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Based on complaint investigation Acts intake PR00000604, the review of medical records, policies and procedures, documents, observations, and interviews from 1/10/18 through 1/12/18 from 8:00 am till 4:00 pm, it was determined that the 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: 42 CFR 482.13 Condition of Participation: Patient ' s Rights, 42 CFR 482.21 Condition of Participation: QAPI and 42 CFR 482.41 Condition of Participation Physical Environment which makes this condition 42 CFR 482.12 Governing Body Not Met.

Based on complaint investigation Acts intake PR00000604, review of policies and procedures,incidents and interview with nursing personnel (employees #1) medical director and subdirector ( employee # 3 and # 4), it was determined that the facility failed to ensure that patient right was protected and promoted, which make this condition.

Based on complaint investigation Acts intake PR00000604, review of policies and procedures, incidents and interview with nursing personnel (employees #8) medical director and sub-director (employee # 3 and # 4), it was determined that facility failed to act with prudence; take care and show attention as may be reasonably expected during the management of cases who are receiving services at the emergency room and later elopes from hospital. This deficient practice was identified on 4 out of 50 cases review (RR #1, # 20, # 30 and # 35).

Findings include:

1. A mechanism to ensure that facility acts upon elopement events in order to identify if occurrences are attributable to a breakdowns in patient assessment and team communication were not performed accordingly with information provided on survey procedures from 1/10/18 through 1/12/18. Failure by the facility to ensure that personnel follow current standards of practice for patient environmental and safety, are evidence by the following findings:

a.R.R. # 1 is a 53 years old male, who visited the Emergency Room on 10/31/17 at 5:11 pm. The patient referred pain general malaise chills, muscle rigidity on the mouth and edema on both legs. This medical record was evaluated and discussed with medical director and sub-director (employee # 3 and # 4), on 1/12/18 at 10:30 am.

Case was triaged at 5:48 pm, the triage nurse classified the patient as a category "3" urgent who accordingly with information provided by the emergency room medical director on 1/12/18 at 10:30 am must be located inside the emergency room due to his acute condition classification. However was sent to the waiting room.

On 10/31/17 at 6 pm physician evaluate the patient diagnose him with Right Upper Quadrant Pain and Ascites and order laboratory samples and abdominal CT.

Accordingly with information documented on the medical record laboratory samples were taken between 7:15 pm and 8:11 pm. A complete pain assessment and re-assessment with non-pharmacologic measures was documented on pain assessment format.

On 10/31/17 at 8:30 pm was documented on the radiology request and final results format that Abdominal CT was performed to the patient.

An admission note dated 11/1/17 at 2:30 pm evidence that patient is admitted due to findings of Ascites, Jaundice Edema and Cirrhosis to the hospital. Orders of absolute bed rest, NPO laboratory samples, heparin lock ,Famotidine 20 mgs IV every 12 hours, Lasix 40 mgs IV daily and Spirinolactone 100 mgs PO daily were also found documented on the medical record.

After 11/1/2017 at 2:30 pm the medical record does not include any other information documented related with patient treatment, evolution of his condition or status of the admission process to the hospital.

On 11/2/17 at 1:45 am on the progress note a nurse document that admission process are finalizing. Five minutes later on 11/2/17 at 1:50 am a nurse document that they were looking for the patient inside emergency room area but they cannot locate him.

On another progress note a nurse document that on 11/2/17 at 3:00 am they continue looking for the patient unsuccessfully.

No evidence was found documented on the medical record that emergency room staff ask security personnel outside emergency room if they identified a patient who elope from the emergency room.

No evidence was found documented on the medical record that patient relatives were informed that patient elope from the emergency room.

Circumstances were the elopement occurs were not clearly documented , no information was found who indicate that patient was receiving treatment due to lack of documentation of services and care offered to this patient from 11/1/17 at 2:30 pm through 11/2/17 at 1:45 am.

There is no documentation on the medical record who indicate where the patient is located and receiving treatment (waiting area, hallway, and observation unit). If patient walk or move leisurely from the emergency room areas was not documented from 10/31/17 at 5:11 pm when he came until 11/2/17 at 1:50 when personnel identified that patient elopes.

On the medical record it was documented on 11/2/17 that the patients' personal items were pick up by patient brother.

Based on the fact that patient relative came to pick up patient personal items; evidence that facility personnel had information of patient status after elopement.

However during interview nursing personnel (employee # 8) on 1/12/18 at 9:50 am does not provide clear information of who call patient relative to come to the hospital to pick up personal items or circumstances were the relative came to pick up patient belongings.

b.R.R. # 20 is a 42 years old female, who visited the Emergency Room on 9/19/17 at 1:17 pm. The patient referred head trauma after car accident. This medical record was evaluated and discussed with medical director and sub-director (employee # 3 and # 4), on 1/12/18 at 10:50 am.
Case was triaged at 1:41 pm, the triage nurse classified the patient as a category "3" urgent and sent the patient to an observation area.

On 9/19/17 at 2:30 pm physician evaluate the patient and diagnose her with Head Trauma. Physician order bed rest with rails up, fall precautions, vital signs every four hours, intravenous fluids laboratory samples and CT of head, cervical area and maxillofacial with contrast.

Accordingly with information documented on the physician progress notes patient elopes from the emergency room on 9/19/17 at 8:00 pm. There is no evidence documented on the medical record of what happen with the patient from 2:45 pm when physician order treatment until 8:00 pm were patient elopes from the area.

c.R.R. # 30 is a 51 years old male, who visited the Emergency Room on 8/10/17 at 2:38 pm. The patient referred dizziness and blurred vision. This medical record was evaluated and discussed with medical director and sub-director (employee # 3 and # 4), on 1/12/18 at 10:45 am. Case was triaged on 8/10/17 at 2:45 pm, the triage nurse classified the patient as a category "3" urgent and sent the patient to an observation area.

On 8/10/17 at 3:49 pm physician evaluate the patient and diagnose him with Diabetes complications. Physician order EKG, heparin lock, pulse Oxymeter, Antivert 25 mgs PO for 1 dose and laboratory samples who include troponin protein in blood test.

Accordingly with nurses progress notes on 8/10/17 at 9:25 pm a troponin critical value was informed by the laboratory and the nurse in charge of the patient report the results to the physician on charge. Physician in charge order to repeat troponin levels.

On 8/10/17 at 10:58 pm laboratory report another troponin level critical value, but there are no evidence that this results were reported to the physician.

Accordingly with information documented on the progress notes patient elopes from the emergency room on 8/10/17 at 11:30 pm.

There is no evidence documented on the medical record of what happen with the patient from 9:25 pm when physician order to repeat troponin levels until 11:30 pm were patient elopes from the area.

d.R.R. # 35 is a 60 years old male, who visited the Emergency Room on 12/3/17 at 11:03 am. The patient referred chest pain. This medical record was evaluated and discussed with medical director and sub-director (employee # 3 and # 4), on 1/12/18 at 10:2 0 am. Case was triaged on 12/3/17 at 11:06 am, the triage nurse classified the patient as a category "3" urgent and sent the patient to an observation area.

On 12/3/17 at 11:25 am physician evaluate the patient diagnose him with Atypical Chest Pain and order Chest Pain protocol who include orders for heparin lock, cardiac monitoring, EKG, vital signs every 4 hours nasal cannula at 2 liter per minute, laboratory samples, chest X-ray, anti-platelet therapy and Zofran 4 mgs IV for one dose.

Accordingly with information documented on the progress notes patient elopes from the emergency room on 12/3/17 at 12:30 pm. There is no evidence documented on the medical record of what happen with the patient from 11:40 am when physician order chest pain /acute coronary syndrome protocol until 12:30 pm were patient elopes from the area.

Medical director and sub-director ( employee # 3 and # 4), stated on interview on 1/12/18 from 10:30 am through 10:50 am after discussion of evidence documented on those medical records they were in agree with survey findings identified during survey on cases # 1,# 20 # 30 and # 35.


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2. A mechanism to ensure an adequate space to provide privacy to the ER patients at the time of performing triage and providing care was not follow.

a. During the observation round of physical plant three cubicles are observed to perform triage. They are observed to have no privacy at the time a patient is seen. The 1/10/18 It is observed that the registered nurse (RN) is taking vital signs and it was heard from the outside what the nurse and patient are talking, there is no privacy.

The cubicles do not have doors or anything that can provide privacy when the patient is interviewed. (Cross reference A701)

b. During the observational tour performed on 1/10/18 at 10:30 am it is observed 8 patients located in the corridor that heads to the hospital lobby without privacy. An RN is observed performing a procedure and three people who have no relationship with the patient observing what she is doing. One of the stretcher was obstructing the emergency door.

c. The facility failed to ensure that the services at the Emergency Room are provided in a safely, privately manner and care provided according to professional standards of practice.

Based on complaint investigation Acts intake PR00000604, records reviewed (RR), review of policies and procedures, incidents and interview with director and sub director (employee # 3 and # 4), it was determined that facility failed to act upon breach in patients safety in order to evidence efforts to prevent further occurrences, improve management of those cases, evidence care, promote goods and services necessary to avoid harm. This deficient practice was identified on 4 out of 50 cases review (RR #1, # 20, # 30 and # 35).

Findings include:

1. A mechanism to ensure that facility determine if occurrences on patient elopement cases
are attributable to atypical incidents or to a trends who might indicate systemic failures and failure to provide goods and services necessary to avoid harm, were not performed accordingly with information provided on survey procedures from 1/10/18 through 1/12/18.

Failure by the facility to ensure that provisions were taken in order to improve emergency room actions and response on cases who are receiving services and elopes from the area are evidence by the following findings:

a. R.R. # 1 is a 53 years old male, who visited the Emergency Room on 10/31/17 at 5:11 pm. The patient referred pain general malaise chills, muscle rigidity on the mouth and edema on both legs. This medical record was evaluated and discussed with medical director and sub-director (employee # 3 and # 4), on 1/12/18 at 10:30 am. Case was triaged at 5:48 pm, the triage nurse classified the patient as a category "3" urgent who accordingly with information provided by the emergency room medical director on 1/12/18 at 10:30 am must be located inside the emergency room due to his acute condition classification. However was sent to the waiting room.

On 10/31/17 at 6 pm physician evaluate the patient diagnose him with Right Upper Quadrant Pain and Ascites and order laboratory samples and abdominal CT. Accordingly with information documented on the medical record laboratory samples were taken between 7:15 pm and 8:11 pm. A complete pain assessment and re-assessment with non-pharmacologic measures was documented on pain assessment format.

On 10/31/17 at 8:30 pm was documented on the radiology request and final results format that Abdominal CT was performed to the patient. An admission note dated 11/1/17 at 2:30 pm evidence that patient is admitted due to findings of Ascites, Jaundice Edema and Cirrhosis to the hospital. Orders of absolute bed rest, NPO , laboratory samples, heparin lock, Famotidine 20 mgs IV every 12 hours, Lasix 40 mgs IV daily and Spirinolactone 100 mgs PO daily were also found documented on the medical record.

After 11/1/2017 at 2:30 pm the medical record does not include any other information documented related with patient treatment , evolution of his condition or status of the admission process to the hospital.

On 11/2/17 at 1:45 am on the progress note a nurse document that admission process are finalizing. Five minutes later on 11/2/17 at 1:50 am a nurse document that they were looking for the patient inside emergency room area but they cannot locate him.

On another progress note a nurse document that on 11/2/17 at 3:00 am they continue looking for the patient unsuccessfully.

No evidence was found documented on the medical record that emergency room staff ask security personnel outside emergency room if they identified a patient who elope from the emergency room.

No evidence was found documented on the medical record that patient relatives were informed that patient elope from the emergency room. Circumstances were the elopement occurs were not clearly documented , no information was found who indicate that patient was receiving treatment due to lack of documentation of services and care offered to this patient from 11/1/17 at 2:30 pm through 11/2/17 at 1:45 am.

There is no documentation on the medical record who indicate where patient is located and receiving treatment (waiting area, hallway, or observation unit). If patient walk or move leisurely from the emergency room areas was not documented from 10/31/17 at 5:11 pm when he came until 11/2/17 at 1:50 am when personnel identified that patient elopes.

b.R.R. # 20 is a 42 years old female, who visited the Emergency Room on 9/19/17 at 1:17 pm. The patient referred head trauma after car accident. This medical record was evaluated and discussed with medical director and sub-director (employee # 3 and # 4), on 1/12/18 at 10:50 am. Case was triaged at 1:41 pm, the triage nurse classified the patient as a category "3" urgent and sent the patient to an observation area.

On 9/19/17 at 2:30 pm physician evaluate the patient and diagnose her with Head Trauma. Physician order bed rest with rails up fall precautions, vital signs every four hours, intravenous fluids, laboratory samples and CT of head, cervical area and maxillofacial with contrast.

Accordingly with information documented on the physician progress notes patient elopes from the emergency room on 9/19/17 at 8:00 pm. There is no evidence documented on the medical record of what happen with the patient from 2:45 pm when physician order treatment until 8:00 pm were patient elopes from the area.

c. R.R. # 30 is a 51 years old male, who visited the Emergency Room on 8/10/17 at 2:38 pm. The patient referred dizziness and blurred vision. This medical record was evaluated and discussed with medical director and sub-director (employee # 3 and # 4), on 1/12/18 at 10:45 am. Case was triaged on 8/10/17 at 2:45 pm, the triage nurse classified the patient as a category "3" urgent and sent the patient to an observation area.

On 8/10/17 at 3:49 pm physician evaluate the patient and diagnose him with Diabetes complications. Physician order EKG, heparin lock, pulse Oxymeter, Antivert 25 mgs PO for 1 dose and laboratory samples who include troponin protein in blood test.

Accordingly with nurses progress notes on 8/10/17 at 9:25 pm a troponin critical value was informed by the laboratory and the nurse in charge of the patient report the results to the physician on charge. Physician in charge order to repeat troponin levels. On 8/10/17 at 10:58 pm laboratory report another troponin level critical value, but there are no evidence that this results were reported to the physician.

Accordingly with information documented on the progress notes patient elopes from the emergency room on 8/10/17 at 11:30 pm. There is no evidence documented on the medical record of what happen with the patient from 9:25 pm when physician order to repeat troponin levels until 11:30 pm were patient elopes from the area.

d. R.R. # 35 is a 60 years old male, who visited the Emergency Room on 12/3/17 at 11:03 am. The patient referred chest pain. This medical record was evaluated and discussed with medical director and sub-director (employee # 3 and # 4), on 1/12/18 at 10:2 0 am. Case was triaged on 12/3/17 at 11:06 am, the triage nurse classified the patient as a category "3" urgent and sent the patient to an observation area.

On 12/3/17 at 11:25 am physician evaluate the patient diagnose him with Atypical Chest Pain and order Chest Pain protocol who include orders for heparin lock, cardiac monitoring, EKG, vital signs every 4 hours nasal cannula at 2 liter per minute, laboratory samples, chest X-ray, anti-platelet therapy and Zofran 4 mgs IV for one dose.

Accordingly with information documented on the progress notes patient elopes from the emergency room on 12/3/17 at 12:30 pm. There is no evidence documented on the medical record of what happen with the patient from 11:40 am when physician order chest pain /acute coronary syndrome protocol until 12:30 pm were patient elopes from the area.

Medical director and sub-director ( employee # 3 and # 4), stated on interview on 1/12/18 from 10:30 am through 10:50 am they were in agree with survey findings during review of cases # 1,# 20 # 30 and # 35.

2. Facility failed to take necessary measures to improve the safety and security of patients with acute conditions or admitted receiving services on the emergency room and kept them from leaving facility without supervision.

Based on complaint investigation Acts intake PR00000604, fifty records reviwed, review of policies and procedures, incidents and interview with nursing supervisor (employees #5) medical director and sub-director ( employee # 3 and # 4), it was determined that the facility failed to establish proactive measures to deal with emergency room patient elopements occurrences based on a coordinated systematic comprehensive and data driven approach to maintain and improve safety and quality of services, which make this condition Not Met.

Based on complaint investigation Acts intake PR00000604, fifty records reviewed, review of policies and procedures, incidents interview with security guard services supervisor (employees #9), interview with security cameras and video surveillance system supervisor (employee #10 ) and interview with emergency room nursing supervisor and quality assessment program ( employee # 5 and # 6), it was determined that the facility failed to evidence continues surveillance or study of trends and occurrences and improvement of processes with the intent to better services and outcomes and prevent or decrease the like hood of emergency room elopement problems.

Findings include:

1. A mechanism to ensure that facility maintain multi-pronged approaches to deal with emergency room patient elopement incidents as an initiative of facility quality assessment and performance improvement program were not performed accordingly with information provided on survey procedures from 1/10/18 through 1/12/18.

During interview on 1/11/18 at 8:56 am security guard company supervisor/director (employee # 9) stated that on the premises near emergency room department they had a security guard surveillance booth were a security guard is assigned 24 hours 7 days at a week.

During interview on 1/11/18 at 9:51 am cameras and video surveillance program director (employee #10) stated that on the premises near emergency room department they had camera surveillance system to record incidents. He explain that the camera system record information 24 hours 7 days every week.

On 1/12/18 at 11:30 am emergency room nursing supervisor and quality assessment program ( employee # 5 and # 6), explain during interview quality initiatives, activities and corrective actions that quality assessment program are following to reduce patient elopement.
Accordingly with information provided it seems, that facility did not incorporate on those quality indicators information derived from security guard surveillance officers and cameras and video surveillance system in order to maintain an approach were not only healthcare professionals and personnel who worked in the emergency room work to improve or reduce patient elopements

Based on complaint investigation Acts intake PR00000604, records reviewed, review of policies and procedures, incidents interview with security guard services supervisor (employees #9), interview with security cameras and video surveillance system supervisor ( employee #10 ) and interview with emergency room nursing supervisor and quality assessment program ( employee # 5 and # 6), it was determined that the facility failed to evidence that clear expectations for the safety of patients who seek for services at the emergency room are established.

Findings include:

1. A mechanism to ensure that facility establish strategies who involve an approach at several levels who are activated simultaneously in order to deal with emergency room patient elopement as quality assessment and performance activity were not performed accordingly with information provided on survey procedures from 1/10/18 through 1/12/18.

During interview on 1/11/18 at 8:56 am security guard company supervisor/director (employee # 9) stated that on the premises near emergency room department they had a security guard surveillance booth were a security guard is assigned 24 hours 7 days at a week.

During interview on 1/11/18 at 9:51 am cameras and video surveillance program director (employee #10) stated that on the premises near emergency room department they had camera surveillance system to record incidents that occur on emergency room areas.

On 1/12/18 at 11:30 am emergency room nursing supervisor and quality assessment program ( employee # 5 and # 6), explain during interview quality initiatives, activities and corrective actions that quality assessment program are following to reduce patient elopement.
Accordingly with information provided it seems, that patient elopement are not a process were security guard company and cameras and video surveillance program had fully integrated as an priority to work as an integrated approach to reduce or improve the occurrence.

Based on complaint investigation Acts intake PR00000604, observation performed on 1/10/18 through 1/11/18 from 8:55 am until 4:45 pm, interview, the review of clinical records and policies/procedures, it was determined that the facility failed to ensure that physical environment, equipment and employees are train and coordinate to maintain a safe and good sanitary environment in the Hospital which makes this condition "Not Met"

Based on complaint investigation Acts intake PR00000604, tests performed on equipment and observations made during the survey for the physical environment with the Emergency Nursing Supervisor (employee #5) and the Emergency Room Medical Director (employee #3), it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well-being of patients receiving services.

Findings include:

1. During the observation performed on 1/10/18 thru 1/12/18 to the physical plant of the facility it was observe from the entrance of the road that leads to the hospital lobby and emergency room area (round plastic orange drum barrier) around the sidewalks and the street.

In an interview with the director of the physical plant (employee #11) on 1/12/18 at 10:16 a.m. he says that drones are there to control that visitors do not park in those areas.
However, no signs were observed in any moment indicating that it was prohibited to park in those areas.

2.In front of the employee parking lot and in the part of the side of the hospital that the multi-level parking lot of the hospital and at another one of the employees, it was observed the same drums around the sidewalks and the street.

Interview with (employee #11) indicates that those drones belong to the contractor that is carrying out the expansion of Degetau Street to the municipality of Caguas.

However, the same situation occurs where there is no sign indicating that this street is under construction; nor that there is caution that there is a construction in the area; creating confusion among visitors and patients who are visiting the facility.

Based on complaint investigation Acts intake PR00000604, tests performed on equipment and observations made during the survey for the physical environment , it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff.

Findings include:

1.The hospital's emergency room was visited on 1/10/17 at 8:55 am with the Emergency Room Nursing Supervisor (employee #5) and provided evidence that there cubicles in the triage area do not have doors, the front wall with glasses permit that patients waiting in the waiting area can see the patients during the performing of the triage.

Also that wall has a 14-inch unsealed space that does not reach the ceiling and allows outside listening to what the patient and nurse talk during the interview.

2. There are two corridors where there are patients on stretchers receiving treatment. 4 patients were observed alone on the stretchers receiving treatment, which had no way of communicating at the time of being assisted of needing anything.

Based on complaint investigation Acts intake PR00000604, and observations made during the survey for the physical environment with the Emergency Room Nursing Supervisor (employee #5), it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' fast track area and halls where patients are treated which are not equipped with an air disinfection system (such as ultraviolet lights).

Findings include:

The emergency room (adult) was visited on 1 /10/18 from 8:55 am through 4:45 pm and provided evidence that the waiting area in the fast track area and the halls where patients are treated not equipped with an air disinfection system (for example: Ultraviolet lights).

According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) the triage area is the point of entry of undiagnosed and untreated airborne infections and should be designed and ventilated to reduce exposure of staff, patients and families to airborne infectious diseases.

Through the facility's infection control program, determinations must be made related to general ventilation and air disinfection similar to inpatient requirements for airborne infection isolation rooms according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". The waiting area and observation area are other areas to provide protection with an air disinfection system.