

5. The Medicine, Surgery and Telemetry located on the five floor was visit and the following was observed:

a. Water filtration per the crystal windows was detected on patient room #502.

b. The car used to maintain the materials used to provide local care and maintain the sheets was observed on the corridor and did not have the left door.

c. The acoustics located on ceiling of the corridor between the patient's room #505 and #506 was observed with brown spots apparently mold related to water filtration.

d. The acoustics of the main entrance on room #511 was observed with brown and yellow color related to the water filtration. The entrance lacked of illumination because did not have bulb and cover bulb. Papers and water was observed on the floor of the bathroom.

e. The storage located in front of the patient room #521 was observed disorganized, four packages of towels used to provide care at the patient during the bath and patient's radiology laminar were observed at the back of the ''armario " closet. The acoustics was observed with brown spots. Dust and papers were observed on the floor.

6. The Medicine, Surgery and Telemetry located on the four floor was visit and the following was observed:

a. The foods refrigerator bulb was observed out of service.

b. Peeling paint was observed on back of the patient bed room #401.

c. The acoustics located around the bulb on the patient room #405 was observed with water related to the water filtration.

d. Three bottles of water, foods, sheets and others patient properties were observed on the border of the crystal windows, water filtration was observed on room #406. One of the bulbs of the bathroom was observed out of services and the other one was observed ' ' tenue ' ' faint.

e. The canalization car was observed in front of the patient room #407 without security.

f. The air conditioning on the patient room #413 was detected with hot temperature at 11:40 a. m during performed the infection control observations.