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Based on the review of medical records, policies and procedures, documents, observations, tests and interviews from 9/22/15 through 9/24/15 from 8:00 am till 4:00 pm, it was determined that the Governing Body failed to carry out its responsibility for the operation and management of the hospital. The Governing Body failed to provide the necessary oversight and leadership as evidenced by the lack of compliance with: Governing Body (42 CFR 482.12), Physical Environment (42 CFR 482.41) (cross refer A701, A709, A724, A725 and A726) and Discharge Planning (42 CFR 482.43) (Cross refer: Tags A 799, A800, A806, A811,A812, A818, A820, A821, A837, and A843).

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

Findings include:

Admission packet that each patient receives during admission to receive services was reviewed on 9/22/15 at 8:50 am with the " Policlinica Castaner " director (employee #24) and on 9/23/15 at 1:55 pm at the " Hospital General Castaner "with registry and admission personnel (employee #32 ). It was identified that updated information of the phone number and address for lodging a grievance with the State agency and the Medicare hot line was not included.

Based on observational tour performed on 9/22 and 9/23/15 from 11:55 am thru 2:30 pm with the Nursing Manager (employee # 22) it was found the facility failed to have an adequate amount of space to provide privacy to the ER patients at the moment of care to patients as needed.

Findings include:

1. The ER adult section has six areas: Treatment and observation with 3 beds, CPR, Cardio, Trauma area with 1 stretcher, inside ER 2 triage area separately for gymsumboard wall for OPD patients, 1 room for respiratory treatment and in the same room 1 stretcher where nursing personnel performs EKG this area lacks of curtain to bring privacy at the moment the EKG was performed. The ER triage lacks of visibility for patients waiting in the reception area. Between the OPD triage area there is a pediatric table with scale integrated where pediatric patients are measure there weights. Besides the table with the scale is located a chair where the nursing personnel took the blood sample of the ER patients. (Cross reference A701)

a. During the observational tour performed on 9/23/15 at 10:30 am it was observed RN (employee # 19) taking a blood sample from a patient and two parents with a child waiting for the nurse because the child is going to receive treatment . The nurse said " I am going to administer a medication by intramuscular way " . The parents and the child observed all the blood sample extraction because no curtain or module was uses to provide privacy to the patient. Also beside this chair is the Respiratory therapy area where one patient was receiving a respiratory therapy without any privacy too.

b. In the same area there are two nursing personnel performing triage and all the patients ' conversations was heard by the parents and the patient who was taking the blood sample. There is lacks of privacy for patients in the OPD triage area.

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

Based on the review of documents and interview with nursing supervisor (employee #14) and medical director (employee #7) it was determined that the facility failed to ensure that updated protocols for the use of physical restraint on patients are maintained.

Findings include:

1. A mechanism to ensure that facility develop and implement physical restraints protocols, policies and procedures accordingly with accepted standards of practice as well as CMS requirements were not performed, not followed accordingly with the following findings identified on 9/23/15 at 1:57 pm:

a. Facility policies and procedures did not include provisions to ensure that patient individualized comprehensive assessment are performed before consider the use of restraint to address any medical issue in order to eliminate or minimize the need for the use of restraints.

b. Facility ' s policies and procedures did not include provisions to ensure that
Staff must assess and monitor a patient's condition on an ongoing basis to ensure that the patient is released from restraint at the earliest possible time.

c. Facility ' s plan of care to be use for restriction includes belts as a device to be used to restrict a patient. Restrictive devices are not considered safe to restrict patients in hospitals were soft restrictions must be use for those purposes.

d. Facility policies and procedures did not include provisions for chemical restrictions to be used or considered instead physical restriction measures.

e. Nursing supervisor (employee #14 ) and medical director (employee #17) stated on interview on 9/23/15 at 1:57 pm that they had few cases on physical restriction and facility promote the right of each patient to be free from restraint. They stated that restraint may only be used for immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

Based on the review of documents and interview with nursing supervisor (employee #14) and medical director (employee #17) it was determined that the facility failed to ensure that protocols for the use of physical restraint on patients comply with CMS Regional Office death reporting requirements.

Findings include:

1. A mechanism to ensure that facility develop and implement physical restraints protocols, policies and procedures accordingly with accepted standards of practice as well as CMS requirements were not performed, not followed accordingly with the following findings:

a. The Facility ' s policies and procedures did not include provisions to ensure that deaths associated with the use of physical restriction are reported to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient's death

b. Facility ' s policies and procedures did not include provisions to ensure that each death that occurs while a patient is in restraint that occurs within 24 hours after the patient has been removed from restraint are reported to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient's death

c. Facility ' s policies and procedures did not include provisions to ensure that each death that occurs within 1 week after restraint where it is reasonable to assume that use of restraint contributed directly or indirectly to a patient's death, are reported to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient's death

d. Facility ' s policies and procedures did not include provisions to ensure that staff must document in the patient's medical record the date and time the death of a patient who was on restriction was reported to CMS.

Based on the review of quality reports with the facility's Quality Improvement Officer, it was determined that the facility failed to analyze and track quality indicators, including adverse patient events and other aspects of performance that assess processes of care, the lack of reports to the pharmacy department and quality assurance program related to medication irregularities.

Findings include:

1. The facility's Quality Assurance Annual Plan and Indicators was reviewed with the Quality Assurance Officer (employee #3) on 9/23/15 at 11:20 am, the plan revealed that they establish medication irregularities as an aspect to be continually evaluated by tracking and reporting events to the quality assurance program on an ongoing basis. However, pharmacy services and nursing services failed to report medication irregularities related with medication not available in pharmacy formulary.

The quality assurance officer stated during an interview on 9/23/15 at 11:20 am that drugs not available on the formulary medications must be reported as appropriate to the pharmacy committee and to the quality assurance program. She stated that is very important to detect, manage and report medication irregularities or the availability of the medications when the physician ordered because the patient needed it.

Based on review of infection control quality program with the infection control officer (employee #13), it was determined that the facility failed to ensure ongoing program that shows measurable improvement of indicators for hand washing, use of glove, use of protective equipment, Foley insertion, ulcer care, medication administration, isolation use to ensure patient safety in infection control.

Findings include:

1.During the review of the infection control program with the infection control officer (employee #13) it was found that the quality indicator for infection control was based on venopuncture process, label of multiple dose vials, Hospital area, Diet department, Respiratory therapy machine and equipment, Autoclave spores culture, emergency room area and outpatient area culture to discard pathogens harmful to health and compliance with the policy on use of garments and long nails and /or artificial.

However, no evidence was found related to quality indicator related to other aspect of infection control as hand washing, use of glove, use of protective equipment, Foley insertion, ulcer care, medication administration, isolation use to ensure patient safety and infection control.

Based on administrative documents review and interviews with the Nursing Supervisor (employee #14) and Director of Nursing (employee #15) on 09/23/15 and 09/24/15, it was determined that the facility failed to ensure a organize nursing services developing a legible nursing job schedule and assigning duties to new personnel according to the professional standards of practice and according the hospital rules and regulations.

Findings include:

1. During review of the hospital nursing job schedules performed by the Nursing Supervisor (employee # 14) it was found on 09/23/15 at 10:00 am the following:

a. The Nursing Supervisor (employee #14) has developed a nursing job schedule with the nursing staff assigned for the hospital area and for the emergency room and outpatient clinics. According to the Human Resources employees list, the hospital area has 6 Registered Nurses (RN), 4 Licensed Practical Nurses (LPN) and 1 Nursing Supervisor. The outpatient clinics and Emergency Room have 9 RN, 9 Associate Degree Nurses (ADN), 7 LPN's and 1 Nursing Supervisor. There is 1 Director of Nursing (DON) in charge of the 3 areas.

b. The hospital area nursing job schedule provided by the Nursing Supervisor (employee
#14) shows 4 RN and 3 LPN. The job schedule does not mention the complete name and degree of the nursing staff that is assigned at the outpatient clinics and emergency room. The Nursing Supervisor writes on each day of the week space, the shift that the nurse is going to work and over the shift writes in small letters the name of the nurse. This presentation of the nursing job schedule does not allow identifying the nursing staff that will perform their duties each day.

c. On the nursing job schedule there is no evidence of the staff that is on sick leave, vacations, etc. There is a legend for: ¿weekend, *Holydays, D double shift, meanwhile, sick leave and vacations are not mentioned on the legend. These items on the legend were not written in the nursing job schedule. Also, the same nursing staff work on per diem (PD) schedules according to patients needs, but the nursing job schedule does not mention which nurses and in which shifts they are working.
d. No evidence was found of the Nursing Supervisor nor the DON to sign the nursing job schedule with date and hour when it was reviewed and approved.
e. The Nursing Supervisor (employee #14) showed during survey process 2 nursing job schedules, which is not recommended due to mismatch information and can create confusion on the nursing staff.
According to the Nursing Supervisor (employee #14) during interview performed on 09/23/15 at 10:30 am, she stated: " the second job schedule was performed on the computer. The problem is that it does not include the whole staff from the 3 areas and I have to include them in hand writing".
f. The facility failed to review the nursing job schedule and to develop one schedule with all pertinent information, easy to understand in a manner that the staff and Nursing Supervisor can identify working areas, days of the week, shifts and who is in charge.
2. The facility has a hospital based outpatient clinics in another town. According to the Human Resources employees list there are 1 RN, 1 ADN and 3 LPN.
During interview with the Nursing Supervisor (employee #14), performed on 09/23/15 at 10:30 am, the DON supervises the staff on that outpatient clinic. Also, it was found that the outpatient clinic and emergency room located at the hospital share1 RN and 1 LPN with the hospital based outpatient clinic in the other town. However, the nursing schedule does not show that it was reviewed and approved by the Nursing Supervisor nor the DON.
3. The facility has developed a program for volunteers. According to the policies and procedures reviewed on 09/23/15 at 2:00 pm establishes that if the candidate is a professional such as a nurse, he/she has to bring all required credentials: Cardiorespiratory (CPR) certification, professional state licensure, health certificate, Hepatitis B vaccine, Influenza vaccine, background check, among other documents. After the candidate is hired as a volunteer, receives orientation from the Human Resources Department and from the clinical department where the volunteer is going to work.
a. During the survey process it was found that there is a Registered Nurse offering services as a volunteer (employee # 16). However, it was observed on 09/22 and 09/23/15 that the volunteer (employee #16) is giving direct care to inpatients under a preceptor schedule with a Registered Nurse.
On 09/22/15 at 2:00 pm the Nursing Supervisor (employee #14) stated in an interview: "the volunteer is not alone giving care to the patients. She is accompanied by a Registered Nurse. Today she is in the hospital area and tomorrow she will be at the outpatient clinics. We have a training schedule and she has to follow it. The person who is in charge has to sign the form. She will be on orientation for 3 months."
The volunteer RN (employee #16) was interviewed on 09/23/15 at 1:30 pm and she stated: "I began on the volunteer program on past July. It will be ending by mid October. When I went here to talk with the Director of Nursing I requested her to give me the opportunity to practice some nursing procedures because I was feeling worried and with fear due to the lack of practice in some procedures such as medications administration. I have been doing everything under the supervision of a staff nurse. I have been taking and writing on the clinical record the vital signs, to administer (oral, subcutaneous and intravenous) medications, venopunction. The nurses countersign my progress notes. Today, I'm at the outpatient clinics, taking the vital signs of the patients. I have assigned to come on 7am /3 pm shifts from Monday thru Friday. I don't receive payments while I am doing this volunteer job. I know that they are not hiring because no positions for RN are available. I just wanted to practice some procedures to be more confident with myself and to ensure what I am going to do as soon as I begin working in a hospital".
On 09/24/15 the Director of Nursing (employee #15) was interviewed at 11:30 am and she stated: "We hired this Registered Nurse on the volunteer program because she wanted to practice some nursing procedures. She received all the orientation that a new employee receives when is hired to work at the hospital. The Human Resources staff gives orientation and then we plan an orientation schedule for her. She offers direct care under the supervision of the Nursing Supervisor and under the nursing staff that is with her. We did not hire her as a new employee because there is no position available".
b. The hospital regulation does not include the volunteer services. The volunteers programs are design to provide assistance to patients that receives nursing care at home with light duties such as: read newspaper, assistance in giving food, bath, cooking meals, wash and dry patient's clothes or even to clean patient's room. The Registered Nurse acting as a volunteer is providing direct care to patients; duties that a volunteer is not allow doing in a hospital setting.
c. No evidence was found on the facility's budget report of how the facility reaches some savings hiring professional personnel doing volunteer duties.
4. The nursing staff orientation calendar does not show the Control Infection and Safety Environment courses. It was not determined when the nursing staff has participated on those mandatory courses.
5. During 4 RR for discharge planning, performed on 09/24/15 from 9:00 am thru 12:00 md, it was found that the nursing staff does not participate on the discharge planning activities.
a. The nursing assessment for adults and for children, has a section named Referral to Social Worker but the nursing staff fails to write this section when they have patients that on the admission process assess that patient will require homecare and hospice services, (Cross reference TAG 806)
a.1. RR # 28, performed on 9/24/15 at 9:00 am, the patient was discharged for home care agency services on 10/15/14. The Social Worker (employee #11) did the discharge planning assessment establishing that the patient requires homecare services. However, no evidence was found of the nursing staff participating in the discharge planning process, such as: indicating on the nursing assessment the referral to the Social Worker, developing a plan of care, offering patient and or caregiver education related to new medications, uses of medical equipment, etc.

a.2. On RR # 28, the section for referral to Social Worker was left in blank by the nursing staff. On 4 out of 4 RR performed on 9/24/15 from 9:00 am thru 12:00 md it was found that the nursing staff failed to identify on the nursing assessment the referral to the Social Worker as part of the discharge planning activities, (RR #28, #29, #30 and # 31).

b. On 4 out of 4 RR performed on 9/24/15 from 9:00 am thru 12:00 md it was found that the nursing staff failed to participate in the plan of care for discharge planning,(RR #28, #29, #30 and # 31), (cross reference TAG 818) .

Based on the observational tour of the medical records department with the medical record supervisor, it was determined that the facility failed to ensure the proper storage and placement of medical records in the medical record department, in the storage area outside of the hospital under the general storage room related to boxes with records with dust covered and records exposed to possible water damage, humidity, dirty area, exposed to fire and unsecure records.

Findings include:

1. During the observational tour of medical record area located on the first floor of the hospital accompanied with the Medical Record Supervisor (employee #1) on 9/22/15 at 11:00 am, the following was observed:

a. The area used to place active medicals records and management the daily information
has a metal door with code system used for medical records employees, this door has a pane of glass and exposed the security of the patients medical records because the door lacks of rail and anyone could break the glass and get inside the area. In addition this area is located at the corridor that accesses the employees parking located at the rear of the hospital. Near of this door was observed a wood door covered with rail however the door has a broken lock and has the padlock however was observed opened all the time. This wood door has access to the interior files where the active medical records are.

b. During the observational tour of the medical record department with the medical record supervisor (employee #1) on 9/22/15 at 11:10 am, it was found that an area where records are reviewed and stored does not have metal bars or rail. A waiting room used for the patient's when received emergency services or when needs to request a medical record services, this area has three spaces divided with wood panel to provide the confidentiality when the patients request information however it was observed that the three spaces (cubicles) has a crystal pane lacks of metal bars or rail and did not protected and safe guard the patient ' s medical records. The crystal pane provides visual accessibility to the interior of the medical records area. Also, medical record personnel use desks to place records on that area (approximately 300 to 400 medical records). These crystals panes are not hermetically sealed, has an opening space used when the patients request the information to the medical record employees, this spaces provide accessibility to the interior of the medical record area and during hours that the facility did not provide services or on weekends they are expose to damage or robbery of the records located on the medical records department because anyone can break the crystal pane.

c. On the medical record area waiting room was observed a wood door that has access to the emergency waiting room, on this emergency waiting room area was observed a metal wall and metal door divided the medical record area and the emergency waiting room, however this metal wall are not hermetically sealed and has an opening space with approximately two to two and a half feet, it was found that this area exposed the accessibility of anyone to come in at the medical record department. The facility failed to protect the patient medical records and other important documents located on the medical record department.

d. During the observational tour of the inactive and active archive medical record department located outside of the hospital on the second floor with the medical record supervisor (employee #1) on 9/23/15 at 9:30 am, it was found that an area where records are stored do not have metal bars on ten crystal windows and two crystal doors to safe guard the records. The second floor has a balcony and a rail was observed but only covered the middle of the space. Also, medical record personnel use plastic shovels to place medical records boxes. These windows are not hermetically sealed because the handles are broken and during rain storms these windows can allow rain water to leak through and damage the records on the shovels. Deteriorate boxes and medical records were observed.
During the observational tour dirty area and much dust was observed inside and outside of the inactive medical record area, dry leaves from a tree that enter the windows were observed in the interior of the room, insect excrement, humidity odor and peeling paint were observed. The area lacks of fire extinguisher, air conditioner, no smoke detectors and acoustic ceiling with dust was observed.
The medical record supervisor (employee #1) was interview and she stated: '' This local is property of the hospital. The medical records located on this area belong to Hospital Castañer and the Policlinic in Adjuntas. There are approximately 4,000 to 5,000 medical records here since 20 to 25 years back. The facility has a project to destroy records but it has not been structure or started.''

Based on the observational tour of the medical record department with the Medical Record Supervisor (employee # 1), 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 9/22/15 at 11:00 am the medical record department was visit with the medical record supervisor (employee #1) and it was found that the entrance door of the medical records department do not provide security and did not prevent unauthorized access. The door has a code system however the door has a glass panel. On 9/23/15 at 11:30 am the medical record department was visited again and the front door locate on the corridor that access the employee parking lot was maintain with broken lock and the pad lock was observed open during the entire survey and the door was not label with a sign for "authorized personnel only". The Medical records for admitted and emergency room patients were observed over different counter tops and tables without being filed because there is not enough space to store them near the patient information counter located on the waiting room.

2. On the medical record area of the waiting room was observed a wood door that has access to the emergency waiting room, on this emergency waiting room area was observed a metal wall and metal door divided the medical record area and the emergency waiting room, however this metal wall are not hermetically sealed and has an opening space with approximately 2 to 2 ½ feet, it was found that this area exposed the accessibility of anyone to entire at the medical record department. The facility failed to protect the patient medical records and other important documents located on the medical record department.

3. During the observational tour of the inactive and active archive medical record department located outside of the hospital on the second floor with the medical record supervisor (employee #1) on 9/23/15 at 9:30 am, it was found that an area where records stored do not have metal bars on ten crystal windows and two crystal doors to safe guard the records. The second floor has a balcony and a rail was observed but only covered the middle of the space. Also, medical record personnel use plastic shelves to place medical records boxes. These windows are not hermetically sealed because the handles are broken and during rain storms these windows can allow rain water to leak through and damage the records on the shelves.

Based on thirty two clinical records review performed on 09/23/15 it was found that the facility failed to ensure that the physicians complete the documentation of the History and Physical form in a period of 24-48 hours after the admission of the patients, as observed in 2 out of 32 records review (RR #26 and RR #27 ).

Findings include:

1. During RR #26 review performed on 09/23/15 at 9:30 am it was found that the physician failed to document the History and Physical form for this patient since the admission was performed on 09/21/15.

2. During RR # 27 review performed on 09/23/15 at 1:00 am it was found that patient was admitted on 09/21/15 at 10:00 am with a diagnose of Bronchial Asthma. The physician partially documented the History and Physical leaving blank spaces on: Chief complaint, present illness, habits, family history, Review of system, pain assessment, laboratory results, provisional diagnosis, date of examination, signature of the physician and hour.

a. On the past and personal history the physician made an annotation but is illegible as well as the surgical history.

During interview with the Medical Director (employee #17) performed on 09/23/15 at 1:30 pm he stated: "the physicians have 24-48 hours to complete the History and Physical examination form. We have been working this concern with the faculty and I recently hired a person to review the documentation of the clinical record, which it should be complete before the record goes to the Record Room. The faculty by-laws establish that time of period and they have to comply".

3. The facility failed to ensure that physicians comply with the documentation of the History and Physical Form as established on the staff by laws.

Based on thirty two clinical records review performed on 09/22/15 and 09/23/15 and interview with the Medical Director (employee #17), it was found that the facility failed to ensure that the clinical records have complete physicians orders and documentation of patients that can help to determine patients response to provided care, as observed in 4 out of 32 records review (RR #24, #25, #26 and #27).

Findings include:

1. During RR performed on 09/22/15 at 2:15 pm and on 09/23/15 at 9:30 am and 1:00 pm it was identified illegible documentation on the clinical records performed by some physicians.

According to interview with the Medical Director (employee #17) performed on 09/23/15 at 1:30 pm, he stated: "The illegible documentation is a concern that we had identified and we have quality indicators for surveillance. It has been difficult to deal with some physicians but we still are working with them".

2. During RR #24 performed on 09/22/15 at 2:15 pm and of an 11 years old female who was admitted on 09/21/15 due to a diagnose of Bronchial Asthma, it was found incomplete physician's orders:

a. Order from 09/21/15 11:58 am- Mg SO4 (Magnesium Sulfate) 1 gram IVPB (intravenous piggy bag), Solumedrol 90 mg IV, Sorbotuss 10 cc po, Ampicillin 500 mg IVPB. The physician failed to establish frequency of administration (stat, one dose or how many hours to be administered). On the Sorbotuss order used cc instead of ml (milliliters) as an authorized nomenclature to avoid confusion.

b. The physician wrote the following order on 09/21/15 at 3:00 (it was not determined if was am or pm): Sorbotuss 10 cc QID and Ampicillin 500 mg c /6 hrs. The physician failed to write the route of administration for Sorbotuss and Ampicillin medications. Used unauthorized nomenclature for Sorbotuss liquid medication, cc instead of ml.

3. During RR #25 of a patient receiving treatment for Bronchial Asthma at the Emergency Room on 09/22/15 at 11:15 am, it was found the following order: "Albuterol 0.083% c 30 x 2". According to the Respiratory Therapy Supervisor (employee #29) it means: Albuterol 0.083% every 30 minutes times 2 doses". The physician failed to write a complete order.

4. RR #27 was performed on 09/23/15 at 1:00 pm and it was found the following: female patient who was admitted on 09/21/15 at 10:00 am with a diagnose of Bronchial Asthma. The physician's order was: Solumedrol 40 mg c/6hr and Sorbotuss 10 cc QID. The physician failed to write the route of administration and used unauthorized nomenclature for Sorbotuss liquid medication. For Albuterol 0.083% and Atrovent 0.2% orders every 6 hours each to be administered, the physician failed to write the modality of administration and for how long the respiratory therapy will be administered.

According to interview with the Respiratory Therapy Supervisor (employee #29) on 09/23/15 at 1:40 pm the respiratory therapy should be administered until 3 days. If the physician does not specify for how many days the respiratory therapy will be administered, the therapist puts a label with an automatic stop until the physician re evaluates the treatment and reorders it if patient needs to continue with the respiratory therapy.

5. RR #26 was performed on 09/23/15 at 9:30 am and it was found that the physician ordered on 09/21/15 to do dextrostix and chart at 6:00 am and 9:00 pm. Patient is receiving Solumedrol 40 mg IV due to an edema on his left side of his face due to an infection on the maxilla. According to dextrostix chart patient had the following results: 9/21/15-9:00 pm/179 mg/dl, 9/22/15-6:00 am/142 mg/dl, 9/22/15-9:00 pm/250 mg/dl, 9/23/15-6:00 am/150 mg/dl. No evidence was found of the re-evaluation made by the physician to determine if hyperglycemia, caused as a secondary effect of the Solumedrol IV administration, is going to be treated with oral hypoglycemic medications or insulin. The physician's progress notes does not show evidence of having evaluating on a daily basis the patient's dextrostix results.

6. RR #26 was performed on 09/23/15 at 9:30 am and it was found that patient has a history of Hypertension but this problem was not identified on the plan of care since the day of admission, considering that he is taking Atenolol 25 mg daily. On 9/22/15 at 10:00 pm it was found a nurses ' progress note where patient showed "oppression" on his chest, the emergency room physician was consulted and ordered an electrocardiogram (EKG). No further orders were prescribed. The RN called the head physician and he ordered Protonix 20 mg by mouth and blood samples for Troponin, cardiac enzymes and keep him in observation. One hour later patient refered that he was feeling better. However, nursing staff failed to identify this new problem in the plan of care. The physician's progress notes does not show what really happened with the patient. It was not determined if patient's symptoms were related to his history of Hypertension or gastrointestinal discomfort due to reflux.

Based on observation of the medication carts and the verification for locks of the medications carts and storage, it was determined that the facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel.

Findings include:

1. During the observational tour and verification of proper storage of the drugs and biological on 9/22/15 at 2:40 pm accompanied with the Register Nurse (RN#28), the following was found:

a. The medication cart was found beside the Nursing station unlock and unattended with medications inside. The facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel.

Based on the inspections of the medications stock on the hospital ward with the Register Nurse (RN #28) it was determined that the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs and biological are not be available for patient use.

Findings include:

1. During the inspections of the medications stocks on the hospital ward on 9/22/15 at 2:30 pm accompanied with the RN#28, the following was found:

a. Children Ibuprofen elixir expire on August 2015.The facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs and biological are not be available for patient use.

Based on observations, review of documents and interview with the Pharmacist (employee #18), it was found that the facility fail to follow the state pharmacy regulation 133 article 7.06 of December 29, 2008 for dispense of medications on the pharmacist absence.

Findings include:

1.During interview on 9/24/15 at 11:35am employee #18 state that when the pharmacy is close and the medications are not in the ward or emergency room storage, the physician call him for the medications availability then he call the pharmacy technician for the dispense of the medications. The facility does not provide evidence of policies and procedures when the pharmacist is not available and the medications are not in stock in the ward or in emergency room storage. On the pharmacy state regulation 133 articles 7.06 of December 29, 2008 is written the pharmacy technician can not realized functions related with the medications dispense on the pharmacist absence. The facility fail to follow the state pharmacy regulation 133 article 7.06 of December 29, 2008 for dispense of medications on the pharmacist absence.

Based on the kitchen observational tour with the kitchen supervisor (employee #6), review of policies/procedures and food code 2013 guidelines, it was determined that the facility failed to develop policies and procedures to ensure that relative humidity and temperature of dry food storage are on parameters (temperature 50-70 F and relative humidity 50- 60%), recorded and registered. The facility fail to provide a policies and procedure based on the food code of 2013 for the laundered of wiping cloths and lines.

Findings include:

1. During the observational tour on 9/22/15 from 11:18 to 11:40 am it was identified that the facility dry food storage did not have an air conditioning. Employee #6 was asked for the temperature and humidity log book of the dry food storage and it was not provide. The facility failed to develop policies and procedures to ensure that relative humidity and temperature of dry food storage are on parameters (temperature 50-70 F and relative humidity 50- 60%), recorded and registered as recommended on the Food code 2013 guidelines

a. On the cleaning lines the facility uses a manual chemical disinfection. The facility can not provide evidence of the accurate concentration of the sanitizing solution determine by the test kit or other device as recommended on the Food code 2013 guidelines. Facility did not provide the policies and procedure for the laundered of the wiping cloths and the lines as recommended on the Food code 2013 guidelines.

Based observation performed on 9/22/15 through 9/24/15 from 8:00 am till 4:00 pm, interview, the review of clinical records and policies/procedures, it was determined that the facility failed to ensure that physical environment, equipment and employees are train and coordinate to maintain a safe and good sanitary environment in the Hospital and Policlinic Castañer (off site location) which makes this condition "Not Met" (cross reference A701, A709, A724, A725 and A726 and also "Not met " with Life Safety Code (Cross reference K0018, K0046, K0048, K0050, K0051, K0052, K0054, K0054, K0064, K0104, K0130, K0144 and K014).

Based on tests performed on equipment and observations made during the survey for the physical environment with the Physical environment supervisor (employee #5), it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well-being of patients receiving services.

Findings include:

1. The diesel tank used to store and provide diesel to the essential electrical system (EES) was found out in the open and walking path for the employees not separated or protected by a fence as observed on 9/22/15 at 2:30 pm. The diesel tank is located in an area that makes it accessible to non-authorized persons.

2. One (1) Electricity Generator located between parking and entrance to the medical office does not have the appropriate sign posted. During the touring on 09/22/15 at 2:30 pm Cars parked near of diesel tank are not allowed. The diesel tanks used to store and provide diesel to the essential electrical system (EES) was found out in the open and not separated or protected by a fence as observed on 9/22/15 at 2:30 am. The diesel tank is located in an area that makes it accessible to non-authorized persons.

3. As observed during a tour in the Policlinic and Pharmacy (Off site location) Unit with the Nurse Supervisor employee #24 and the Physical Plant manager employee # 5 on 09/22/15 at 9:55 am thru 11:30 am , it was found that the facility failed to maintain a physical environment free of hazards.

On the Diabetic Foot office " Pie Diabetico " it was found 4 empty boxes of the whirlpool used for the patients, 2 tables with rust and scratch and broken Formica, the Formica has old stains of tapes. The equipment uses to soften diabetic patient feet was located in the sink with brown stains inside of them.

In front the optical area it was observed an emergency exit door uneven and opened because the lock does not latch properly. This door is one of the emergency exit door shown on the evacuation plan.

Behind the Ice machine, the floor and walls tiles have an excessive dust.

Men restroom was observed and the following was found:

The urinal has a black plastic bag covering it. The bag does not have any sign indicating the urinal it is out of service.

Interviewing the housekeeping employee (employee #27) indicates that the urinal is out of service since a lot of time ago.

The lavatory does not have hot water because the faucet is out of service.

The Housekeeping Storage:

One (1) mop inside a bucket and one (1) mop inside the sink.
Two (2) Wooden shelves and on the top touching the ceiling there were four foam cooler use to keep the vaccines.

Women restroom does not have hot water.

General Storage:

No smoke detector and fire extinguisher was found. (Cross reference K-51 and K-130)
Eight (8) boxes and 7 black plastic bag touching the ceiling
One (1) biohazard disposable trash of 62 gals.
Box of toilet paper
Tools
Eight (8) boxes full of paper; these boxes are waiting to be send to the hospital.
This storage was observed disorganized and with a lot of dust covering the boxes before mentioned.

Medical Offices:

The trashcans that has to be push and touch the cover. (Cross reference A749)
Pulmonary function offices the clinical record file does not have lock for the drawers.
Four (4) boxes on the floor.
No smoke detector (Cross reference K-51)

Observation Area:

Supply storage: (1) AED (3) printer cartridge, (1) pulse oxymeter (out of function), (5) boxes of staples, (7) bottles of sterile water, (1) tray uses for venipuncture, books of receipts, bandage (all these items were found in the same shelve).
Two stretchers with rust
Two intravenous stands with rust
Two mattresses with old stain of tape.

Nurse Station: All bottle of medication opened and without opened date labeled. The counter was rusty and the counter Formica has old tape stain. Wooden storage full of medications was observed.

Clinical Record Area:

Office area: no smoke detector, (1) 10 lbs. ABC fire extinguisher (Cross reference K-51).

Reception area: no smoke detector and no fire extinguisher.

Inactive Clinical Record Area:

Outside storage with window without screen and bars to protected the records from outsider. The door of this storage is in aluminum with a window in the middle of the door without screen and bars.
The boxes full of files were stock on wooden shelves.
No air conditioning was found in this storage.
Strong humidity odor was perceived in the storage.
Dead bugs were observed under the racks.

Pharmacy Area:

Office area: No smoke detector, No fire extinguisher, no emergency light.
Storage: (1) rack full of boxes with prescription inside, (1) rack full of different products to be sale in the pharmacy, (1) rack with boxes of water, soda, juices and some comestible products for be sale in the pharmacy. On the same rack there were (1) Microwave and (1) coffee maker. The smoke detector has uncharged battery, no emergency light and no fire extinguisher.

4. As observed during a tour in the Hospital with the Nurse Supervisor employee #14 and the Physical Plant manager employee # 5 on 09/22/15 at 11:30 am thru 3:00 pm, it was found that the facility failed to maintain a physical environment free of hazards.

a. Morgue: (Cross reference A749)

During the tour the following was found:

No air conditioner, no biohazard disposal trash receptacle, no regular disposal trash receptacle, no thermometer to record the temperature and relative humidity inside the room, no lavatory sink, no hand sanitizer dispenser. The room only has a fridge with 3 shelves and it was turn off at the moment of the morgue visit.

Interview with employee #22 on 9/22/15 at 11:45 am reveals that the fridge is always off. At the moment of a patient death they start the procedure of the delivery of the death body.

Record review performed on 9/24/15 at 9:30 am reveals that the facility has a P&P ' s (policy and procedures) indicating that nursing personnel turn on the morgue (fridge) for acquire the temperature. No evidence of fridge temperature was provided. Also no record for disinfection of the fridge or the room and that it does not have housekeeping facilities to ensure that spills can be cleaned appropriately and that the area is cleaned after use and does not have a hand sink with soap and paper dispensers was provided.

b. Emergency room:

1. Nursing station:

One emergency light was observed with wires exposed and tied with black tape.

c. Respiratory therapy area:

The bathroom use for the patients in that area does not have:

Grab bars requires by Americans with Disabilities Act (ADA).
Lavatory sink, mirror and toilet with the requirements by Americans with Disabilities Act (ADA).
A metal file with 4 drawers was found without lock in this area.
Three lounge chairs were observed and no curtain for privacy was provided.
Lounge chair deteriorated
Window air conditioning is uses in this area. On 9/22/15 at 11:55 am patient was observed taking a respiratory therapy in the area and the air conditioning was turn on and the windows of the air conditioning was directly to the patient.

d. Observation area:

On the Supply (cabinets), where they have pads, bed linens out of plastic under the sink, paper linens and other materials. The intravenous supply was found without lock.

Cubicle #2 in the observation area it was found that the call system do not have the cord.
A black cord extension was suspended on the window.
Floor tiles with brown stain.
Strong odor of humidity.
Walls with peeling off paints.

e. Cardio, Trauma Observation Area:

The stretcher has linen with an old stain of blood. It was observed emergency room nurse (employee #8) performing an EKG. The blood stain linen has paper linen over it. (Cross reference A749)
Ceiling tiles with filter stains.
Floor tiles with brown stains.
IV stands with dust and rusty.
Wall air conditioner in this area was observed with spider web.
Windows was observed with old dust on it.
Call system in this area was far from the stretcher where the patient was observed.

5. As observed, at the patients ' room area was found:

In the bathroom emergency calls without the strings and far from the toilet and bathtub was found in rooms 1, 2, 3,4,5,6,7,8,9 and 10.

In room #1 it was found: cement detaching from the ceiling because the leaking. The bathroom do not met American Disability Act (ADA). The toilet area do not has grab bars. The toilet paper dispenser is far from the toilet 3 ' -1/2 " far from the patient when is sit.

In room #2 it was found: that the air conditioning is leaking and the wall where the A/C is installed has mold stain. A small window without screen was found. 2 chairs covered with cloth with stain and scratches. The bathroom do not met American Disability Act (ADA). The toilet area do not has grab bars. The toilet paper dispenser is far from the toilet 3 ' -1/2 " distance from the toilet to the dispenser when the patient is sit. The wall of the bathroom door has crack tiles and the door seal is broken. The string from the lamp on the room 2A is short.

In room #3 two chairs covered with cloth and scratches. The lavatory sink do not have hot water. 3A the lamp has one light burn. One small window without the operator to open it was found. 3B do not have the call system. The oxygen valve does not have the cap or the regulator. Spider web was observed between the corner of the ceiling and the window. One bed frame was stock in front of the bed. The mattress has stains. The frame of the bathroom door has rust and some part of it is broken. The floor tiles of the bath with mold stain.

In room #5 bed A the lamp string is short. Bed C the lamp do not function. The wall where the lavatory sink was installed has peeling off paint.

In room #6 the sink has a lot of scratches. Bed A the string of the lamp is short. One of the small windows lacks of operator. Left big window has the operator loose and broken (this part can cause a patient, staff or visitor harm). The toilet paper dispenser is located besides the sink and the paper towel dispenser is located upside the toilet (bathroom from room #7 has the same situation). The sink does not have hot water. A big hole was observed besides the air conditioner diffuser.

In room #9 (Intensive care Unit) there just one sink and the height of this sink is 26 " from the finish floor. Visitor was observed bended to reach the sink. Bed B the lamp does not have string to turn it on. Do not have call system. The oxygen valve located in the wall do not have cap. Ceiling tiles with leaking stain. In the bathroom was found: (one) commode without back holder. Mold and old stain in floor tiles were found.

6. The General storage was visit on 9/22/15 at 1:25 pm with the warehouse manager (employee #9) and the following was found:

This storage is the dry storage of the kitchen and lacks of air conditioning and the facility do not keep a temperature and relative humidity register log of this area.

This storage has beside the dry storage of the kitchen housekeeping material, disinfecting detergent and office supplies.

This storage has a second floor and looks disorganized and with lots of boxes and unused material.

7. The Intravenous solution general storage was visit on 9/22/15 at 1:45 pm with the warehouse manager (employee #9) and the following was found:

The storage is located beside the laundry and the door always is open because of the lack of air conditioning. In front of the storage door there was a conveyor where then dirty linen was throw by there. (Cross reference A749)

Nursing staffs have different kind of intravenous solutions (IV). The recommended temperature by the manufacturers is 77 Fahrenheit (F) grades (º). The temperature that the thermometer of the surveyor shows is 88º F.

Interview to employee #9 on 9/22/15 at 1:48 pm reveals that the storage lack of a thermometer to keep track the temperature and relative humidity of the room. Also it was reveals that the facility does not have a daily temperature and relative humidity register log for this storage.

It was found besides the intravenous solution boxes, 1 box covered with dust and mold stain.

Dead bugs around the IV solution boxes.

Wall with mold.

Boxes with account payables sheets.

One box full of old bed linen was found.

One wooden baby crib was found.

Two plastic bags full of bed linen were found.

Wooden racks with intravenous solution boxes.

8. All sharp containers placed in patients rooms, nursing medication room and the ones in the medication carts are not labeled with date, hour and initials of the registered nurse who placed them.

9. As observed, there are two (2) medication carts used by the nursing staff. Those carts were not clean. They showed heavy dust and black sticky spots related to dressing tape used for IV bandages.

10. Boiler Room was visited on 9/22/15 at 2:10 pm with Laundry supervisor (employee #10); it was found that back of the room there is a grid door with a sign indicating " Caution High Voltage. " This little room back of the boiler room has three (3) transformer of 75 KVA. It was observed outside this little room the main transfer switch with a distance of 8 ' -0 " from the water tank. There were 3 small electrical panels and in front of this electrical panel there was a small fan on.

Interview with employee #10 at 2:13 pm reveals that this fan is there because the panels get very hot and turn off the energy.

The surveyor took the temperature inside the room and reveals a temperature of 108º Fahrenheit.

This room does not have an exhaust fan to extract the hot air out of the room and does not have any window to keep circulating hot air for fresh air.

11. Kitchen was visited on 9/22 and 9/23/15 at 1:20 pm until 1:40 pm with kitchen supervisor (employee # 6), it was found three (3) trash can without foot pedal, wooden cabinet with broken Formica where food tray was stoke. The chiller of the meet fridge was observed dirty. There was a ceiling fan turn on and one of the employees was cutting vegetables and chicken.

Surveyor took the temperature on 9/23/15 at 9:00 am and reveals a temperature of 92º Fahrenheit and the stoves were turn off. Surveyor took temperature again at 11:15 am with the stoves on and reveals a temperature of 103º Fahrenheit.

Interview with employee #6 on 9/23/15 at 11:15 am reveals that she has to turn on the fan during the processing and the cooking of the meals because it is too hot.

12. X-ray department was visit on 9/23/15 at 10:30 am with the X-ray department supervisor (employee #2); it was found the patient bathroom beside the reception area do not met with the American of Disabilities Act (ADA). These bathroom lacks of grab bars besides and back of the toilet, the door measure do not permit the entrance of a patient that use wheelchair or walker. The bathroom door is wooden with louver.

13. Housekeeping room besides the nursing staff kitchen in the medicine ward was found with wooden cabinets, one missing ceiling tile, and pipes crossing the ceiling without seal with fire stop material, wooden shelves, no smoke detector and no exhaust fan.

14. Another Housekeeping room was visited on 9/23/15 at 9:30 am with housekeeping employee (employee #20), it was found that the room do not have exhaust fan, smoke detector, pipe crossing the ceiling without seal with fire stop material, ceiling in some areas without cement because the leaks of the ceiling, wooden shelves and the room do not have the mops rack. Four mops face down against the wall (Cross reference 749).

15. Linen storage on medicine ward was visited on 9/23/15 at 9:30 am; it was found wooden shelves with carton boxes touching the ceiling with spring decoration, Christmas lights and decoration. Shelves were observed with old dust and stains. This room does not have smoke detector.

16. In front of the emergency room entrance door it was observed on 9/22/15 at 1:25 pm it was found an electrical panel open without any lock.

17. Interview and record review performed with employee # 5 on 9/22/2015 from 2:20 pm until 3:15 pm, it was found that the facility fails to keep register log for the maintenance of services performed by subcontractors. Maintenance of electric generator, water tank disinfecting and cleaning, air conditioning etc.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Engineers (employee #11) , physical environment supervisor (employee #12) and the security officer (employee #28), 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 from 3/11/14 through 3/14/14 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, K0038, K0066, K0069, K0072, K0075, K00104, K0130, and K0141).

Based on observations made during the survey for the physical environment with the facility's Physical Plant Supervisor (employee #5), 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 maintenance closets with mops and brooms placed upward and the emergency call system in the lack of call system in the bathtub.

Findings include:

1. Mops and brooms were observed maintenance closets of the medicine floor and the policlinic (outside location) on 9/22/15 leaning up against the wall (mop heads up and the poles down) and inside of a sink . This procedure contaminates the walls and allows water from the wet mops to leak down the poles and is not an acceptable practice related to infection control standards.

2. In rooms # 5 and 9 the nurses call system does not function. In the bathroom of room every bathroom the nurse's call box besides the toilet does have strain and the bathtub lack of nurse call system.

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

Findings include:

1. The morgue was visited on 9/22/15 at 11:45 am with the ER supervisor (employee #22) and provided evidence that it does not have housekeeping facilities to ensure that spills can be cleaned appropriately and that the area is cleaned after use and does not have a hand sink with soap and paper dispensers, biohazard waste disposal and air conditioning.

2. The bathroom located near the respiratory therapy area was visited on 9/22/15 at 11:55 am and provided evidence that grab bars are needed behind and at one side of the toilet, the toilet seat needs to be between 17 and 19 inches in height and the door does not have a universal handicapped sign, all of which does not comply with Americans with Disabilities Act (ADA).

3. The bathroom located near the observation area in the ER was visited on 9/22/15 at 12:20 pm and provided evidence that grab bars are needed behind and at one side of the toilet, the toilet seat needs to be between 17 and 19 inches in height and the door does not have universal handicapped sign, all of which does not comply with American with Disabilities Act (ADA).

4. The hospital's emergency room was visited on 9/23/15 at 12:00 pm with the ER supervisor (employee #22) and provided evidence that there are three wall oxygen outlets valves that are in a room that is used to provide respiratory therapy to patients. The three oxygen outlets were placed side by side with little space between them and no curtains were found between the lounge chairs. In order to provide emergency treatment to a patient at least four feet between lounge chairs is needed to accommodate emergency staff and equipment and the curtains are needed to provide privacy during treatment.

5. Maintenance closets throughout the hospital and off-site emergency room were observed from 9/22/15 through 9/24/15 from 9:30 am until 3:00 pm. These closets were found with chemicals to clean the facility and equipment and did not have air extractors or smoke detectors connected to the fire alarm system.

2. The room inactive and active filed medical record department located outside of the hospital on the second floor with the medical record supervisor (employee #1) on 9/23/15 at 9:30 am was visited and provided evidence that on this area a deteriorate boxes and medical records were observed. During the observational tour dirty area and much dust was observed inside and outside of the inactive medical record area, dry leaves from trees that enters though the window were observed inside the room, insect excrement, humidity odor and peeling paint were observed. The area lacks of extinguisher, air conditioner, no smoke detectors and acoustic ceiling with dust was observed.
The medical record located on this area is of Hospital Castaner and Policlinica Castaner located on Adjuntas. Actually approximately 4,000 to 5,000 medical records here are from 20 to 25 years back.
On 9/22/15 at 11:30 am during the review of infection control policies and procedure, no evidence was found related to policies and procedure relevant to disinfection, maintenance and repair of this area. The infection control manual did not include requirement for Infection Control risk assessment.



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Based on observations made during the survey for the physical environment , 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) and record rooms without required ventilation.

Findings include:

The emergency room and OPD area was visited on 9/22/15 from 9:30 am through 3:00 pm and provided evidence that the waiting area, triage area and the observation area of the adult and OPD area 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 air disinfection.

Based on review of documentation of the program of Infection Control, review of Policies and Procedure and interview with the infection control officer (employee #13), it was determined that the facility failed to developed and implemented policies relevant to construction, renovation, maintenance, demolition and repair including requirement for Infection Control risk assessment.

Findings include:

1.On 9/23/15 at 10:15 am during the review of infection control policies and procedure, no evidence was found related to policies and procedure relevant to construction, renovation, maintenance, demolition and repair including requirement for Infection Control risk assessment that define the scope of project and needs of barrier measure before a project get underway.

Interview with the infection control officer on 9/23/15 at 10:17 am state that the facility did not have policies and procedure in case of construction, renovation, maintenance, demolition and repair including requirement for Infection Control risk assessment.

Based on review or the infection control program it was determine that the facility failed to have a mechanism to ensure that facility maintain infection control precautions accordingly with accepted recognized guidelines and requirements was not promoted not followed accordingly with the following findings identified during survey procedures from 9/22/15 through 9/23/15.
Findings include:

1. In "Policlinica Castaner " on 9/22/15 at 9:55 am it was identified that housekeeping personnel (employee #27) transfer a chemical used to clean and disinfect while working in the different areas of the facility from its original container to another container. However the container were he transfer the chemical was not label the rebottle with the name and contents.

Housekeeping personnel (employee #27) of "Policlinica Castaner " stated on interview on 9/22/15 at 10:03 am that he dilute some quantity of bleach in water to clean certain common areas. CDC recommends a 1:10 dilution of 5.25% - 6.15% bleach (5250 ppm - 6150 ppm sodium hypochlorite solution).

2. However (employee #27) did not state the exact quantity of bleach that he dilutes on the container that he used to clean and disinfect.
3. The door of the office were Pulmonary Function Testing (PFT) are performed were found unlock. Equipment to be used with the tests; were found storage on a box that was observed located directly on the floor.
Facility director (employee # 21) stated during interview on 9/23/15 at 10:25 am that
they did not establish procedures to disinfect blood pressure equipment, glucometers, respiratory therapy equipment, thermometers and pulse oxymeter. Facility failed to establish procedures and responsibilities to ensure that non critical items are disinfected with an EPA registered disinfectant accordingly with CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008.

4. Stainless steel container was observed in patient treatment area with a bunch of gauzes exposed to the environment.


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20. During the observational tour of the inactive archive medical record department located outside of the hospital on the second floor with the medical record supervisor (employee #1) on 9/23/15 at 9:30 am, it was found that an area where records stored does not have metal bars on ten crystal windows and two crystal doors to safe guard the records. The second floor has a balcony and a rail was observed but only covered the middle of the space. Also, medical record personnel use plastic shelves to place medical records boxes. These windows are not hermetically sealed because the handles are broken and during rain storms these windows can allow rain water to leak through and damage the records on the shelves. Deteriorate boxes and medical records were observed.

During the observational tour dirty area and much dust was observed inside and outside of the inactive medical record area, dry leaves from trees that enter through the window observed in the interior of the room, insect excrement de, humidity odors and peeling paint were observed. The area lacks of air conditioner, no smoke detectors and acoustic ceiling with dust was observed.

The medical record supervisor (employee #1) was interview and she stated: '' This local is property of the hospital. The medical records located on this area belong to Hospital Castaner and Policlinica Castaner located on Adjuntas. Actually approximately 4,000 to 5,000 medical records here since 20 to 25 years back. The facility has pending a project to destroy medical records but did not have the structure yet.''

The facility failed to establish procedures and responsibilities to ensure that non critical items are disinfected with an EPA registered disinfectant accordingly with CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008.



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5. During the initial tour with the Nurse 'Supervisor (employee #14), Safety officer (employee #4) and Infection Control (employee #13) to patients rooms, respiratory therapy area, Sterilization Area, Laundry and medical-surgical storage and Morgue on 9/22/15 from 9:30 am till 2:30 pm the following was found:

a. At 9:30 am the RN identified that patient in room #4 as Isolation, however, no label of Isolation and type of Isolation was observed in patient room door.

b. At 9:40 am the RN identified that patient in room #8 as Isolation, however, no label of Isolation and type of Isolation was observed in patient room door.

c. At 10:15 am the respiratory therapist supervisor (employee #29) identified the room to disinfect the ventilator a room near the respiratory therapist office. The area was observed that it lacks an appropriate space for the disinfecting and storage of clean mechanical ventilators. The area where respiratory therapy personnel clean and disinfect used mechanical ventilator was observed that has only one door to entrance and exit. The area was observed unorganized and the following was found:

c1. In the same room that clean and disinfected the mechanic ventilator was located the autoclave to disinfected critical equipment as Laryngoscope blade, scissors suture and other equipment.

The facility did not meet with the CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 that recommended that central processing area(s) ideally should be divided into at least three areas: decontamination, packaging, and sterilization and storage. The Physical barriers should separate the decontamination area from the other sections to contain contamination on used items.

c2. The room was observed with multiples equipment as 3 box with equipment used in case of bioterrorism over the cabinet where the auto clave was place.

c3. The clean material was near the area to disinfect the critical equipment and near the auto clave.

c4. Under the cabinet were the auto clave was place was observe a mop cube and a stainless steel basin on the floor.

c5. It was observed a toilet pool in the room, a Metal cabinet drawers and a metal closet with material stored in the room where the autoclave is place.

d. At 11:00 am it was observed in the Laundry area the following:

A Metal Wall fan with dust and mold near the dryer and fan directly over the industrial ironing board.

e. At 11:05 am it was observed in the hall way between the laundry and the medical surgical storage 41 boxes directly in the floor containing sterile water, normal saline at 0.9%, saline solution at 0.45%, primary and secondary Intravenous line.

f. The storage was found without air conditioning and did not have a log o temperature and Humidity registered.

g. At 11:48 am in the medicine ward it was found that the glucometer control was opened and without a label with date, hour and sign of person that opened, according to manufactured literature recommended discard after 90 days after opened.

h. At 11:59 am the refrigerator of the medicine ward was found a Vial of Novoline N opened on July 26, 2015 available for patient use, according to nurse supervisor (employee #14) the policy and procedure state discard after 28 days after opened.

i. At 2:00 pm it was observed that the morgue room did not have air condition and the morgue refrigerator was turn off.

7. R.R #17 is a 51 years old female admitted with a diagnosis of infected second degree burn in abdomen a Right leg. RN #30 stated that was in isolation, however the room was not labeled with isolation and no evidence was found related to physician ordered isolate this patient.

8. No evidence was provided to ensure that respiratory fit testing is provided at regular intervals to personnel at risk.

The evidence provided of respiratory testing fit not cover the 100% of all personnel at risk during 2013, 2014 and 2015. The infection control officer and the respiratory therapist supervisor do not know what is the percent of personnel at risk that has the respiratory fit test.


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9. During policies and procedures (P&P's) review from the Respiratory Therapy services performed on 9/22/15 at 10:00 am accompanied by the Respiratory Therapy Supervisor (employee # 29) it was found that there are not P&P's for cleaning and disinfection of the mechanical ventilators machines.

10. The Respiratory Therapy services have available 2 mechanical ventilators machines, one at the Supervisor's office and the other at the Emergency Room of the facility. However, both ventilators machines are not covered with a plastic bag when are not in use, to avoid cross contamination.

11. During observational tour performed on 09/23/15 between 11:00 am thru 12:00 noon, it was identified the following:

a. Patient at room #4 was calling the nurse staff due to intravenous (IV) pump alarm was activated. As observed with other RN (employee # 28), the RN (employee #31) went to the room which was identified that patient was on isolation by contact precautions. However, the RN (employee #31) failed to use personal protective equipment as: gown and non sterile gloves. The RN is not following the 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, published by the Centers for Disease Control and Prevention (CDC), (Cross Reference Tag 749 item #6 a and b)

b. As observed during venopuncture procedure performed by RN (employee # 31) on 9/23/15 at 11:15 am, she failed infection control practices because she put the tape, gauzes, and iodine swabs directly over the bed's sheets. The RN (employee #31) failed to put an under pad over the sheet to create a clean barrier. Other deficient practice was that the RN cleaned the selected venopuncture area with alcohol toilette with ups and downs motions instead of circular motion from inside to outside of the site. The RN failed to follow standards of practice for infection control application procedures during the venopuncture process. Also, she failed to follow the Venous Access and Periferal Phlebotomy Care policies and procedures, Section IV step 12 established by the facility.

c. As observed on 9/23/15 while performing her duties, RN (employee #31) was wearing long nails, over 1/8 inches of the finger-tip. The RN failed to follow policies and procedures established by the facility and by the State Administrative Order Number 284 from May 31, 2011.


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12. As observed during venopuncture procedure performed by RN (employee # 7) on 9/22/15 at 11:15 am, the facility failed to ensure nursing staff follows infection control practices related to employee #7 at the moment to perform the venopuncture procedure do not wash his hand, cut the tape and put it on the counter beside the stretcher, put the gauzes and iodine swabs directly over the stretcher sheets. Employee #7 failed to put an under pad over the sheet to create a clean barrier. The RN cleaned the selected venopuncture area with alcohol toilette with ups and downs motions instead of circular motion from inside to outside of the site. The RN does not follow standards of practice for infection control application procedures during the venopuncture process. Also, RN do not follow the Venous Access and Peripheral Phlebotomy Care policies and procedures, Section IV step 12 established by the facility.

13. The Emergency room was visited on 9/22/15 at 11:35 am and it was observed in the Cardio, Trauma observation area a stretcher with white bed sheet linen and over it there was a paper stretcher covering the area where the patient is lying. RN was performing an EKG and it was observed the bed sheet with and old blood stain.

14. Observation area was visit on 9/22/2015, it was found under sink cabinet clean bed sheet out of the plastic.

15.At the emergency room behind the nursing station it was located the area where nursing staff prepared the medication. On 9/22/2015 it was found the pill crusher dirty. Open bottle of medications opened without labeled with the date and shift when it were opened. However, a sign was observed in one of the cabinet door indicating " Favor de anotar la fecha de cuando se abren los medicamentos y soluciones " Please record the date when drugs and solutions were opened.

16. All patients ' rooms has chairs covered with cloth. This material does not permit an adequately cleaning and disinfection.

17. All sharp containers placed in patients rooms, nursing medication room and the ones in the medication carts are not labeled with date, hour and initials of the registered nurse who placed them.

18. At the linen room was found dirty and with old stain wooden shelves. Over these shelves it was found three boxes of gloves opened, clean bed sheets out of the plastic, two pillows without cover, adult cuff, blue pads and disposable sheets out of plastics.

19. Cart crash from the intensive care unit was revised on 9/23/15 at 10:10 am and it was found: the laryngoscope and the laryngoscope blades were out of sterilized plastic inside of a tray; the tray was covering with the tubes, battery pack.

Based on observation, review of the infection control quality indicator it was determined that the facility fail to ensure that the hospital-wide quality assessment and performance improvement (QAPI) program and training programs address problems identified by the infection control officer or officers; and be responsible for the implementation of successful corrective action plans in affected problem areas.

Findings include:

1. During the review of the infection control program with the infection control officer (employee #13) it was found that the quality indicator for infection control was based on venopuncture process, label of multiple dose vials, Hospital area, Diet department, Respiratory therapy machine and equipment, Autoclave spores culture, emergency room area and outpatient area culture to discard pathogens harmful to health and compliance with the policy on use of garments and long nails and /or artificial. However no evidence was found related to quality indicator related to other aspect of infection control as hand washing, use of glove, use of protective equipment, Foley insertion, ulcer care, medication administration, isolation use to ensure patient safety in infection control.

2. During observation of nursing procedure it was observed that the nursing personnel did not use glove for the different procedure with patient. Nursing personnel did not wash their hand before and after taking care of the patient.

Based on review of policies and procedures, interview with the Social Worker (employee # 11) during the survey process performed on 9/22/15 through 9/24/15 it was determined that facility failed to establish an organized and effective discharge planning process which makes this condition 482.43 Discharge Planning Condition of Participation "Not Met". (Cross reference Tag A 800, A 806, A 811, A 812, A 818, A 820, A 821, A 837 and A 843).

Based on four records review (RR) for discharge planning performed on 9/24/15 from 9:00 am thru 12:00 md accompanied by the Social Worker (employee #11) it was determined that the facility failed to ensure that patients needs will be identified early during the hospitalization process and that a discharge plan will be develop to address the services that patients need after leaving the hospital for 4 out of 4 RR for discharge planning. (RR # 28, #29, #30 and #31).

Findings include:

1. The facility has criteria that help to identify faster those patients that need discharge planning. However, it was found that the physician order the intervention of the Social Worker the same day that patient has order to go home. The admission physician's order has a section where the physician, since the day of admission, can request the intervention of the Social Worker. However, on 4 out of 4 records review the space was left blank by the physician. This practice does not allow that the Social Worker can coordinate in advanced the services that patient needs and there is no enough time to coordinate with other professional services the orientation or instructions that patient/caregiver has to receive to continue providing care.

2. The facility has not develop a discharge plan where the interdisciplinary group can write their interventions and facilitate that other disciplines can observed the recommended activities. The lack of a discharge plan can promote a delay in the coordination of services.

Based on four records review (RR) for discharge planning, performed on 9/24/15 from 9:00 am thru 12:00 md and accompanied by the Social Worker (employee #11), it was found that the facility failed to develop a detailed and interdisciplinary discharge planning evaluation which includes an assessment of patient's capacity for providing self-care or to be cared by trained caregivers, to coordinate services with community agencies for medications, transportation, medical equipment services, to identify specialized facilities that can provide services to patients that required specialized skilled procedures in a manner that self-care is not interrupted, as observed in 4 out of 4 records review (RR # 28, #29, #30 and #31).

Findings include:

1. The discharge planning assessment that is documented by the Social Worker (employee #11), has the following items:

a. demographic information of the patient
b. insurance plan name
c. admission date and reason for admission
d. Identified needs: Homecare or Hospice Services, Medical Equipment, abuse and neglect, adequate uses of medications, special diet at home, respiratory therapy at home, other services.
e. Orientation to patient/caregiver: Medicare Beneficiaries, "Reforma", Homecare, Hospice, QIO, others
f. Referral to committees: interdisciplinary, nutritionist, health educator, others
g. Summary, Social Worker and patient/caregiver signatures

However, the assessment form does not have: documentation of the results of the discharge planning evaluation, assessment of patient's post discharge needs being met in the environment from which she/he entered the hospital, patient's ability to perform activities of daily living (ADL's), patient's and/or support person's ability to provide self-care/care, home and/or physical environment modifications and if these modifications can be made safely while patient is at the discharge planning coordination process, availability community-based services to meet post-hospital needs. Also, there is not financial assessment and there is no evidence of the participation of the physician, nursing staff, respiratory therapy staff, Dietitian and other professional staff in determining post-hospital needs that the discharge planning process address to their patients.

According to interview performed to the Social Worker on 9/24/15 at 10:00 am, she stated: "I'm the only one that coordinates the services that a patient needs. The hospital has develop criteria ' s to determine which patients needs discharge planning, like patients over 65 years old, patients that require homecare or hospice care and any other services that patients need. Usually the physician places the order for discharge planning a day before the discharge home order. The nursing staff sometimes, notifies me if they see special needs in the patients and they understand that my intervention is needed. The interdisciplinary group does not participate as a group for share patient's information. Once, the whole team made the morning report in front of each patient's room and that is an important activity to obtain patient's information and determine the need for discharge planning process."

Based on four records review (RR) for discharge planning, performed on 9/24/15 from 9:00 am thru 12:00 md and accompanied by the Social Worker (employee #11), it was found that the facility failed to ensure that the Social Worker and the interdisciplinary group discuss the results of the discharge planning evaluation with patient and or caregiver, as observed on 3 out of 4 records review (RR # 28, #29 and #30).

Findings include:

1. According to 4 out of 4 records review (RR #28, #29, #30 and # 31) for discharge planning performed on 9/24/15 from 9:00 am thru 12:00 md it was determine that the Social Worker (employee #11) failed to write in the clinical record the discussion of the results of the discharge planning evaluation that has performed with patient and/or caregiver.

According to interview performed with the Social Worker (employee #11) performed on 9/24/15 at 10:00 am, she stated: "After I had coordinated the services that patient needs, I discuss the results with the patient or caregiver. I only write on the assessment form the name of the agency with whom I made the coordination. Any other explanation, orientation or clarifying doubts given to patient or caregiver, I do not write them on the clinical record."

2. The discharge planning assessment form provides that patient or caregiver sign it as evidence that coordination of services were discussed and performed. However, the Social Worker (employee #11) does not specify what topics she discussed with patient and caregiver and the arrangements made to ensure that patient will receive adequate services according to his/her needs.

3. During RR #28 and #29 performed on 9/24/15 at 9:00 am and 10:00 am, both patients were going to receive at home, homecare and hospice services, respectively. However, there is no evidence of the discussion that the Social Worker had with patients and caregivers and the agreements that both established.

3. RR # 30 performed on 9/24/15 at 11:00 am, patient admitted on 1/6/15 with a diagnosis of Cellulites and ulcer on second toe of left foot and uncontrolled Diabetes Mellitus. The discharge planning evaluation performed by the Social Worker (employee #11) on 1/8/15, assessed that patient would need homecare services. However, she summarizes that patient will be transferred to a substitute home with the coordination of Family Department (Departamento de la Familia). No written evidence was found of the discussion of this patient's situation with family members.

Based on four records review (RR) for discharge planning, performed on 9/24/15 from 9:00 am thru 12:00 md and accompanied by the Social Worker (employee #11), it was found that the facility failed to ensure that the Social Worker writes in the clinical record complete data related to the coordinated activities that has performed to fulfill the patients needs at home and help to corroborate that patient is receiving the services that were identified during the discharge planning process, as observed on 1 out of 4 records review (RR #30).

Findings include:

1. According to 4 out of 4 records review (RR #28, #29, #30 and # 31) for discharge planning performed on 9/24/15 from 9:00 am thru 12:00 md it was determine that the Social Worker (employee #11) failed to write in the clinical record the results of the discharge planning coordinated activities. No evidence was found of the documentation that ensures that patients are receiving care according to their needs, if medical supplies arrived at home, if the professional staff of the home health agencies has begun care at home, if patient is receiving other community services that were coordinated by the Social Worker during the discharge planning process.

2. RR # 30 performed on 9/24/15 at 11:00 am, patient admitted on 1/6/15 with a diagnosis of Cellulites and ulcer on second toe of left foot and uncontrolled Diabetes Mellitus. The discharge planning evaluation performed by the Social worker (employee #11) on 1/8/15, assessed that patient would need homecare services. However, she summarizes that patient will be transferred to a substitute home with the coordination of Family Department (Departamento de la Familia). No evidence of detailed documentation related to social needs that were observed by the Social Worker (employee #11) to determine the intervention of a government agency to transfer the patient to a substitute home. No evidence was found of documentation related to which home health agency will provide care to patient after patient has been transferred to a substitute home.

Based on four records review (RR) for discharge planning, performed on 9/24/15 from 9:00 am thru 12:00 md and accompanied by the Social Worker (employee #11), it was found that the facility failed to ensure that a plan of care for patients participating in the discharge planning process is develop, including participation of the interdisciplinary group, as observed on 4 out of 4 records review, (RR #28, #29, #30 and # 31).

Findings include:

1. According to 4 out of 4 records review (RR #28, #29, #30 and # 31) for discharge planning performed on 9/24/15 from 9:00 am thru 12:00 md it was determine that the Social Worker (employee #11), failed to develop and implement a plan of care for discharge planning. Also, the nursing staff failed to participate in the discharge planning activities.

a. RR #28 was discharged home with homecare services on 10/15/14. This patient was admitted with severe dehydration, Leucopenia and Clinical Sepsis. The physician added on her medications list at discharge home orders, Pre-protein 10 milliliters (ml) by mouth and Apetigen 10 ml by mouth. However, no evidence was found on the clinical record the orientation given by the nursing staff to the patient/caregiver related to these nutritional supplements.

b. No evidence was found of the Dietitian participating in the discharge planning process related to the nutritional plan that patient has to follow at home.

2. RR # 29 was discharged home on 4/14/14 with hospice services due to Acute dehydration, renal disease, Diabetes Mellitus and Bronchitis. The Dietitian performed a nutritional evaluation on 4/12/14 and on her recommendations at discharge home are to consider the nutritional plan with Renal cal to run at 63 ml times 12 hours by nasogastric tube. However, no evidence of the discussion of this nutritional plan was found on the discharge planning plan of care. No evidence was found of the nursing staff or Social Worker requesting the Dietitian services to intervene in the discharge planning activities. Also, on the discharge summary that physician wrote on 4/14/14, he ordered that patient continues at home a nutritional intake with Glucerna QID, a 1800 calories diabetic diet and to use Humulin N 10 units in the morning. However, the Dietitian has already planned a nutritional intake of 1500 calories including Renal cal supplement due to renal disease that patient has. The physician failed to coordinate with the Dietitian the nutritional plan that patient has to follow at home; coordination that should be done during the discharge planning process.

3. RR # 30 performed on 9/24/15 at 11:00 am, patient admitted on 1/6/15 with a diagnosis of Cellulites and ulcer on second toe of left foot and uncontrolled Diabetes Mellitus. The physician ordered Augmentin 875 mg by mouth twice a day to be taken at home after the discharged home process. The local care to second toe of his left foot will be done with a bactericidal ointment (illegible documentation of the ointment ' s name) four times a day. However, no evidence was found of the orientation given by the nursing staff for foot care. No evidence to determine if patient can provide self-care or identification of a family member capable to provide care. No orientation of the Dietitian related to the diabetic diet and how to manage uncontrolled hyperglycemia.

4. d. RR #31 male patient admitted on 1/15/15 with diagnoses of Pneumonia and Chronic Obstructive Pulmonary Disease (COPD) and discharge home on 1/22/15. Patient was treated with intravenous antibiotics, medications for controlling hyperglycemia and hypertension, anti-inflammatory medication for controlling bronchospasm, respiratory therapy and providing oxygen by nasal cannula. However, no evidence was found of the orientation given by the respiratory therapy staff related to type of medication to used at home, availability of respiratory therapy equipment and how to use it and frequency of the respiratory therapies that patient has to receive.

5. The facility failed to develop a discharge plan that has the identified needs as determined by the discharge planning evaluation.

Based on four records review (RR) for discharge planning, performed on 9/24/15 from 9:00 am thru 12:00 md and accompanied by the Social Worker (employee #11), it was found that the facility failed to implement the initial discharge plan, as observed in 4 out of 4 records review, (RR # 28, #29, #30 and #31).

Findings include:

1. The facility failed to ensure that the interdisciplinary group place on the clinical record a discharge plan with evidence of the orientation given to family and/or caregiver with specific instructions related to the procedures that they have to perform at home to ensure that care is provided after patient leaves the hospital.

a. During RR #28 and #29 performed on 9/24/15 at 9:00 am and 10:00 am, both patients were going to receive at home, homecare and hospice services, respectively. However, there is no evidence of the referrals that the Social Worker did with the home health agencies.

3. RR # 30 performed on 9/24/15 at 11:00 am, patient admitted on 1/6/15 with diagnoses of Cellulitis and ulcer on second toe of left foot and uncontrolled Diabetes Mellitus. The discharge planning evaluation performed by the Social Worker (employee #11) on 1/8/15 assessed that patient would need homecare services but patient will be transferred to a substitute home. However, no evidence was found of the referrals that the Social Worker sent to the Family Department (Departamento de la Familia) and the home health agency.

4. The nursing services has a Nursing Discharge Summary where establish the instructions that patient/caregiver has to follow at home. However, it was found that the nursing staff failed to be consistent in documenting the Discharge Summary Form, as observed:

a. RR #28 female patient that was admitted on 10/10/14 and discharged home on 10/15/14. The diagnoses were Clinical Sepsis, Dehydration receiving in hospital treatment with antibiotics, intravenous solution with multivitamins and nursing staff placed a Foley catheter. Physician ordered at discharge, nutritional supplements with Pre-Protein 10 ml and Apetigen 10 ml by mouth daily. However, the Discharge Summary with the instructions has incomplete documentation on: name of nutritional supplements and frequency to be taken at home, no evidence of the home health agency that will provide care. Also, they failed to write on the emergency guidelines what patient will do if condition worsen.

b. RR #29 female patient that was admitted on 4/10/14 and discharged home on 4/14/14. The diagnoses were Acute Dehydration, renal disease, Diabetes Mellitus and Bronchitis. After been treated with intravenous solutions for hydration, controlling hyperglycemia levels and the nursing staff having placed a Foley catheter, the patient was sent home. However, the Discharge Summary has incomplete information related to new medications, no information of the hospice agency that will provide care and the instructions of what to do if patient's condition worsen.

c. RR #30 male patient admitted on 1/6/15 with Cellulitis and ulcer on second toe of left Foot and discharged home on 1/9/15. After patient been treated with antibiotics, control of hyperglycemia levels and local care, patient was sent home with oral antibiotics and local care with bactericidal ointment. However, the nursing staff failed to document the Discharge Summary and there is no evidence of the instructions given to patient/caregiver that has to follow at home.

d. RR #31 male patient admitted on 1/15/15 with diagnose of Pneumonia and Chronic Obstructive Pulmonary Disease (COPD) and discharge home on 1/22/15. Patient was treated with intravenous antibiotics, medications for controlling hyperglycemia and hypertension, anti-inflammatory medication for controlling bronchospasm, respiratory therapy and providing oxygen by nasal cannula. The patient was sent home with oral antibiotics, respiratory therapy and appointment with physician in 2 weeks but the Discharge Summary was not documented by the nursing staff. No evidence was found of the instructions given to patient/caregiver that has to follow at home.

Based on four records review (RR) for discharge planning, performed on 9/24/15 from 9:00 am thru 12:00 md and accompanied by the Social Worker (employee #11), it was found that the facility failed to establish a mechanism to reassess the discharge plan.

Findings include:

1. According to discharge planning policies and procedures discussed with the Social Worker (employee #11) on 9/25/15 at 10:00 am, the facility failed to include an ongoing reassessment of the discharge plan based on changes in patient condition, changes in available support and changes in post-hospital care requirements.

Based on four records review (RR) for discharge planning, performed on 9/24/15 from 9:00 am thru 12:00 md and accompanied by the Social Worker (employee #11), it was found that the facility failed to establish a mechanism to transfer medical information to agencies that will provide continuous care to patients. For 3 out of 4 records reviewed (RR #28, #29 and # 30).

Findings include:

1. According to discharge planning policies and procedures reviewed and discussed with the Social Worker (employee #11) on 9/25/15 at 10:00 am, no evidence was found of the medical information transferred to the professional staff of the agencies that accepted the patients for continuous care. For example: RR #28 and #30 were going to receive services by homecare agency while RR # 29 was going to receive post-hospital care by hospice service, (Cross Reference TAG 818 and 820).

Based on four records review (RR) for discharge planning, performed on 9/24/15 from 9:00 am thru 12:00 md and accompanied by the Social Worker (employee #11), it was found that the facility failed to establish a mechanism that ensure a reassessment of the discharge planning process on an ongoing basis as observed in 4 out of 4 records review, (RR #28, #29, #30 and #31).

Findings include:

1. According to discharge planning policies and procedures discussed with the Social Worker (employee #1) on 9/25/15 at 10:00 am, the facility failed to review a quantity of clinical records to determine if the activities performed during the discharge planning activities while patient was admitted, were enough to provide care to patients after leaving the hospital and to identify if any of those patients had a readmission order to the facility.

2. During RR #28, #29, #30 and #31, performed on 9/24/15 from 9:00 am thru 12:00 noon, no evidence was found of the evaluation performed by the Social Worker (employee 11) or other personnel to track patients to determine if they received the services that they needed and if any of those patients were readmitted to the facility.

3. The QAPI plan and activities does not show evidence of the evaluation performed to determine how many patients that were discharged home receiving services, were readmitted to the hospital.

Based on observations during initial tour on Castañer Adjuntas polyclinic outside location with facility outside location director (employee #24) it was identified that facility failed to ensure that the emergency services organization requirements are met.

Findings include:

1. As established by " Hospital General Castañer "policies procedures and regulations, they had a polyclinic who is a dispensary where diseases and injuries of some kinds are and diagnosed and treated. Accordingly with hospital description of services this polyclinic is not an urgency or emergency room department. However visible information who indicated that this outside location is not an urgency or emergency room department were not found posted outside the facility to inform patients that Castaner Adjuntas polyclinic outside location is a clinic for short term, non life threatening care.

Based on administrative documents review and interview with the Respiratory Therapy Supervisor (employee # 29) on 09/22/15, it was determined that the facility failed to ensure an organized Respiratory Therapy services, developing a legible respiratory therapy job schedule and assigning duties according to the professional standards of practice and according the hospital rules and regulations.

Findings include:

1. During review of the hospital respiratory therapy job schedules performed by the Respiratory Therapy Supervisor (employee # 29) it was found on 09/22/15 at 10:30 am the following:

a. The Respiratory Therapy Supervisor (employee #29) has developed a respiratory therapy schedule with the respiratory therapy staff assigned for the hospital area and for the emergency room. According to the Respiratory Therapy Supervisor (employee #29) during interview performed on 9/22/15 at 10:30 am, she stated: "I'm a full employee and in charge of the services. The hospital has respiratory therapy services under arrangement with a company. They have a respiratory therapist that coordinates and develop every 2 weeks the job schedule. She also, does perdiem shifts at the hospital. I supervise the contracted employees. There is another respiratory therapist that performs the Pulmonary Function Test on Thursdays at the Policlinica Adjuntas (outpatient clinic in other town)".

b. According to the Human Resources employee's list, there are 6 respiratory therapists with 1 Supervisor and on the respiratory therapy job schedule there are 7 respiratory therapists. However, the job schedule does not mention which employees are assigned at the hospital area and in the emergency room.

c. On the respiratory therapy job schedule there is no evidence of the staff that is on sick leave, vacations, etc.; items that are not mentioned on the job schedule legend. Also, the same respiratory therapy staff work on per diem (PD) schedules according to patients needs, but the respiratory therapy job schedule does not mention which respiratory therapists are working PD shifts.
d. No evidence was found of the Respiratory Therapy Supervisor (employee #29) signing the respiratory therapy job schedule with date and hour when it was reviewed and approved.
e. The Respiratory Therapy Supervisor (employee #29) showed during survey process 2 respiratory therapy job schedules, which is not recommended due to mismatch information and can create confusion on the respiratory therapy staff.
f. The facility failed to review the respiratory therapy job schedule and to develop one schedule with all pertinent information, easy to understand in a manner that the staff and Respiratory Therapy Supervisor can identify working areas, days of the week, shifts and who is in charge.

Based on administrative documents review accompanied by the Respiratory Therapy Supervisor (employee #29) performed on 9/22/15 at 10:00 am, it was determined that the facility failed to develop policies and procedures (P&P's) for equipment maintenance according to the standards of infection control measures approved by the Centers for disease Control and Prevention (CDC) and other accredited agencies.

Findings include:

1. The Respiratory Therapy Supervisor (employee #29) and the Medical Director (employee # 17) failed to follow infection control measures:
a. No evidence was found of P&P's for cleaning and disinfection of the 2 mechanical ventilators machines that are available in the facility. Also, both mechanical ventilators are not covered with a plastic bag to avoid cross contamination, (Cross Reference TAG 749).

Based on 32 clinical records review performed on 09/22/15 and 09/23/15 accompanied by the Respiratory Therapy Supervisor (employee #29), it was found that the facility failed to ensure that the physician's orders have complete information of the medication to be administered including: dose, route and frequency of administration, as observed in 2 out of 32 records review (RR #24 and #25).

Findings include:

1. During RR #24 performed on 09/22/15 at 2:15 pm and of an 11 years old female who was admitted on 09/21/15 due to a diagnose of Bronchial Asthma, it was found incomplete physician's orders:

a. The physician wrote the order for respiratory therapy as: "FFT Albuterol 0.083% C 30 x 3, c 2x2". After discussing it with the Respiratory Therapy Supervisor (employee #29) on 09/23/15 at 2:30 pm, it means: FFT Albuterol 0.083% every 30 minutes times 3 doses, then every 2 hours times 2 doses. The physician failed to write a complete order indicating frequency and quantity of doses.
b. The physician wrote the following order on 09/21/15 at 3:00 (it was not determined if was am or pm): "FFT previously ordered". The physician failed to write a complete order for the respiratory therapy which includes: name of the medication, concentration, frequency and route of administration.
2. During RR #25 of a patient receiving treatment for Bronchial Asthma at the Emergency Room on 09/22/15 at 11:15 am, it was found the following order: "Albuterol 0.083% c 30 x 2". According to the Respiratory Therapy Supervisor (employee #29) it means: Albuterol 0.083% every 30 minutes times 2 doses". The physician failed to write a complete order.