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Based on the review of documents, observations, tests and interviews from 8/30/11 through 9/1/11 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. It did not provide the necessary oversight and leadership as evidenced by the lack of compliance with: (42 CFR 482.41) Physical Environment and (42 CFR 482.56) Rehabilitation Services.

Based on observations made of Pediatric Intensive Care Unit (P.I.C.U) with the Dietitian (employee #25), it was determined that the facility failed to promote patient rights related to personal privacy while personnel provide care and the right to treated patients with respect and comfort for one out of ten patients at this unit.

Findings include:

During observations at the P.I.C.U with the dietitian (employee #25) and nursing supervisor (employee #11) on 8/31/11 at 2:30 pm, it was found that nursing and respiratory therapy personnel were intervening with the patient in cubicle #10. The patient was completely without clothes except for disposable brief and they did not run the curtain to provide privacy for the patient. Personnel and visitors in front of this cubicle could see the patient.

Based on seven medical records reviewed, review of policies and procedure (P&P) related to restraint protocol, it was determined that the facility failed to ensure that the order for the use of restraints is never used as on a "as needed basis" (PRN) .

Finding include:

The facility's restraint policies and procedure reviewed on 8/31/11 at 9:30 am states "Discontinuation of the restriction by the nurse during the period of validity of the medical order. If the patient has no reason for the behavior of the restraining order. The nurse notifies the physician in charge. Discontinued the restriction. Documented interventions in the progress note. If the patient continued with the same conduct that prompted the restriction, the nurse implements alternatives to prevent the use of restraints. If the measures are ineffective, shall verify that the restraining order is still in force. (A restraining order lasts 24 hours). If the restraining order is still in force, shall restrict the patient. If the restraining order expires, the physician shall be informed to get a verbal or written order. The period that elapses from the restriction and obtaining the order may not exceed 12 hours. The physician reported that his patient was restricted and proceeded to evaluate the patient in person and places a written order within a period no longer than 24 hours of onset of the restraint" (this policy does not meet with the restraint regulation at 482.13 (e)(5)).

Based on the review of six closed and active records reviewed (R.R), policies/procedures manual and the observational tour with the emergency room nursing supervisor, it was determined that the facility failed to implement restraints that the physician ordered a specific time period for the patient's restrictions (for patients less than 9 years of age the time period shall not exceed 1 hour) and no evidence was found of the restriction re-evaluation based on the initial order placed by the physician for one out of one restrained patients' records reviewed (R.R #1).

Findings include:

R.R #1 is an 8 years old female who visited the emergency room on 8/27/11 with diagnosis of Uncontrolled Seizures with Severe Mental Retardation and the record review was performed on 8/30/11 at 2:30 pm. The patient was triaged at 8:45 am and was classified as non-urgent with the following vital signs (V/S): temperature-36ºC, pulse-86, respiration-24 and blood pressure-101/59. The patient was evaluated by the physician at 9:30 am and ordered Dilantin levels, Zantac 35 mg every 8 hours, Keppra 780 mg one loading dose and V/S every 4 hours. On 8/29/11 at 9:30 am the physician ordered Noctec 2 mg by mouth for one dose. On 8/29/11 at 2:25 pm the emergency room physician documents that the patient is to be restrained due to aggressive behavior related to removing her I.V lines related to her mental condition as the principle factor. The initial medical order did not have the time period that the patient was to be on restrictions (bilateral upper extremities). Nursing documentation reviewed from 8/29/11 form the 7-3 shift provided evidence that the patient was restrained from her upper extremities and to re-evaluate every two hours. Nursing documentation reviewed from 8/29/11 form the 3-11 shift provided evidence that the patient was observed alert, active and free from restrictions. No evidence was found when the facility removed the patient's restrictions, no evidence was found that the physician ordered a specific time period for the patient's restrictions (for patients less than 9 years of age the time period shall not exceed 1 hour) and not evidence was found of the restriction re-evaluation based on the initial order placed by the physician.

Based on the review of medication irregularities incidents, interviews and review of policies and procedures, it was identified that the facility failed to provide necessary care and services to monitor, document and implement improvement activities to ensure safety during the administration process of high alert drugs and medications to patients.

Findings include:

1. A mechanism to ensure that proactive measures are implemented in order to prevent medication administration errors and irregularities was not followed nor evidenced. During the survey process on 8/31/11 from 8:45 am through 3:00 pm the following was identified:

a. During the period of January 2011 through April 2011; 28 irregularities of high alert medications (Lanoxin, Fentanyl, Total Parenteral Nutrition, Insulin Drip and Intralipids) administration incidents were reported to the quality assurance program. These incidents failed to provide evidence that they were double checked by two nurses according with facility policies and procedures in order to ensure the safe administration of the medication or stopping the inappropriate medication with the double check process.
b. On 4/4/11 Lanoxin 25 micrograms orally (PO), every (q) 12 hours was ordered for a two month old patient who was receiving care at the pediatric intensive care unit with a diagnosis of Congestive Heart Failure and Sepsis. The medication was dispensed by a pharmacy personnel who did not double check the order and sent 0.25mgs (250 micrograms) a dose higher than the ordered by the physician. Once in the area the nurse did not double check the medication's dose and it was administered to the patient incorrectly on 4/4/11 at 6:00 pm. Routine lanoxin blood level samples were taken for the patient on 4/5/11 at 4:00 am, at 4:45 am and panic levels (levels were higher than normal values) of lanoxin were notified to a nurse who reported it to the physician. However no correction of the dose was performed. The medication was administered incorrectly to the patient again on 4/5/11 at 6:00 am. After this incident the facility analyzed the situation and established a correction plan in order to ensure that a situation like this does not happen again.
c. After the event of 4/4/11 the facility was in the process of improving the mechanism of ordering, dispatching and administration of high alert medications, however they still have irregularities in the process related with high alert medications management that could cause adverse results to patients. During the period of May/2011 through August 2011 thirteen irregularities of high alert medication administration incidents were reported to the quality assurance program. These incidents failed to provide evidence that they were double checked by two nurses according with facility policies and procedures in order to ensure the safe administration of the medication or stopping the inappropriate medication with the double check process. The facility failed to implement appropriate measures in order to permanently improve the process of medication administration in order to maintain a safe process of medication administration.
d. Irregularities of high alert medication administrations for the period of January/2011 through August/2011 were discussed with the Director of Nursing (employee #5) and Quality Assurance Officer (employee #3) on 9/1/11 at 10:42 am. The following was a summary of the information given during this interview: "Irregularities on the administration of high alert medications are more common at the neonatal intensive care unit. This is because the area does not have an adequate number of personnel to comply with the double check required before administration of these types of medications and because the process of double checking the nurse does not perform it when reviewing the physician's order. The facility is concerned about these medication incidents and they are in the process of trying to establish mechanisms to perform the double check appropriately by pharmacy and nursing personnel. They are working on mechanisms to be aware of risk reduction in order to react to it before something serious takes place. Pharmacy personnel staffing are not complete nor is neonatal intensive care unit nursing personnel.

Based on the review of quality assurance activities with the quality assurance officer (employee #3), it was determined that the facility failed to ensure that as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care.

Findings include:

1. The facility failed to provide evidence on 9/1/11 at 3:44 pm of performance improvements projects where an information technology system is used to improve quality of care of services offered to patients.

2. Performance improvement activities reviewed on 9/1/11 at 3:44 pm, conducted by the facility according with their types of services does not include improvement projects which implements technology systems designed to improve quality of care of services offered to patients, as required by 482.21 (d)(2) standard of QAPI Condition of Participation.

Based on the review of twenty-three 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) and State Narcotic License for eight out of twenty-three medical staff's C.Fs (C.F #14, #15, #17, #18, #19, #20, #21 and #23).

Findings include:

1. During the review of twenty-three medical staff credential files on 9/1/11 from 8:20 am till 9:20 am the following was found:

a. Six out of twenty-three medical staff's credential files provided evidence of expired Health Certificates (C.F #14, #15, #17, #18, #21 and #23).

b. Two out of twenty-three medical staff's credential files provided evidence of expired cardio-respiratory certificates (C.Fs #19 and #20).

c. One out of twenty-three medical staff's credential files did not have evidence of their updated State narcotic license (C.F #19).

Based on the review of ninety-three nursing credential files, it was determined that the facility failed to examine credential files (C.F) to ensure that nursing staff have updated Health Certificates and Cardio-pulmonary Resuscitation Certificates (CPR), hepatitis B vaccine, updated annual evaluations and competencies and duty and responsibility for twenty-nine out of ninety-three credential files reviewed (C.Fs #4, #6, #7, #8, #11, #15, #18, #19, #23, #31, #34, #35, #36, #40, #50, #51, #52, #54, #61, #64, #68, #71, #72, #73, #76, #84, #85, #91 and #92).

Findings include:

1. During the review of ninety-three nursing credential files files on 8/31/11 at 10:30 am the following was found:

a. Three out of ninety-three nursing credential files provided evidence of expired Health Certificates for C.Fs #7, #31 and #54.

b. Two out of ninety-three nursing credential files provided evidence of expired cardio- respiratory certificates for C.Fs #17 and #23.

c. Six out of ninety-three nursing credential files did not contain evidence of Hepatitis B vaccine (C.F #4, #15, #18, #54, #84 and #85).

d. Seven out of ninety-three nursing credential files did not contain evidence of updated annual evaluation (C.F #4, #8, #11, #19, #23, #50, #51 and #92).

e. Two out of ninety-three nursing credential files did not contain evidence of updated competencies (C.F #23 and #61).

f. Eleven out of ninety-three nursing credential files did not contain evidence of duty and responsibility (C.F #5, #6, #31, #35, #44, #64, #67, #71, #72, #73 and #76).

Based on the review of six clinical records and policies/procedure with the Director of Nursing (DON) (employee #5), it was found that the facility failed to ensure that nursing staff develop appropriate nursing interventions and implement, individualized and updated care plans for five out of six records reviewed (R.R #15, #16, #17, #18, and #19)

Findings include:

1. Five out of six records reviewed for care plans on 8/30/11 from 1:00 pm through 3:45 pm and 8/31/11 from 9:00 am till 12:00 pm provided evidence that a patient did not have written nursing care plans during the patients' hospitalization and did not provide evidence of an individualized and updated plan of care.

a. R.R #15 is a 4 years old male who was admitted on 8/22/11 with Fever, B Cell lymphoma arterious Mediastinum Status post partial resection.. The patient's record was reviewed on 8/30/11 at 1:25 pm and evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization but didn't individualize the standardized plan of care. No evidence was found of the revision of patients' needs according to the patient's changes during the in-patient stay.

b. R.R #16 is a 16 years old male who was admitted on 8/29/11 with Osteosarcoma and Right femur above knee amputation. The patient's record was reviewed on 8/30/11 at 1:40 pm and evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization but was not individualized for the standardized plan of care.

c. R.R #17 is a 7 years old male who was admitted on 8/24/11 with Diabetes Ketoacidosis, Diabetes Mellitus De Novo. The patient's record was reviewed on 8/30/11 at 2:10 pm and evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization and did not individualize the standardized plan of care. No evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

d. R.R #18 is a 16 years old male who was admitted on 8/24/11 with Suspected Acute Appendicitis. The patient's record was reviewed on 8/30/11 at 3:00 pm and evidence was found that the registered nurse did not activate the plan of care according to the patient's needs during the hospitalization. No evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

e. R.R #19 is a 7 years old female who was admitted on 8/29/11 with Intracerebral Hemorrhagia. The patient's record was reviewed on 8/31/11 at 9:30 am and evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization but did not individualize the standardized plan of care. No evidence was found of the revision of patients' needs according to the patient's changes during the in-patient stay.

Based on observations of the medication drug cart with the nursing director (employee #5), it was determined that the facility failed to ensure that drugs and biologicals are stored and protected in a proper manner related to medications not secured in the medication cart and failed to follow nursing staff competence for Medication Administration for eight out of eight patients observed.

Findings include:

1. During the observational tour of the third floor ward on 8/31/11 at 9:10 am with the nursing director (employee #5), the medication cart was observed unattended while the nurse (employee #32) was in patient's rooms.

a. Medication drug carts were observed unlocked and unattended while a nurse administered medications to the patient at the third floor ward room #317A at 9:25 am.

2. The following was observed during the medication administration on 8/31/11 from 9:10 am through 9:30 am related to medication administration:

a. During observations in rooms #15 and #17 of the medication administration (oral route) performed on 8/31/11 from 9:10 am through 9:30 am, accompanied by a Registered Nurse (RN) (employee #32) she was observed introducing the medication cart into patient's room
#15 for four patients, she placed the cart between patient's beds "A" and "B" then she served the medications for the patient in bed "A", after finishing with the patient, the nurse did not wash her hands and moved the medication cart to patient's bed C then she proceeded to wash her hands. RN #32 failed to follow professional standards of practice related to hand washing during the medication administration. The RN #32 performed the same procedure with the patients in room #17.

Based on the review of the policies and procedure's manuals, a manual of abbreviations and incomplete medical records report provided by the medical record supervisor (employee
#18), it was determined that the facility failed to complete clinical records within 30 days following discharge and maintain an updated and approved by the Governing Body abbreviations and signature registry and are reviewed and revised as needed.

Findings include:

1. No evidence was found on 9/1/11 at 9:30 am of an abbreviation manual that was updated and approved by the Governing Body and includes the pharmacy supervisor's signature of participation.

2. The signature registry of physicians and other disciplines were reviewed with the Medical Record Supervisor (employee #18) on 9/1/11 at 9:30 am. The signature registry was not updated nor was it approved by the Governing Body.

3. The incomplete medical record report reviewed on 9/1/11 at 3:30 pm with the Medical Record Supervisor (employee #18), revealed that there are 1,255 incomplete records over 30 days. However, no evidence was found of the incomplete medical record report for the nursing staff and other disciplines. There is an average of 368 monthly discharges. No evidence was found in the incomplete medical record report of the amount of days of the incomplete records that corresponds to this information.

4. Three transfer records were requested from the facility's medical record department, however only one (R.R #13) was provided for review and the other two were not retrieved for review (R.Rs #12 and #14) on 9/1/11 at 10:00 am.

Based on the observational tour of the medical record department with the medical record supervisor (employee #18), it was determined that the facility failed to ensure that unauthorized individuals gain access to the record department and that the records are protected.

Findings include:

1. On 9/1/11 at 9:45 am personnel and visitors were observed entering and leaving the medical records department. The visitors were asking questions and requesting copies of medical record. The entrance door of the medical record department was not locked and did not prevent unauthorized access. The door was left open during the entire survey and this area was observed with incomplete records for personnel to complete on a table near the entrance (approximately 100 medical records).

2. During observations of the medical record department on 9/1/11 at 9:55 am with the medical record supervisor (employee #18), it was determined that a microwave and a small refrigerator were located at a corner of the medical record room. The area was found full of records for review and stored and the microwave and refrigerator are fire hazards due to their close proximity and lack of separation (approximately 200 medical records, microwave and refrigerator).

Based on the review of forty-six closed and active clinical records, it was determined that the facility failed to ensure that medical staff, nursing personnel and other disciplines maintain legible entries for forty-six out of forty-six records reviewed (R.R #1 through #46).

Findings include:

Forty-six clinical records reviewed from 8/30/11 through 9/1/11 from 9:30 am till 3:30 pm contained portions that are not legible. Most notable were the physician's progress notes, nurse's notes, signatures (physicians and nurses), consults, diagnosis, operative reports, informed consent forms, anesthesia reports and physician's orders.

Based on the review of pharmacy reports of inspections of controlled drug areas with the Pharmacy Director (employee #15) and interview, it was determined that the facility failed to
comply with policies and procedures which govern pharmaceutical services.

Findings include:

1. During the review of pharmaceutical services administrative duties and responsibilities with the pharmacy director (employee #15) on 8/30/11 from 2:00 pm though 3:12 pm the following was found:

a. In April of 2011 the fifth north ward controlled medication stock was not inspected by pharmacy personnel.

b. In May of 2011 the pediatric intensive care controlled medication stock was not inspected by pharmacy personnel.

c. In June of 2011 the emergency room controlled medication stock was not inspected by pharmacy personnel.

2. The Pharmacy Director (employee #15) stated during interview on 8/30/11 at 3:10 pm that controlled medication stocks must be inspected on a monthly basis in order to ensure that these areas are managed according with applicable Federal and State Law and accepted professional principles. However pharmacy services does not have an adequate number of personnel to comply with these inspections.

Based on observations and review of policies/procedures and twenty-five credential files of pharmacy service employees with personnel from the human resource officer (employee
#30), it was determined that the facility failed to supervise all activities of the pharmacy as evidenced by a lack of updated health certificates for seven out of twenty-five credential files, and performance evaluations for fifteen out of twenty-five pharmacy credential files.

Findings include:

1. Seven out of twenty-five pharmacy employees credential files were reviewed on 9/1/11 at 3:45 pm with the human resource officer (employee #30) and provided evidence that C.Fs
#5, #6, #13, #20, #21, #22 and #23) did not have updated health certificates.

2. Fifteen out of twenty-five pharmacy employees credential files were reviewed on 9/1/11 at 3:45 pm with the human resource officer (employee #30) and provided evidence that C.Fs #1, #4, #7, #8, #9, #10, #11, #12, #14, #16, #19, #21, #22, #24 and #25 did not have annual updated performance evaluations.

Based on observations of the medication storage room with the Pharmacist (employee #15) and interview, it was determined that the facility failed to ensure that all drugs and biologicals are stored in a proper and safe manner accessible only to authorized personnel.

Findings include:

1. During the initial observational tour with the pharmacist (employee #15) on 8/30/11 from 9:04 am though 11:55 am the following was found:

a. At the neonatal intensive care unit it was observed the medication stock area was open. Medications were available to non authorized personnel. A nurse (employee #28) was observed trying to close the lock with a broken key. No information was given to the pharmacist (employee #15) when the key was broken.

b. Medication carts on the fifth floor and emergency room were found without locks. Medication storage inside were available to non-authorized personnel.

c. At the fifth floor south area ward it was observed that the medication room was open. Proventyl, Vaponefrin and Modudose ampules used for respiratory therapy were available to non-authorized personnel.

Based on the review of documents with the human resource officer (employee #30) and eighteen credential files (C.F), it was determined that the facility failed to ensure that credential files of the Radiology Department are updated related to ten out of eighteen credential files that lacked updated health certificates, ten out of eighteen credential files lacked updated cardiopulmonary certificates and eighteen out of eighteen lacked the annual performance evaluations (C.F #1 through #18).

Findings include:

1. Review of eighteen radiology credential files on 9/1/11 at 3:31 pm provided evidence of the following:

a. Ten out of eighteen radiology employee credential files were reviewed on 9/1/11 at 3:31 pm with the human resource officer (employee #30) and provided evidence that C.Fs #7, #8,#11, #12, #13, #14, #15, #16, #17 and #18) did not have updated health certificates.

b. Ten out of eighteen radiology employee credential files were reviewed on 9/1/11 at 3:31 pm with the human resource officer (employee #30) and provided evidence that C.Fs #2, #3,#5, #7, #8, #9, #11, #15, #16 and #17) did not have updated cardiopulmonary certificates.

c. Eighteen out of eighteen radiology employee credential files were reviewed on 9/1/11 at 3:31 pm with the human resource officer (employee #30) and provide evidence that C.Fs #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17 and #18 did not have updated performance evaluations.

Based on the emergency room and contract kitchen observational tour with the facility's dietitian (employee #21) and kitchen dietitian manager (employee #27) of the facility's contract kitchen that serves and prepares patient's meals, review of menus and policies/procedures, temperature verification and interview, it was determined that the facility failed to clean, maintain and prepare food in a safe and sanitary manner related to formula storage, clean enteral nutrition machines were not covered, formula preparation without date of expiration, already prepared food exposed to the cleaning process of the coffee makers, food not maintained at the appropriate temperature, cleaned pots are stored wet, the formula room has high humidity, prepared formula past date of expiration, there is a ceiling leak above the dish washer and the dietary manual related to policies/procedures was not approved by the governing body.

Findings include:

1. During the emergency room (ER) observational tour performed with the ER supervisor (employee #19) and facility dietitian (employee #21) on 8/30/11 from 10:00 till 10:30 am the following was observed:

a. The formula room was visited on 8/30/11 at 10:00 am and the temperature was taken with a laser thermometer and it was found to have a temperature of 75ºF and inside of the formula cabinet (where the formula was stored) the temperature was 79ºF. Manufacturer's recommendations suggest that formulas are to be stored to avoid excessive heat. No evidence was found that the facility is measuring and recording the temperature of this room to ensure that the formulas are properly maintained.

b. Two enteral nutrition machines were found in the formula room over the disaster equipment cart. The ER supervisor (employee #19) stated during an interview on 8/30/11 at 10:10 am that the machines were clean and ready to use. However, the machines were found uncovered and according to policies/procedures reviewed on 8/30/11 at 2:00 pm, cleaned enteral nutrition machines are to be covered. The facility failed to ensure that infection control standards are followed related to covering clean enteral nutrition machines.

c. The formula room was found on 8/30/11 at 10:15 am with a refrigerator that contained one bottle of 4 ounces of formula (a preparation of Pregestimil and Propimex 2) with a date of preparation of 8/29/11 at 9:30 am, however it did not have the date of expiration on it for when personnel need to discard. Policies/Procedures stated to discard after 24 hours as reviewed on 8/31/11 at 2:00 pm.

2. During the contract kitchen observational tour performed with the kitchen manager dietitian (employee #27) and facility dietitian (employee #13) on 8/31/11 from 10:30 am till 12:15 pm the following was observed:

a. During observations of the serving kitchen on 8/31/11 at 10:45 am with the facility's dietitian (employee #13), it was found that while staff were taken the temperature of the food on the steam table, kitchen personnel (employee #26) was on a step ladder with a hose cleaning two large coffee makers. The coffee makers were within 1 foot of the steam table with food exposed to the cleaning process of the employee. This practice does not ensure infection control standards related to food protection.

b. The steam table was observed on 8/31/11 at 11:00 am with four open slots where metal trays are supposed to be placed and the hot vapor from the steam table was seen above these four open slots. The temperature of the steam table water was taken by the kitchen supervisor (employee #28) on 8/31/11 at 11:10 am and was found to be 140ºF. The steam table contained covered trays with chopped meat and the temperature was also obtained and found to be 120ºF. When the amount of food cooked does not allow a tray for each slot the facility must ensure that these slots are covered to reduce heat loss and the steam table (temperature should be 140ºF or above) maintains appropriate temperature to guarantee that food is safe for consumption and patients can eat hot food.

c. Already cleaned metal container were found on 8/31/11 at 11:20 am stacked upside down one next to the other on shelves and they were found wet with an accumulation of water.

d. The formula room of the kitchen was visited on 8/31/11 at 11:30 am with the facility dietitian (employee #13) and contract kitchen dietitian manager (employee #27) and it was found that the temperature of this room was 63ºF with 99% humidity. The contract dietitian manager (employee #27) stated on 8/31/11 at 11:35 am that the relative humidity was high because the temperature was low.

e. Three containers of dry milk of 8 ounces (Polycose, Ele-Care and Enfamil) were found on the counter in the formula room on 8/31/11 at 11:35 am. The date opened of the Enfamil was 7/20/11 and the manufacturer suggests to discard after 30 days. The Polycose was opened on 8/25/11 and the Ele-Care was opened on 8/17/11, the formula preparation employee (employee #29) stated on 8/31/11 at 11:45 am that both formulas are to discard after 3 days from when opened. The manufacturer suggestions were found for these formulas (Polycose and Ele-Care) and it states to discard after 30 days as reviewed on 8/31/11 at 2:00 pm. The facility failed to ensure that formula personnel are familiar with manufacturer's suggestions related to discarding opened formula.

f. During observations of the dish washing room on 8/31/11 at 11:45 am it was found that the ceiling acoustic tiles that are directly above the dish washer machine were wet and leaking down on the floor in front of the dish washer machine.

3. The last revision of the Diet Administrative Manual of policies and procedures was from 2007 and lacks the signature of approval by the governing body members.

Based on closed clinical record review (R.R), policies/procedures and dietitian interview, it was determined that the facility failed to ensure that patients receive appropriate diet for age and nutritional status is being monitored for R.R #11.

Findings include:

R.R #11 is a 1 year old female who was admitted on 2/26/11 with a diagnosis of Respiratory Failure with Acute Bronchospasm. The record was reviewed on 9/1/11 at 1:30 pm and provided evidence that the patient was ordered "nothing per mouth" (NPO) since admission on 2/26/11 to the oncology ward. The patient was ordered BIPAP at 40% and .45% D/NS with KCL to run 40 ml per hour. The physician's nutritional assessment performed on 2/26/11 at 9:00 am provided evidence that the patient had a nutritional risk of "4" (which is described as mild and no action required). The physician also writes to put the patient on a liquid diet on 2/27/11 and then regular diet according to the patient's age on 2/28/11. The nurse documents on 2/26/11 at 3:00 pm that the patient has an altered nutritional status. The Hemo/Onco dietitian (employee #21) was interviewed on 9/1/11 at 1:45 pm and referred that Policies/Procedures states that patients admitted to the Hemo/Onco ward are all to be evaluated by the dietitian. No evidence was found of the initial dietitian evaluation and who is to determine the age appropriateness of the diet.

Based on tests performed on equipment, interview and observations made during the survey for the physical environment with the facility's Safety Officer (employee #1) and Engineer (employee #2), 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 related to the air extractor system of the hospital not working, the elevator machine room with machinery and motors that control elevators #3, #4 and #5 did not have a working cooling system (air conditioner), bathrooms, dirty utility rooms and housekeeping closets did not have door closers, the facility failed to ensure that the infant protection system/alarm is tested and working properly, the Neonatal Intensive Care Unit (N.I.C.U) has two janitor's closets but the door knobs did not work properly, there is an accumulation of trash around and near the garbage dumpster in the parking area, no evidence was found of periodic smoke barrier door maintenance, the facility failed to follow established procedures for the storage of biohazardous trash related to the outside biohazardous storage room that was found with its door unlocked, the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to the use of improper biohazardous sharp container, the emergency nursing call system was not working properly, the 8,000 gallon diesel storage tank has a double wall which was rusty, crash carts are not equipped with ready to use oxygen cylinders, maintenance carts found with cleaning chemicals on top and in the middle of the carts and did not have cabinets with locks and no evidence was found that a biomedical technician verified the function of the negative pressure system of the isolation rooms, the facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff related to handicapped bathrooms, the waiting area of the emergency room does not have a water fountain or sign for the handicapped bathroom, the triage room does not provide privacy, a ramp is not appropriately designed, the operating room department is not appropriately designed, Cidex OPA is not used in an appropriate manner, medical record room found with a microwave and refrigerator, the location of the janitor's closet in a storage room of the emergency room does not ensure infection control standards related to possible cross contamination, no evidence was provided that the elevators have recall capacity, stair cases have signs at each floor stating in Spanish that there is no exit at the roof and what floor to exit on but it should also be in English, janitor's closet at the renal dialysis unit does not have a floor sink, janitor's closet does not have a mop holder at the follow-up clinic, the south exit staircase of building C was found that there is only handrail on one side of the staircase from the second to first floor, the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas which are not equipped with an air disinfection system (such as ultraviolet lights) and failed to ensure that applicable provision of the 2000 edition of Life Safety Code of the NFPA 101 are met: K0018, K0021, K0033, K0046, K0050, K0051, K0052, K0062, K0064, K0072, K0130 and K0147. These findings make this condition "Not Met".

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Safety Officer (employee #1) and Engineer (employee #2) and interview, 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 related to the air extractor system of the hospital not working, the elevator machine room with machinery and motors that control elevators #3, #4 and #5 did not have a working cooling system (air conditioner), bathrooms, dirty utility rooms and housekeeping closets did not have door closers, the facility failed to ensure that the infant protection system/alarm is tested and working properly, the Neonatal Intensive Care Unit (N.I.C.U) has two janitor closets but the door knobs did not work properly, there is an accumulation of trash around and near the garbage dumpster in the parking area and no evidence was found of periodic smoke barrier door maintenance.

Findings include:

1. During the observational tour of the facility from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2) it was found that the air extractor system of the hospital is not working. Bathrooms, dirty utility rooms and housekeeping closets did not have working air extractors. The facility's Engineer (employee #2) stated during an interview on 8/31/11 at 8:45 am that the main extractor on the roof is out of balance and in need of repair and this effects the entire facility.

2. The elevator's machine room on the roof was visited on 8/31/11 at 8:50 am with the facility's Safety Officer (employee #1) and Engineer (employee #2). This elevator machine room has the machinery and motors that control elevators #3, #4 and #5, however the cooling system (air conditioner) in this room used to protect the control panels and machinery in this room does not work.

3. During observations of the facility from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2) it was found that bathrooms, dirty utility rooms and housekeeping closets did not have door closers.

4. During the observational tour of the Emergency Room on 8/30/11 at 10:15 am with the
facility's Safety Officer (employee #1) and Engineer (employee #2) it was found that the exit door of the hallway near cubicle #1 is connected to the facility's alarm related to the protection of infants (Law #133). However a patch was placed over the magnetic poles to prevent the door from locking in the event that the alarm system was activated.

5. During the observational tour of the facility from 8/30/11 through 9/1/11 from 8:00 am till 4:00 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) it was found that the south staircase of building "B" exit doors located on the second and fifth floors are part of the facility's alarm system related to the protection of infants (Law #133). However these doors were recently replaced with new doors but the magnetic poles were not placed on these doors which will not allow the doors to lock in the event that the alarm system is activated.

a. Review of the facility's periodic testing of the infant protection alarm system (Law #133) with the facility's Safety Officer on 9/1/11 at 11:50 am provided evidence that the last test was performed in October of 2010. According with Law #133 from June of 1999, at least two tests/drills shall be performed and documented per year to ensure the proper function of this system.

6. The Neonatal Intensive Care Unit (N.I.C.U) was visited on 8/31/11 at 8:45 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and it was found that this area has two janitor closets, but the door knobs did not work properly.

7. The door that separates the 5th south ward from the elevator area was found in the open position on 8/31/11 at 11:00 am.

8. There is an accumulation of trash around and near the garbage dumpster in the parking area as observed on 8/30/11 at 11:50 am with the facility's Safety Officer (employee #1) and Engineer (employee #2).

9. No evidence was found that the facility is testing on a periodic basis the smoke barrier doors of the hospital as determined on 9/1/11 at 11:25 am with the facility's Safety Officer (employee #1). The doors shall be released from their hold open devices and verified for how fast they close (doors can not close too fast because they can harm a patient passing through these doors-according with "Americans with Disabilities Act" section 4.13.10 (Door Closers) door closers should be adjusted so that from an open position of 70 degrees, the door will take at least 3 seconds to move to a point 3 inches from the latch) and shall be verified to ensure that they close flush and latch properly.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed with the facility's Safety Officer (employee #1) and Engineer (employee #2), from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0018, K0021, K0033, K0046, K0050, K0051, K0052, K0062, K0064, K0072, K0130 and K0147).

Based on the review of policies/procedures (P&P) and observations made during the survey for the physical environment with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that the facility failed to follow established procedures for the storage of biohazardous trash related to the outside biohazardous storage room that was found with its door unlocked.

Findings include:

The outside biohazardous storage room located at the back of the hospital was visited on 8/30/11 at 11:45 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and provided evidence that the door was not locked to prevent unauthorized access. Facility policies and procedures reviewed on 9/1/11 at 1:00 pm provided evidence that this door where biohazardous trash is placed is to be kept in a locked and secure area, away from unauthorized persons (a lock was placed on this door as observed on 8/30/11 at 3:30 pm).

Based on observations made during the survey for the physical environment with the facility's Safety Officer (employee #1) and Engineer (employee #2), 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 to the use of improper biohazardous sharp container, the emergency nursing call system was not working properly, the 8,000 gallon diesel storage tank has a double wall which was rusty, crash carts are not equipped with ready to use oxygen cylinders, maintenance carts found with cleaning chemicals on top and in the middle of the carts and did not have cabinets with locks and no evidence was found that a biomedical technician verified the function of the negative pressure system of the isolation room.

Findings include:

1. Biohazardous sharp containers were observed throughout the entire hospital from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2). Some of the biohazardous sharp containers were found on wall brackets and some were found placed on counter tops without brackets. It was determined that the biohazardous sharp containers do not meet minimum standards as recommended from "Selecting, Evaluating, and Using Sharps Disposal Containers" related to:
a. Sharp containers did not have their lids tightly placed on the containers.
b. The design of these lids does not prevent reaching in and obtaining its contents.
c. The design of these lids does not protect staff from accidental needle pricks when depositing material in these containers.
d. All sharp containers located throughout this Pediatric Hospital were found on wall security brackets or placed on top of counters without brackets but were not secured with locks to prevent them from tipping over and loosing their contents or from un-authorized removal (special care shall be placed for height and security based on the patients (pediatric) treated at this hospital). According with recommendations from "Selecting, Evaluating, and Using Sharps Disposal Containers" sharp containers should have mounting brackets and locking devices.
e. All sharp containers were found at different heights throughout the hospital (a sharp container found in the emergency room was found at three feet from the ground). According with recommendations from "Selecting, Evaluating, and Using Sharps Disposal Containers" sharp containers where they are fixed to walls or other permanent sites, the vertical height should allow the worker to view the opening of the container and Appendix B determines an optimal installation range between 52 and 56 inches (from the floor) at a standing workstation and within arms reach (11 to 19 inches).
f. Special attention shall be made at this hospital dedicated for pediatric patients related to height, placement and locking device to ensure that they are protected from unauthorized access.

2. The emergency nursing call system throughout the hospital were tested from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2). Some call systems at the Emergency Room and wards were not working and the facility's Safety Officer (employee #1) provided evidence that the facility identified this situation and provided evidence of a contingency plan related to documented rounds by nursing personnel and security staff and education provided to care givers. By 9/1/11 at 3:00 pm the complete emergency nursing call system of the emergency room was repaired and found functional. The facility must continue to enforce the contingency plan and repair the remaining emergency nursing call systems in a timely and effective manner.

3. The 8,000 gallon diesel storage tank located at the outside of the facility was visited on 8/30/11 at 11:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2). This tank has an outside double wall which is to prevent a diesel leak from the main tank from spilling on the ground and possibly entering ground water. However observations of this outer tank provided evidence that it is rusty along its weld lines and no evidence was found of its maintenance.

4. The crash cart located at the treatment area on the 5th south ward was found without a type E oxygen cylinder attached to the cart on 8/31/11 at 10:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2). To ensure that patients receive immediate care in the event of an emergency the oxygen cylinder shall be attached to the crash cart to ensure that it goes where the cart goes.

5. The crash cart located at the follow-up clinic was found without valve meter on the type E oxygen cylinder attached to the cart on 9/1/11 at 10:10 am with the facility's Safety Officer (employee #1) and Engineer (employee #2). To ensure that patients receive immediate care in the event of an emergency the oxygen cylinder shall have the valve meter attached to ensure that it is ready to use.

6. Maintenance carts were observed from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm with cleaning chemicals on top and in the middle of the carts and did not have a cabinet on these carts where personnel can lock these cleaning solutions to limit its accessibility to non authorized persons.

7. Isolation rooms of the facility were visited with the facility's Safety Officer (employee #1) and Engineer (employee #2) from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm and provided evidence that the rooms have negative pressure. No evidence was found that a biomedical technician verified the function of the negative pressure of these rooms nor was documentation found of the periodic filter changes as suggested by the manufacturer.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Safety Officer (employee #1) and Engineer (employee #2), review of policies and procedures, incident and accident reports, 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 related to handicapped bathrooms, the waiting area of the emergency room does not have a water fountain or sign for the handicapped bathroom, the triage room does not provide privacy, a ramp is not appropriately designed, the operating room department is not appropriately designed, Cidex OPA is not used in an appropriate manner, medical record room was found with a microwave and refrigerator, the location of the janitor's closet is located in a storage room of the emergency room does not ensure infection control standards related to possible cross contamination, no evidence was provided that the elevators have recall capacity, stair cases have signs at each floor stating in Spanish that there is no exit at the roof and what floor to exit on but it should also be in English, janitor's closet at the renal dialysis unit does not have a floor sink, janitor's closet does not have a mop holder at the follow-up clinic and the south exit staircase of building C was found with only one handrail on one side of the staircase from the second to first floor.

Findings include:

1. During the observational tour of the emergency room on 8/30/11 from 9:00 am till 10:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2), the following was found:
a. The waiting area does not have a water fountain.
b. The waiting area does not have a sign with instructions related to the location of the handicapped toilet.

2. The triage room was visited on 8/30/11 at 9:10 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and it was found that the triage room is located across from the waiting room of the emergency room. The triage room does not have a door to provide privacy during interviews and interventions from persons in the hallway or those persons standing near the waiting room or in the three examination cubicles located within the triage area.

3. During observations of the medical record department on 8/31/11 at 11:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) it was determined that a microwave and a small refrigerator were located at a corner of the medical record room. The medical record room was found full of records being reviewed and stored and the microwave and refrigerator are fire hazards due to their close proximity and lack of separation (medical records, microwave and refrigerator).

4. A storage room located at the emergency room (E.R) was visited on 8/30/11 at 9:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and it was found with multiple boxes stacked one on the other filled with papers, equipment used for E.R patients, stretchers and mobile blood pressure cuffs. Within this room was a janitor's closet where housekeeping personnel keep buckets, mops, brooms and a large garbage container. The location of the janitor's closet in this storage room with E.R equipment does not ensure infection control standards related to possible cross contamination.

5. A utility room located at the emergency room (E.R) was visited on 8/30/11 at 9:40 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and it was found that there were trays of Cidex OPA. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media (this room did not have a working air extractor) and no evidence was found that this room has a spill kit to use if Cidex OPA accidentally falls on the floor.

6. The ramp located in front of the hospital near the administration offices was visited on 8/30/11 at 11:05 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and part of the ramp was found with only one hand rail on one side of the ramp. To ensure that persons with impediments on either side of their bodies can safely access this ramp, hand rails are needed on both sides of the ramp according with the "Americans with Disabilities Act" (Ley ADA) requirements.

7. The elevators were visited from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2). No evidence was provided that the elevators have recall capacity (if the fire alarm is activated the elevator shall open to the closest floor and remain open).

8. The operating room department was visited on 8/31/11 from 1:30 pm through 2:30 pm with the facility's Engineer (employee #2) and provided evidence of the following:
a. Male and female ambulatory patients dressing room is the same as the phase II area and patients were observed entering through the semi-restricted area also used by personnel already in scrubs.
b. The facility operates on ambulatory patients and they have a designated phase II area with three lounge chairs, however the lounge chairs were too close to each other, this area must be separated by curtains and there needs to be at least four feet between each chair and the seats should be placed to avoid visual contact from patient to patient, there needs to be a bathroom for patients, area for patient's family members and area for nursing personnel to write and have visual contact with patients.
c. The facility has a room that is used to process equipment with Cidex OPA. The exhaust fan in this room is located across from the the Cidex OPA tray which places employees working in this area in the direct line of the ventilated exhaust. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media.
d. There are four operating room suites, however only three buckets were found to clean the operating suites, instead of one mop and one bucket per suite. Also, a separate mop and bucket are needed for the hallways and recovery.
e. The janitor's closet does not have an air extractor or smoke detector.
f. Some personnel were observed without shoes covers and with long sleeve shirts under their scrubs.
h. The bathroom of the phase II area does not have a bench for patients to sit on when changing their clothes.

9. This facility has six floors as determined on 8/30/11 at 2:00 pm with the facility's with the facility's Safety Officer (employee #1) and Engineer (employee #2). The stair cases have signs at each floor stating in Spanish that there is no exit at the roof and what floor to exit on, however this facility served a varied population and the signs should also be in English.

10. The janitor's closet located at the renal dialysis unit was visited on 8/31/11 at 2:50 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2) and provided evidence that it does not have a floor receptor (floor sink). A service sink was found at approximately three feet high (from the floor), which increases the risk of staff hurting themselves when lifting pails filled with dirty water and splashing. The room does not have an air extractor and the door does not have a door closer.

11. The handicapped toilet located at the General Pediatric ward was visited on 8/31/11 at 3:00 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2) and it was found that the door of this bathroom did not have the international symbol related to handicapped accessibility and no mirror was found.

12. The handicapped toilet located at the surgery ward was visited on 8/31/11 at 3:30 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2) and the following was found:
a. The toilet lacks grab bars at both sides of the toilet (or one side and behind the toilet).
b. The door of this bathroom did not have the international symbol related to handicapped accessibility.
c. No mirror was found.
d. No door closer.

13. The janitor's closet located at the follow-up clinic was visited on 9/1/11 at 10:10 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and provided evidence that it does not have a mop holder.

14. The south exit staircase of building C was visited on 9/1/11 at 10:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and it was found that there is only handrail on one side of the staircase from the second to first floor.

Based on observations made during the survey for the physical environment with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas which are not equipped with an air disinfection system (such as ultraviolet lights).

Findings include:

The emergency room was visited on 8/30/11 at 9:00 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and provided evidence that the waiting area, triage area and the observation area of the pediatric emergency room are 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.

Based on the observational tour with the infection control officer (employee #7) and the nursing director (employee #5), review of policies/procedures (P&P) and interview, it was determined that the facility failed to promote sanitary and safe care through its infection control program at the Neonatal Intensive Care Unit (NICU), the fifth floor general pediatric, Oncology, third floor general pediatric, second floor, related to packages of non sterile gauze opened and exposed to the environment, dirty open incubator, used sterile water available for patient use, sharp containers without security racks, foley bags without labels, no labels for the nasogastric drainage bag, Cidex OPA room without an extractor, nurse washed her hands for less than 5 second, cabinet used to store medical/surgical material was in wood and was broken, broken cabinet formica, reclining chair with broken vinyl, respiratory therapy equipment without label, night table with broken formica.

Findings include:

1. During the observational tour with the infection control officer (employee #7) and the nursing director (employee #5), at the North and South NICU ward on 8/30/11 from 9:30 am till 12:00 md the following was found:

a. It was observed that all sharp container were placed in security racks, however without locks were found NICU A-1 through NICU A-25, medication carts, crash carts, sample carts and sharp container without a security rack at NICU A-26 through NICU A-50.

b. Open cribs with evidence of dirt with brown stains in the grooves and on the rails and it had tape and tape spots on the rails and mold on the frame (NICU A-29, A-31, A-32, A-41).

c. Drainage bags of gastric secretions were observed without a label with the date and hour when it was placed there (NICU A-10, A-29, and A-38).

d. A bottle of sterile water of 1000 ml opened available for patient use without a label with the date and hour when opened and what used for. The manufacturer recommends to discard unused portion (NICU A-14 and A-29).

e. A non sterile gauze pack of 200 gauze of 4x4 and a pack of 200 of 2x2 open on the incubator and exposed to the environment (NICU A-1 through A-50).

f. A drainage bag for a cysteomy was observed without a label with the date and hour when placed there (NICU A-38).

g. The entrance door of the storage room, pantry room, utility room, exit door between the North and South NICU were observed with peeling paint that does not allow for adequate cleaning.

h. It was found in the pantry room a Cidex OPA container, the room did not have an extractor. The Director of Nursing (DON) stated during an interview on 8/30/11 at 10:30 am that the emergency kit is placed in the night cabinet. If an emergency arises with the cidex personnel call the general supervisor then she calls housekeeping to get the kit and cleans up the area.
i. In the formula room it was observed that a box of baby bottle nipples was placed over the sink, and the sink was observed dirty.
j. It was observed that the bags used to store manual ventilators were observed touching the bottom of the cabinet near the floor (NICU A-1 through A-24).
k. A buretrol was attached to a foley catheter as observed without a label with the date and hour when placed (NICU A-311).

2. During the observational tour with the infection control officer (employee #7) and the nursing director (employee #5), at the South Fifth floor ward on 8/30/11 from 1:15 pm till 2:00 pm the following was found:

a. It was observed in the treatment room that a sharp container was on the counter without a security rack and a small sharp container over the counter was also without a security rack.

b. The canalization tray was observed placed directly on the bed where the nurse performs the canalization or the blood sample.

c. Non Sterile gauze packages of 200 gauze of 2x2 were observed opened and exposed to the environment of the cannulization tray, in the sample cart.

d. The sharp container of the sample cart was observed tied to a basket secured with tape without a safety rack.

e. The cabinet of the medical/surgical storage area where materials are store in the treatment room was observed with broken formica near the sink. Other medical/surgical cabinets near the door of the treatment room was observed with broken wood.

f. It was observed that nurse #22 was performing the procedure of venepuncture to a vein of the patient on 8/30/11 at 1:30 pm, during the procedure the nurse cleaned the venipuncture site in a spiral motion and performed the same procedure on the same spot twice.

g. It was observed that lounge chairs with broken vinyl that does not allow for proper cleaning to prevent cross contamination (rooms #3B, D, #52 B and #51A).

h. It was observed that respiratory therapy equipment is placed in a plastic bag, however without a label with the patient's name, date and hour when it was opened on (patient's room #3C, 52B and 51A).

i. It was observed that a ventury mask was placed on the oxygen meter without a plastic bag to protect it from the environment (room #53).

j. It was observed that the walls of the room with peeling paint that does not allow for proper cleaning to prevent cross contamination (room #53).

k. It was observed that a package of 200 non sterile gauze 4x4 was on the night table of rooms #52B and #51C exposure to the environment.

l. It was observed that a syringe (Asepto) for patient's feeding was without a label with the date and hour when opened (room 52 B).

m. It was observed that Nurse #31 washed her hands for less than 5 seconds, the nurse failed to wash her hands according with the CDC guidelines for hand washing in health care settings and failed to use acceptable standards of practice of infection control.

n. It was observed that a sharp container was without the security rack in the medication room.

3. During the observational tour with the infection control officer (employee #7) and the nursing director (employee #5) at the third floor ward on 8/30/11 from 2:05 pm till 2:35 pm the following was found:

a. In the treatment room it was observed that there were four sample trays with packages of 200 gauze of 2x2 opened exposure to the environment.

b. It was observed that there was a sharp container without a security rack in the treatment room.

c. It was observed that a syringe (Asepto) for patient feeding was without a label with the date and hour when opened (room 38A).

d. It was observed that on 8/31/11 at 9:10 am that nurse #32 was performing the medication administration in room #315, the nurse entered the medication cart in the patient's room because the medication cart did not lock. During the procedure the nurse failed to wash his hands according with the CDC guidelines for hand washing in health care settings and failed to use acceptable standards of practice of infection control. The nurse wash his hands for less than 7 second. After nurse #32 administered the medication to the patient in bed 315 B, without washing his hands he touched the medication cart and moved it to patient 315 C patient. Then wash her hand for less than 7 second. And performed the same procedure to the next patient and patient rooms.

Based on the review of policies and procedures related to the Discharge Planning Program, it was determined that the facility failed to ensure that discharge planning policies and procedures include provisions to comply with the process for weekends and after hours.

Findings include:

1. During the review of policies and procedures and medical records reviewed on 8/31/11 from 9:05 am till 11:49 am with the discharge planning nurse (employee #23 ), the following was identified:

a. Discharge planning screening evaluations are performed for all patients. The process of screening is performed with the participation of the nursing personnel and physician. If special needs for the discharge process are identified, a consult is requested from the discharge planning office to intervene. Facility policies and procedures for discharge planning evaluations and services establishes that the discharge planning officer must answer the consult and plan the discharge of the patient within 24 hours. The discharge planning officer only works from Monday through Friday from 7:00 am through 3:00 pm. During the weekends, holidays and after hours nursing personnel and the physician in charge of the patients intervene related to the discharge planning. The mechanism of evaluating patients in need of discharge planning on weekends and after hours is not included in the facility's policies and procedures.

Based on the review of fifteen nursing credential files (C.F), it was determined that the facility failed to ensure that nursing personnel have complete and updated credential files for fifteen out of fifteen C.Fs (Operating Room nurses and Operating Room TQM-C.F #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and #15) related to annual evaluations, duties and responsibilities, professional college association and Hepatitis vaccines.
Findings include:

1. The following was found on 9/1/11 at 9:30 am during the review of ten Operating Room nurses' and TQM credential files:
a. Eleven out of fifteen credential files did not contain evidence of duties and responsibilities (C.F #5, #6, #31, #35, #44, #64, #67, #71, #72, #73 and #76).
b. Fifteen out of fifteen credential files did not have evidence in their records of Hepatitis vaccine (C.F #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and #15).
c. Four out of fifteen credential files did not have evidence of updated annual evaluations (C.F #5, #13, #14 and #15).
d. One out of fifteen nursing credential files failed to provide evidence of their professional college association (C.F #5).

Based on observations made of the surgical department, interview and review of policies/procedures with the development program employee (employee #6) and Operating Room Manager (employee #14), it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice and patients' care.

Findings include:

1. Observations made of the surgical department on 8/31/11 from 9:30 am till 3:00 pm provided the following evidence:
a. At the entrance to the operating room was found on 8/31/11 at 9:30 am a table, three chairs and a cabinet with a mask, shoe cover and hat.
2. It is required by local law to comply with the guidelines for Design and Construction of Hospital and Health Care Facilities. These guidelines on table 7.2 (ventilation requirements for areas affecting patient care in hospitals and outpatient facilities) requires that the relative humidity must be kept between 30-60 % and temperature of 68-73ºF in the operating suites, the following relative humidity and temperatures were measured on 8/31/11: in suite #C the temperature registered 68ºF and relative humidity registered 62% at 9:50 am, in suite #D the temperature registered 69ºF and relative humidity registered 61% at 10:00 am. Material room relative humidity registered 71% at 10:20 am and in the tray room which had a relative humidity registered at 81% at 9:30 am.

3. The disinfecting area used to process equipment with Cidex OPA was visited on 8/31/11 at 10:00 am and it did not have an exhaust hood: Manufacturers' recommendations suggests that the solution is used in a well-ventilated area and stored in closed containers with tight fitting lids and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media.

4. No evidence was found that the operating room department has a spill kit to deal with spills and no evidence was found that they are following manufacturer's recommendations related to "Disinfectant/Container Disposal Information" for neutralizing Cidex-OPA before disposal.

5. Operating suites #A through #D did not have hands free intercom systems within the suites connected to the nursing station and recovery room as observed on 8/31/11 at 10:00 am.

6. Mechanisms were not developed to ensure that infection control practices are followed as reviewed on 8/31/11 from 9:30 am till 3:00 pm to properly maintain a sanitary environment as evidenced by the following:

a. In operating suite #A-1 on 8/31/11 at 9:55 am, on a table was observed cleansing Foam, Dermal Wound Cleanser, iodine and a container of GASC disinfectant and detergent. The anesthesia cart was found opened and unlocked.

b. In operating suite #B-1 on 8/31/11 at 10:15 am, IV pumps up against the biohazardous trash containers.

c. In operating suite #C-1 on 8/31/11 at 10:15 am, two nurses were observed without a mask in the suite and a box of mask over the sharp container. A bottle of Marcaine 0.25% was observed without a label with the signature and the date and time when open.

d. The house keeping room was observed on 8/31/11 at 10:55 am with two mops and two pails with identification labels. During interview with the housekeeping personnel (employee #28) he said he has four mops for all suites and a one mop for recovery and the hallway and a two pail for fours suite and one pail for recovery. No evidence was found of a pail for all area. This procedures does not protect the facility's patients from possible cross contamination from one suite to the another. The regular trash container and the biohazardous trash container is the same container and has no lid.

e. During observations of the biohazardous closet and regular garbage, it was found in the same area of the operating room department on 8/31/11 at 11:10 am, it was found that this closet does not have an air extractor.

f. The holding area on 8/31/11 at 11:15 am was observed with two sinks blocked by two cribs and a stretcher.

g. No evidence was found on 8/31/11 at 2:40 pm of the daily and weekly terminal cleaning for the operating suites for July 15, 22, 29 and August 5, 12, 19 and 25.

h. On 8/31/11 at 10:30 am, in operating suite #D-1 during the preparation of the patient for an operation, two employees were observed in the restrictive area with long sleeve shirts under their surgical scrubs.

i. During observations performed on 8/31/11 at 11:50 am, one personnel was observed with a hair cover, shoe covers and face mask going to unrestricted area to restricted area and to the elevator without changing the shoe covers and hair cover and mask, increasing the likelihood of cross contamination.

Based on the review of seven medical records and policies/procedures of the operating room with the development program employee (employee #6), it was determined that the facility failed to execute complete surgery informed consents that includes date, hour, name of the hospital, license number, surgical procedure, name of the anesthesiologist and surgeon for five out of seven records reviewed (R.R #27, #28, #29, #31 and #32).

Findings include:

A. During the review of seven medical records on 8/31/11 from 2:30 pm till 4:00 pm, the following was determined:

1. R.R #27 provided evidence that the surgical procedure consent form did not include the name of the anesthesiologist.

2. R.R #28 provided evidence that the surgical procedure consent form did not include the name of the surgeon, name of the hospital, license number of the physician who took the consent.

3. R.R #29 provided evidence that the surgical procedure consent form did not include the surgical procedure and the name of the anesthesiologist.

4. R.R #31 provided evidence that the surgical procedure consent form did not include the date, hours, name of patient, name of surgeon, name of hospital.

5. R.R #32 provided evidence that the surgical procedure consent form did not include the name of the anesthesiologist.

Based on documents reviewed with the development program employee (employee #18) and Operating Room Manager (employee #6), it was determined that the facility failed to ensure that the operating room log registry is complete.

Findings include:

1. The surgery registration log book was observed on 8/31/11 at 10:05 am with incomplete spaces and left in blank.

2. The recovery room registration log book was observed on 8/31/11 at 10:10 am with whiteout (Liquid Paper) in spaces.

Based on the review of seven medical records to evaluate anesthesia services, it was determined that the facility failed to ensure that informed consent forms are properly executed for five out of seven medical records reviewed (R.R #26, #28, #29, #30 and #32).

Findings include:

A. During the review of seven medical records on 8/31/11 from 2:30 pm till 4:00 pm, the following was determined:
1. R.R #26 was incomplete due to the lack of the name of anesthesiologist, signature of anesthesiologist and license number of who took the consent.
2. R.R #28 was incomplete due to the lack of the anesthesiologist's name.
3. R.R #29 was incomplete due to the lack of the anesthesiologist's name.
4. R.R #30 was incomplete due to the lack of the anesthesiologist's name.
5. R.R #32 was incomplete due to the lack of the check type of anesthesia.

Based on the review of six closed and active records reviewed (R.R), policies/procedures manual, interview and the observational tour with the emergency room nursing supervisor (employee #19), it was determined that the facility failed to comply with sign posting in the ambulance entrance, a sign was not posted in the entrance/waiting area notifying patients that arrive to the emergency room (E.R) where the triage is located, the pediatric triage area does not promote privacy and safety, infection control issues and two out of six clinical records was found that the patient was sent after being seen by the physician until the nurse took the patient's blood sample and no evidence was found of the restriction re-evaluation based on the initial order placed by the physician (R.Rs #1 and #3).

Findings include:

1. The following was observed related to the review of the policies/procedures manual and observations of the emergency department with ER supervisor (employee #19) on 8/30/11 from 8:45 am till 3:00 pm and 8/31/11 from 8:00 am till 10:00 am:

a. No signs were posted at the entrance (ambulatory/ambulance) and admitting area for the notification of the rights of the individuals who enter the E.R as observed on 8/30/11 at 8:55 am.

b. The Emergency Room administrative manual for policies and procedures was reviewed on 8/31/11 at 9:00 am and was found that the last revision was in 2005.

2. The triage area was observed on 8/30/11 at 9:00 am with the Nursing Supervisor (employee #19) located in the hallway near the entrance area, however a sign was not posted in the triage area notifying patients that arrive to the E.R where the triage is located. The triage is across from the waiting area separated by a hallway and the information area. During the triage process the nurse was observed performing her assessment on the patient and during interviews. The triage room does not have a door to provide privacy during interviews, also within the triage area were three physician examination rooms and persons were standing near the triage area waiting for their assessment and physician evaluation. This process is seen by the persons in the waiting area and violates the patients' privacy and confidentiality.

3. Observation made from 8/30/11 through 8/31/11 at 9:30 am of the back door (exit door) of the Emergency Room provided evidence that this route is used by patients to access the hallway in front of the elevator. Family members, maintenance staff and hospital personnel were observed using this back exit door of the E.R. A patient was observed on a stretcher in this area accompanied by her mother near the exit door. This practice affects patient privacy and safety related to the free access of this route.

4. A cart used to store blood sample tubes, small vein, Angiocatheters and Vacutainers needles located in front of the nursing station was found open and could be accessed by non authorized persons on 8/30/11 at 10:20 am.

5. A cart used to store emergency disposable sterile material for the management of patients with burns located in the nursing station hallway was found uncovered with dust and could be accessed by non authorized persons on 8/30/11 at 10:30 am.

6. A crash cart in the critical care area was observed locked on 8/30/11 at 10:40 am, however when slight pressure was applied to the crash cart's locking device (bar) it allowed access to the medication inside without breaking the plastic lock.

7. The Ob-gyn examination room located in the emergency room (E.R) was observed with the facility's E.R nursing supervisor (employee #19) on 8/30/11 at 10:10 am and provided evidence that female patients are examined in this room and pelvic exams are performed. However, the part of the examination bed where patients put there feet is facing the door, the room does not have a curtain and the bed is up against the wall. The bed needs to be repositioned to ensure that patients can be attended by staff on three sides of the beds in the event of an emergency and in order to protect the patients' privacy if someone accidentally walks in on a procedure.

8. The following was observed in the emergency room on 8/30/11 from 8:45 am till 3:00 pm related to infection control procedures:

a. Eight I.V bags of .45 normal saline were observed on 8/30/11 at 9:45 am in the medication room with an expiration date of July of 2011.
b. All sharp containers (1 gallon size) were observed without security bases during the observational tour of the emergency room on 8/30/11 from 8:45 am till 11:30 am in the following areas: triage area, medication room, blood sample cart and treatment room. Security bases are needed to protect the sharp containers from unauthorized removal
c. Large packages of gauze were observed in the treatment area, triage area, patient bathroom, critical care area and on I.V access trays without protective covers, exposing them to the environment.
d. Approximately 20 fitted sheets were observed on a clean linen cart, they were uncovered and exposed to the employees handling them on 8/30/11 at 10:30 am.
e. Respiratory therapy equipment were found in cubicles #9 and #9A without a label with the date and time that the equipment was first used on. The facility's policies and procedures provided evidence that the respiratory equipment is to be labeled with the patient's name and changed every 72 hours..

9. During the emergency room (ER) observational tour performed with the ER supervisor (employee #19) and facility dietitian (employee #21) on 8/30/11 from 10:00 till 10:30 am the following was observed:

a. The formula room was visited on 8/30/11 at 10:00 am and the temperature was taken with a laser thermometer and it was found to have a temperature of 75ºF and inside of the formula cabinet (where the formula was stored) the temperature was 79ºF. Manufacturer's recommendations suggest that formulas are to be stored to avoid excessive heat. No evidence was found that the facility is measuring and recording the temperature of this room to ensure that the formulas are properly maintained.

b. Two enteral nutrition machines were found in the formula room over the disaster equipment cart. The ER supervisor (employee #19) stated during an interview on 8/30/11 at 10:10 am that the machines were clean and ready to use. However, the machines were found uncovered and according to policies/procedures reviewed on 8/30/11 at 2:00 pm, cleaned enteral nutrition machines are to be covered. The facility failed to ensure that infection control standards are followed related to covering clean enteral nutrition machines.

c. The formula room was found on 8/30/11 at 10:15 am with a refrigerator that contained one bottle of 4 ounces of formula (a preparation of Pregestimil and Propimex 2) with a date of preparation of 8/29/11 at 9:30 am, however it did not have the date of expiration on it for when personnel need to discard. Policies/Procedures stated to discard after 24 hours as reviewed on 8/31/11 at 2:00 pm.

10. Two out of six clinical records were reviewed on 8/30/11 from 1:30 pm till 3:00 pm for emergency room services and provided evidence of the following:

a. R.R #3 is a 16 years old female who visited the emergency room on 8/29/11 with a diagnosis of Menometrorrhagia with Asymptomatic Anemia and the record review was performed on 8/30/11 at 1:45 pm. The patient was triaged at 11:50 pm and was classified urgent with the following vital signs (V/S): temperature-37.1ºC, pulse-86, respiration-26 and blood pressure-106/67. The patient was evaluated by the physician at 12:27 am and ordered .45% of Normal Saline to run 92 ml per hour, nasal canula, V/S every 4 hours and blood sample of CBC, Retic Count, PT/PTT, Beta Factor and Type/Screen. The emergency room physician consulted a gynecologist on 8/30/11 at 11:25 am and the consultant evaluated the patient on 8/30/11 at 4:37 am. The physician's orders were taken by the registered nurse on 8/31/11 at 5:30 am not immediately after they were ordered. The laboratory sample was taken at 5:30 am and the hemoglobina was found to be 8.3 g/dl. No evidence was found in the medical record where the patient was sent after seen by the physician until the nurse took the patient's blood sample and orders 5 hours later.

b. R.R #1 is an 8 years old female who visited the emergency room on 8/27/11 with diagnosis of Uncontrolled Seizures with Several Mental Retardation and the record review was performed on 8/30/11 at 2:30 pm. The patient was triaged at 8:45 am and was classified as non-urgent with the following vital signs (V/S): temperature-36ºC, pulse-86, respiration-24 and blood pressure-101/59. The patient was evaluated by the physician at 9:30 am and ordered Dilantin levels, Zantac 35 mg every 8 hours, Keppra 780 mg one loading dose and V/S every 4 hours. On 8/29/11 at 9:30 am the physician ordered Noctec 2 mg by mouth for one dose. On 8/29/11 at 2:25 pm the emergency room physician documents that the patient is to be restrained due to aggressive behavior related to removing her I.V lines related to her mental condition as the principle factor. The initial medical order did not have the time period that the patient was to be on restrictions (bilateral upper extremities). Nursing documentation reviewed from 8/29/11 form the 7-3 shift provided evidence that the patient was restrained from her upper extremities and to re-evaluate every two hours. Nursing documentation reviewed from 8/29/11 form the 3-11 shift provided evidence that the patient was observed alert, active and free from restrictions. No evidence was found when the facility removed the patient's restrictions, no evidence was found that the physician ordered a specific time period for the patient's restrictions (for patients less than 9 years of age the time period shall not exceed 1 hour) and not evidence was found of the restriction re-evaluation based on the initial order placed by the physician.

Based on observations, interviews with the Occupational Therapist (employee #12) and Nursing Supervisor (employee #11) and records reviewed on 8/30/11 from 1:40 pm till 4:00 pm, it was determined that the facility failed to ensure that services are provided according to the scope of services offered related to the implementation of policies/procedures related to services, to indicate lines of authority and delegation of responsibilities within the department, staffing and schedules, temperature registry for cold pads and hot pads, cleaning registry for hot pads and cold pads, broken curtain, exercise mat with rips and infection control procedures, maintain credential files updated of the occupational therapist and physical therapist personnel and the physician writes complete orders for treatment services and occupational therapist and physical therapist note.

Based on the observational tour and eight records reviewed (R.R) with the Occupational Therapist (employee #12) and Nursing Supervisor (employee #11), it was determined that the facility failed to ensure that services are provided according to the scope of services offered related to the implemention of policies/procedures related to services, updated organizational chart, staffing and schedules, temperature registry for cold pads and hot pads, cleaning registry for hot pads and cold pads, broken curtain, exercise mat with rips and infection control procedures.

Findings include:

1. No evidence was found on 8/30/11 at 9:20 am of the policies and procedures to verify that the scope of rehabilitation services offered is defined in writing.

2. No evidence was found on 8/30/11 at 9:30 am of the updated organizational chart to indicate lines of authority and delegation of responsibilities within the department or services offered in the rehabilitation services.

3. No evidence was found on 8/30/11 at 9:40 am of the Physical Therapy and Occupational Therapy staffing and schedules to determine adequacy.

4. No evidence was found on 8/30/11 at 9:50 am of the temperature registry for cold pads and hot pads.

5. No evidence was found on 8/30/11 at 9:55 am of the cleaning registry for the hot pads and cold pads.

6. No evidence was found on 8/30/11 at 10:00 am of the temperature registry for whirlpools when the equipment is used on patients.

7. Two whirlpool tanks used to give treatment to patients were observed stored in the basement due to the lack of space in the physical therapy area as observed on 8/31/11 at 1:47 pm. According with information given by the Occupational Therapy (employee #12) on on 8/31/11 at 2:00 pm, the tanks are first cleaned and prepared in this area. Temperature and disinfection of the tank procedure are not documented or registered by personnel who manage the equipment in order to ensure that facility policies of management and disinfection of the tanks are performed according with accepted standards of practice.

8. The area where the exercise mattress is located has a broken curtain and does not provide privacy to a patient receiving therapy at this area as observed on 8/30/11 at 10:15 am.

9. A bed exercise mat was observed with rips on 8/30/11 at 10:20 am, that can scratch patients during exercise. During the cleaning process of this equipment, disinfectant solutions enter the inside of this equipment and can not be disinfected properly.
10. The physical therapy area was observed with 15 towels and during an interview with the Occupational Therapist (employee #12) she stated on 8/30/11 at 10:30 am, that the towels are used for the patients when they use the hot and cold pads and these towels are returned to the department and not washed after they are used.

Based on the review of credential files with the Occupational Therapist (employee #12) and Nursing Supervisor (employee #11), it was determined that the facility failed to maintain credential files updated for occupational therapist and physical therapist personnel.
Findings include:
No evidence was provided on 8/30/11 at 9:30 am that the facility maintains credential files updated for the occupational therapist, the last annual evaluation was 6/11/94 and the Physical Therapist last annual evaluation was 6/8/04 which is not in accordance with state and local laws.

Based on the review of eight clinical records with the Occupational Therapist (employee #12) and Nursing Supervisor (employee #11) and interview, it was determined that the facility failed to ensure that the physician writes complete orders for treatment services and occupational therapist and physical therapist notes for eight out of eight active records reviewed (R.R #33, #34, #35, #36, #37, #38, #39 and #40).

Findings include:
1. Eight out of eight active records reviewed (R.R #33, #34, #35, #36, #37, #38, #39 and #40) on 8/30/11 from 1:40 pm till 4:00 pm provided evidence that a physician placed an order for consultation. The physiatrist answered the consult, however no evidence was found of the physician's order for treatment for the patient, frequency of treatment and duration of the treatment for patients.
2. Eight out of eight active records reviewed (R.R #33, #34, #35, #36, #37, #38, #39 and #40) on 8/30/11 from 1:40 pm till 4:00 pm provided evidence that the Physical Therapy and Occupational therapy have one weekly note of five days of treatment. The facility failed to act according with accepted standards of practice and State law.
3. During the interview with the Occupational Therapist (employee #12) on 8/30/11 at 10:00 am, she said that the occupational therapist and physical therapist always perform one weekly note for five days of treatment.
4. R.R #36 provided evidence that it lacks documentation of the occupational therapist's weekly notes based on policies and procedures of occupational therapy department.
5. R.R #40 provided evidence on 8/30/11 that the physician asked for a consult with a physiatrist on 7/5/11 at 10:00 am. The Physiatrist evaluates the patient on 7/5/11 at 2:20 pm and makes a treatment plan for occupational therapy. However no evidence was found of the occupational therapy notes from 7/6/11 until 7/20/11 because the occupational therapist was on vacation.

Based on the review of thirty-six respiratory therapists credential files (C.F) with the Director of the Respiratory Therapy Department (employee #8) and Respiratory therapy supervisor (employee #9), it was determined that the facility failed to ensure that one out of thirty-three respiratory therapists personnel meet the qualification specified and consistent with State laws related to certificate of health (C.F #3, #4, #6, #8, #10, #13, #14, #22, #23, #24, #26, #28, #32, #33, #34, #35).

Findings include:

1. One out of thirty-six respiratory therapists credential files provided evidence of expired Health Certificates for C.F #23.

b. Five out of thirty-six respiratory therapists credentials did not contain evidence of Hepatitis B vaccine (C.Fs #10, #14 #26, #28 and #32).

c. Fourteen out of thirty-six respiratory therapists credentials did not contain evidence of updated annual evaluations (C.F #3, #4, #6, #8, #10, #13, #22, #23,#24, #28, #32, #33, #34 and #35).

d. Six out of thirty-six respiratory therapists credential files did not contain evidence of updated competencies (C.F #3, #8, #24, #33, #34 and #35).

Based on the review of four medical records, policies/procedures, it was determined that the facility failed to ensure that the organization of respiratory therapy services is appropriate to the scope and complexity of the services provided for two out of four clinical records reviewed (R.R #42 and #43).

Findings include:

1. Four medical records were reviewed on 9/1/11 from 8:50 am till 12:00 pm and provided evidence that respiratory therapists do not administer respiratory therapy treatment in accordance with the physician's order for two out four records reviewed with therapy.

a. R.R #42 is a 3 month old female admitted on 5/1/11 with a diagnosis of Pre term gestational Age (Pre TAGA) baby of 35 week of gestation. The record review was performed on 9/1/11 at 8:50 am with the Respiratory Therapist Supervisor (employee #9) and Respiratory therapy Program director (employee #8) and provided evidence that the physician ordered on 8/21/11 at 10:50 am Albuterol 0.3 ml/ 3 ml NSS by power nebulizer (PN) every 4 hours. Pulmicort 0.25 mg by PN every 12 hours. However the Respiratory therapy medication and treatment administration response of the patient's sheet from 8/21/11 at 7-3 shift did not provide evidence of the treatment administration at 8:00 am and did not fill in the complete patient assessment during the treatment administered at 12:00 md and lacks the patients tolerance, if some reaction, respiratory rate, heart rate, respiratory sound. From 8/22/11 at 11-7 shift no evidence was provided of the treatment administration at 12:00 mn and did not fill in the complete patient assessment past the treatment administered at 4:00 am and lacks the patient's respiratory rate, heart rate, respiratory sound after treatment. On 8/22/11 at 11:00 am the physician places an order at 11:00 am of Albuterol 0.25 ml/ 3 ml of NSS by PN every 4 hours and Pulmicort 0.25 mg by PN every 12 hours. The Respiratory therapy medication and treatment administration response of the patient sheet from 8/22/11 at 12:00 md provided evidence that the respiratory therapist administered Albuterol 0.3 ml. and at 11-7 shift no evidence was found of treatment administered at 12:00 mn and did not fill in the complete patient assessment past the treatment administered at 4:00 am and lacks the patient's respiratory rate, heart rate and respiratory sound after treatment. On 8/23/11 at 1:15 pm the physician ordered Albuterol 0. ml/ 3 mlNSS every 6 hours and on 8/24/11 at 4:20 pm the physician ordered Albuterol 0.3ml/ 3 ml NSS by PN every 8 hours, the Respiratory therapy medication and treatment administration response of the patient sheet from 8/23/11 for 7-3 shift provided evidence that the treatment was given at 12:00 md then at 4:00 pm the treatment was given every 4 hours until 8/25/11 at 4:00 am that started every 8 hours and the Respiratory therapy medication and treatment administration response of the patient sheet from 8/25/11 did not provide evidence of the treatment at 4:00 am. No evidence was found of the treatment administered on 8/25/11 on 3-11 shift, on 8/26/11 at 7-3 shift, on 8/27/11 at 11-7 shift, on 8/28/11 at 3-11 shift and 8/29/11 at 7-3 shift.

b. R.R #43 is a 31 days old female admitted on 8/1/11 with a diagnosis of Pre term gestational Age (Pre TAGA) baby of 27 week of gestation and Ducto Arteriosa Patented. The record review was performed on 9/1/11 at 9:50 am with the Respiratory Therapist Supervisor (employee #9) and Respiratory therapy Program director (employee #8) and provided evidence that the physician ordered on 8/23/11 at 9:55 am Albuterol 0.3 ml/ 3 ml NSS by power nebulizer (PN) every 12 hours. Pulmicort 0.25 mg by PN every 12 hours. However, the Respiratory therapy medication and treatment administration response of the patient sheet from 8/23/11 at 3-7 shift did not provide evidence of the Pulmicort treatment administration at 8:00 pm and did not fill in the complete patient assessment during the Albuterol treatment administered at 8:00 pm and lacks the patient's tolerance, if some reaction, respiratory rate, heart rate and respiratory sound. On 8/25/11 at 10:45 am the physician ordered to Discontinue Albuterol Therapy, however the Respiratory therapy medication and treatment administration response of the patient sheet from 8/25/11 at 4:00 pm the respiratory therapist continued to provide Albuterol Therapy on 8/26/11 at 8:00 am, at 8:00 pm and 8/27/11 at 8:00 am.