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Based on a validation surver, the review of medical records, policies and procedures, official documents, observations, and interviews from 5/9/17 through 5/12/17 from 8:00 am thru 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: Patient Rights Condition (42 CFR 482.13), Medical Record Services Condition (42 CFR 482.24), Infection Control (42 CFR 482.42), Physical Environment Condition (42 CFR 482.41) and Emergency Services Condition (42 CFR 482.55) which makes this condition not met: Governing Body (42 CFR 482.12).

Based on a validation survey, observation tour for delivery of care and patients rights, medical record reviwed, it was determined that the facility failed to ensure that patient right was protected and promoted related to ulcer care at the hospital without medical orders, which make this condition Not Met (Cross reference TAG # A130).

Based on a validation survey, observation and interview on 5/9/17, 5/10/17 at 1:30 pm with the Medical Surgical A Unit Nursing Supervisor (employee #5), Nursing Leader (employee # 18) at the Medical Surgical A Unit, ulcer and wound care coordinator (employee # 6) and patient's daughter, it was determined that the facility failed to prevent patients from harm. This constitute an Immediate Jeopardy (IJ) to 1 out of 56 patient's sample, (RR #20).

Findings include:

An 82 year old female patient that came to this facility through the emergency room due to respiratory distress on 5/4/17, this patient is bedridden, requesting changes position every 2 hours due to lack of mobility. At home, she was receiving ulcer treatment and care with a Vacuum Assisted Closure (VAC System) over the stage III Sacral Ulcer and stage IV hip left ulcer. Both ulcers are infected. The sacral ulcer showed Klebsiella pneumonia and Morganella morganii and the hip left ulcer showed Escherichia coli.

During observational tour on 5/9/17 at 9:30 am and record review performed on 5/9 and 5/10/17 it was found the following:

1. No orders for VAC System since admission process on 5/4/17.

According to interview with the patient's daughter on 5/9/17 at 10:00 am she refer that she talked with the head physician related to the ulcer treatment. She referred that the head physician failed to explain her ulcer treatment and she decided to bring the VAC System and put it by herself over her mother's ulcers.

2. No evidence of the communication between the nursing staff and the head physician.

During interview with the wound and ulcer care coordinator (employee # 6) on 5/10/17 at 10:00 am, she referred that performed the initial assessment of the patient and identified the use of the VAC System. However she referred that she can not contacted the head physician because he comes to the hospital at late evening and she is not at the hospital.

No evidence was found on the clinical record of the communication between the nursing staff with the head physician notifying the use of the VAC System.

The use of the VAC System without the supervision of the physician puts the patient on a potential harm because the ulcers can have fatal injury.

The facility's corrective plan was received on 5/10/17 at 5:25 pm.

Immediate Jeopardy Situation Identified on 5/10/2017

1. Medical Director discussed the situation with Head Physician emphasizing the importance of effective communication with family members and the patient's right to know about his/her condition and treatment. Communication from Medical Director and Head Physician occurred 5/10/17.

2. Conference call between Head Physician, Medical Director and Surgeon was held 5/10/2017 and condition of the patient's ulcers was discussed. It was determined to continue with VAC System and a telephone order was placed in the patients' medical record.

3. Education was provided by the Director of Nursing to the nursing and skin management staff to ensure that no treatment is given without a physician's order. (05/10/2017). Continuous education and follow up will be given to all nursing staff by 5/31/2017.

The facility's POC was evaluated and accepted on 5/10/17 at 5:30 pm

Based on a validation survey performed from 5/9 thru 5/12/17 from 8:30 am to 5:00 pm accompanied by the Nursing Supervisor of the Medical Surgical A Unit (employee # 5) and the Nursing Leader from the Medical Surgical A Unit (employee # 18), review of clinical record documentation, policies and procedures (P&P's) review, it was determined that the facility failed to ensure privacy practices related to the content of patient's information in the computerized system.

Findings include:

1. During observational tour on the Medical Surgical A unit performed on 5/9 thru 5/11/17 at different hours, it was observed at the nursing station that there is other room where the professional staff sits to write on the clinical record. There is a counter where is a computer monitor. It was displaying a list of all patients admitted to the Medical Surgical A Unit with room number, account information, physician names and other symbols that are used to identify diet, medications laboratories and radiological results.

During interview with the Nurse leader (employee #18) of this unit, performed on 5/10/17 at 10:00 am, she stated: "Each staff member has a password to enter the computer. This monitor only shows the patients list admitted to our unit with the names of the head physicians. We do not have electronic record. When a staff member finishes looking for patient's information he/she has to close the monitor in manner that no patient information has to be seen".

Observational tours were performed on 5/10 and 5/11/17 during morning hours and the display of patient's information on the computer monitor was not corrected.

2. The facility failed to ensure that patient's information content in the computer complies with the privacy of information that mention in their policies and procedures.

Based on a validation survey, observation tour at the General Storage room and interview with the Administrative Dietitian (employee # 13) and Infection Control Officer (employee #12) on 5/9/17 at 10:15 am it was determined that the facility failed to promote patients confidentiality and privacy of his/her clinical record.

Fndings include:

Observational tour at the General storage room perform on 5/9/17 at 10:15 am until 10:45 am, it was found that the facility failed to promote patients confidentiality due to clinical records and radiology films were at a storage room located at the ground floor of this facility.

Based on a validation survey performed from 5/9 thru 5/12/17, interview with QAPI Coordinator ( employee #24) performed on 5/12/17 at 2:00 pm it was determined that the facility failed to obtain data to be included in the Hospital Compare Quality of Care Profile.

Findings include:

1. The Hospital Compare report from this facility was discussed with the QAPI coordinator (employee # 24) on 5/12/17 at 2:00 pm. After identifying with her the areas where the facility failed to submit data, she stated: "The person who was responsible of performing this duty does not work with us. I do not know who will provide the information to the system. "

The facility failed to establish an ongoing mechanism to ensure collection of data, to enter the data in the CMS compare profile, to analize and discuss it in the QAPI meetings.

Based on a validation survey performed from 5/9 thru 5/12/17, interview with QAPI Coordinator ( employee #24) performed on 5/12/17 at 2:00 pm it was determined that the facility failed to ensure the participation of different departments on the QAPI activities.

Findings include:

1. During interview with the QAPI Coordinator (employee #24) it was found that the following departments or services are not participating actively on the QAPI activities and meetings:

a. Discharge Planning
b. Radiologic Services
c. Respiratory Therapy services
d. Rehabilitation Services (Physical Therapy)
e. Cardiology Services ( Cardiologist technician)

The QAPI Coordinator (employee #24) provided evidence of the efforts made to promote the participation of these services but has not succeed.

Based on a validation survey, the review of twenty five medical staff credential files perform on 5/12/17 at 11:55 am with the Medical Staff Clerk (employee #15), it was determined that the facility failed to comply with federal and state local law related to Influenza Vaccine in accordance to State Administrative Order #244 of 10/10/08 and #362 of 12/8/16 of the Department of Health of Puerto Rico, Hepatitis Vaccines, profiles or responsibility exoneration, Health Certificate, updated Cardiorespiratory certification (CPR), Certificate of negative criminal record, and State local Law #300 sex offender certification for 25 out of 25 Physician (MD) Credential Files (C.F.) reviewed (C.F. MD#1, MD#2, MD#3, MD#4, MD#5, and MD#6).

Findings include:

1. During the review of twenty five medical staff credential files on 5/12/17 at 11:55 am with the Medical Staff Clerk (employee #15), the following was found:

a. Twenty-four out of twenty five medical staff's credential files did not have evidence of their updated Influenza vaccination, profiles or responsibility exoneration. (C.F #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24 and #25)

b. Thirteen out of twenty five medical staff's credential files did not have evidence of their updated Hepatitis Vaccines, profiles or responsibility exoneration. (C.F #1, #4, #6, #8, #15, #16, #17, #19, #20, #21, #22, #23, and #25)

c. Two out of twenty five medical staff's credential files did not have evidence of their Health Certificate. (CF #17 and #23)

d. Two out of twenty five medical staff's credential files did not have evidence of their updated cardiorespiratory certification (CPR). (CF #6 and #23).

Based on a validation survey, administrative documents review and interviews with the Nurse Director DON (employee #1) and the Nursing Department Manager (employee #4) on 05/09/17 through 05/11/17, it was determined that the facility failed to ensure that the patient needs are meet by ongoing assessments of patient's needs and provide nursing staff to meet those needs for 1 out of 10 patient observation for delivery of care.

Findings include:

a. During the initial round on Medicine Ward fifth floor for nursing services evaluation on 05/09/17 at 9:50 a. m. with the associated nurse (employee #4) and the nurse supervisor (employee # 5) the review of the patient's assignment and the requested patient classification she stated: '' I performed the patient classification first thing in the morning, the census of the ward is maintained on 23 patients.''

b. On 5/9/17 at 10:00 a. m. during the tour visit performed at the patient room #201, on this room it was observed only one patient on bed #2 and a patient caregiver. The patient caregiver was interviewed and she stated: '' She's my mother, she is 82 years and was admitted on 5/4/17 due to respiratory problems and has ulcers on lower back. My mother did not received the medications at this time and the nurse came to this room and she puts a plastic bag with small black case, then she went out of the room but did not oriented the reason of the black case. My mother did not received ulcer care at this time and the nurse did not change of position every two hours as supposed per the physician orders. My mother was sent to the operating room for ulcers debridement however, the physician did not explain. At home my mother was receiving ulcer treatment and care with a Vac. System over the stage III Sacral Ulcer and stage IV hip left ulcer. I decided to bring the Vac System in hospital and put it by myself over my mother's ulcers because the physician did not explain to me her ulcer treatment. ''

c. The nurse supervisor was notified related to this situation immediately. At 10:10 a. m. the register nurse (employee #7) goes to the patient room with a canalization cart he enters the cart at the patient room then enters his hand in his right pocket and takes two gloves puts it on his hands then enters again his right hand on his right pocket take a gauze and then removed the patient angio catheter and discard the IV lines and IV fluids. The nurse takes an angio catheter and a sterile solution of the canalization cart puts it directly on the patient bed, prepared the IV solution and initiated the canalization on the right arm however during the canalization procedure the nurse touch the area in all occasions but failed the canalization, then he tried on the left hand and canalized the patient. When the nurse removed the angio and during performed the canalization the nurse did not wash his hands, puts a pair of gloves and used a same gloves all the time and when finished he wash his hands not according with hand washing protocol.

During performed the canalization procedure did not explain the procedure to her or patient daughter and was maintain uncommunicative. The nurse used his pocked to put a medical surgical materials gauzes, gloves, adhesive tape and the keys. The canalization cart was maintain in the interior of the patient room at all time. R.N #7 failed to follow agency's policies and procedures related to the patient canalization. Did not clean his hands according with appropriate standards of infection control, which pose risk of cross contamination.

d. The R.N #7 failed to follow agency's policies and procedures related to hand washing and failure to adequately set up the materials that she was going to use according with appropriate standards of infection control.

e. This patient room #201 has three glass windows the base of the second windows lacked of tiles and the cement wall had exposed small pieces of cement which can pose risk of cross contamination.

f. The nursing treatment kardex provide evidence that the patient was admitted on 5/4/17 with diagnosis of '' Respiratory Distress ''According to the daily categorization this patient was classified on level III with 24 points. On 5/9/17 at 10:00 a. m. the patient was observed bedridden with oxygen by Ventury mask, foley catheter, IV fluids, Vac therapy machine. However, the patient did not received the I.V fluids and the medications treatment according to the physician's order and patient needs because her IV was closed by the nurse approximately at 9:00 a. m. and was pending to canalized.

Based on a validation survey performed from 5/9 thru 5/12/17 from 8:30 am to 5:00 pm accompanied by the Nursing Supervisor of the Medical Surgical A Unit (employee # 5) and the Nursing Leader from the Medical Surgical A Unit (employee # 18), review of clinical record documentation, policies and procedures (P&P's) review, it was determined that the facility failed to ensure that the nursing staff develop a plan of care for each patient.

Findings include:

1. During record review (RR) #20 performed on 5/10/17 at 9:19 am the plan of care was reviewed and no evidence was found for the activation of the following problems that were identified by the nursing staff and where they performed skilled interventions:

a. low hemoglobin- On 5/7/17 at 8:32 am the head physician performed a phone call and ordered Type and cross for 2 units of Packed Red Blood Cells (PRBC) because patient was showing hemoglobin levels on 6.9 mg/dl since 5/6/17. The transfusion for PRBC was performed on 5/7/17 and blood samples were taken to verify if hemoglobin levels increased after transfusion.

b. skin integrity alteration- the nursing staff failed to include their interventions with the management of the VAC System over the stage III Sacral Ulcer and stage IV hip left ulcer. Also, the patient has a Bilevel Positive Airway Pressure (BPAP) and the continuous use of the mask caused skin lesions besides patient's nose and both cheeks. However, the wound and ulcer coordinator (employee #6) provided treatment applying Allevyn patches with interventions of the nursing staff on weekends and holidays and no evidence was written of those interventions on the plan of care.

c. gastrointestinal system- the patient has a gastrostomy and the nursing staff failed to include their interventions related to gastrostomy care.

d. the patient has a Foley catheter #18 and no interventions were written on the plan of care.

Based on Validation survey on 5/9/17 through 512/17, policy and procedure review and interview with the medical record manager Employee # 8 it was determined that the facility failed to ensure the medical record must be maintained for every individual evaluated or treated in the hospital. Related to insecure and available for non authorized personnel asses, incomplete medical record. Failed to ensure that medical record document the results of all consultative evaluations of the patient by clinical and other staff involved in the care of the patient. Failed to ensure the proper storage and placement of medical records in the medical record department, in the storage area outside of the hospital. failed to ensure that medical record was legible, complete, dated, timed, and authenticated by the person responsible for providing the service provided, consistent with hospital policies and procedures. Failed to ensure that medical record document orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient's condition. Failed to ensure that medical record document the results of all consultative evaluations of the patient. Failed to ensure that medical record document properly executed informed consent forms. Failed to ensure that medical record document final diagnosis with completion of medical records within 30 days following discharge which make this condition Not Met (Cross reference TAG #A441, TAG # A450, TAG #A464, TAG #A466, TAG #A467 and TAG #A469).

Based on a validation Survey and observational tour of the medical records department with the medical record manager (employee #8), 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 near the emergency room an near the exit from the facility 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:

During interview with the medical record manager (employee #8) on 5/10/17 at 9:10 am state that the medical records was from an admision and a emergency room visit. She follow the medical records and the original was in the medical record department. She dont have explanation what doing that medical record in that storage have to be copy of them.

1. During the observational tour of inactive medical record storage area located near the exit area of the hospital accompanied with the Medical Record Manager (employee #8) on 5/10/17 at 9:20 am, the following was observed:

During the observational tour dirty area and much dust was observed outside of the box of inactive medical record area, dry leaves and grass trimmed from a tree that enter by opened windows and extractors and air conditioning space were observed in the interior of the room, insect excrement, dead lizard, humidity odor and peeling paint were observed. The area lacks of smoke detector, air conditioner, no smoke detectors and lighting. The atrea have only one light in the front and one medium fire extinguisher. Also, of inactive medical record from the last administration, their are storage laboratory result and copy of transfution report from the depart,ment of laboratory.

During interview wit hte medical recor manager (employee #8) on 5/10/17 at 9:20 am state that she is the only person that have the key fonm this storage, their is the inactive medical recor from the other administration (San Pablo del Este). If some patient came to the hospital with previous admition of the other administration she localizated the medical record.



34043


Based on a validation survey, observation tour at the General Storage room and interview with Administrative Dietitian (employee #13) and Infection Control Officer (employee #12) on 5/9/17 at 10:15 am it was determined that the facility failed to protect and store patients clinical records.

Findings include:

Observational tour at the General storage room perform on 5/9/17 at 10:15 am until 10:45 am, it was found that the facility failed to store and promote patients confidentiality due to clinical records and radiology films were at a storage room located at the ground floor of this facility and not filed at the record room department has required by rules and regulation.

Base on validation survey and fifty seven record reviewed (RR) with medical record manager (employee #8), on 5/9/17 till 5/12/17, it was determined that the facility failed to ensure that medical record are legible, complete, dated, timed, and authenticated by the person responsible for providing the service provided, consistent with hospital policies and procedures for 14 out of 57 record review (R.R. #2, #3, #4, #5, #11, #12, #13, #14, #15, #16, #17, #19, #39 and #57)

Findings included:

1. R.R. #2 is a 78 years old male admitted on 3/29/17 with a diagnosis of End Stage Renal Disease (ESRD), Diabetes Mellitus during the record review performed on 5/11/17 at 9:15 am it was found the following:

a. Cardiologist Consult performed on 3/28/17 at 9:15 pm, was notified to the cardiologist on 3/29/17 at 11:15 am and was answered on 3/31/17 at 11:00 am 47 hour after notification, not accordance to facility policy and procedure.
b. The Dextrose and Insulin Registration Sheet lack of the sign of the RN on 3/29/17 at 6:00 am, on 3/31/17 at 6:00 pm, on 4/1/17 at 12:00 am, at 6:00 am, on 4/2/17 at 12:00 am and at 6:00 am, on 4/3/17 at 12:00 am, at 6:00 am and at 6:00 pm, on 4/4/17 at 6:00 pm, on 4/5/17 at 12:00 am, and at 6:00 am, on 4/6/17 at 12:00 am and on 4/8/17 at 6:00 am.
c. The RN initial assessment lack of the hour when arrive to the ward.
d. During the hospitalization the surgeon put an Quinton quimio port, the discharge instruction sheet lack of evidence of instruction to care the Quinton.

2. R.R. #3 is a 51 years old female admitted on 3/3/17 with a diagnosis of Suspected Obstructive Jaundice, during the record review performed on 5/1/17 at 10:30 am it was found the following:

a. The Discharge summary, performed on 3/16/17 at 11:30 am, lack of the patient or relative sign
b. The physician consult performed on 3/4/17 at 7:50 am, lack of the date and hour when answered.
c. The physician consult performed on 3/4/17 at 10:30 an and notified to the physician on 3/6/17 at 9:30 am was answered on 3/8/17 at 7:45 pm 2 days later, not accordance to facility policy and procedure.
d. The human immunodeficiency virus (HIV) test consent performed on 3/11/17 at 10:10 pm, lack of the patient sign.
e. The Summary Clinical and Examination at discharge performed on 3/16/17 at 11:20 am lack of patient or relative sign and RN sign.
f. The Dextrose and Insulin Registration Sheet lack of the sign of the RN.
g. The Internal patient transfer sheet performed on 3/4/17 at 1:51 pm, was incomplete, lack of Vital sign (S/V) and how the patient was transferred.
h. The RN initial assessment performed on 3/4/17 was incomplete, the RN left in blank the General information, Vital Sign, Functional assessment, Nutritional Assessment, Social assessment, Discharge planning assessment Spiritual Assessment.

3. R.R. #4 is a 77 years old female admitted on 3/3/17 with a diagnosis of Stage 4 sacral Pressure Ulcer, during the record review performed on 5/11/17 at 3:28 pm it was found the following:

a. The summary Sheet provide evidence of the diagnosis at discharge and the physician not sign, date the sheet.
b. The infectology consult lack of the date and hour when consult was placed.
c. The Consent for the use of railings in bed, lack of patient or relative sign.
d. The anesthesia consent, lack of type of anesthesia to administered to the patient and date and hour when patient sign
e. The physician Telephonic order performed on 3/11/17 at 5:30 am ordered Increase Intropin at 24 ml and transfuse unit of packet Red Blood Cell (PRBC), lack of the physician sign and date and hour when physician counter sign.
f. The Dextrose and Insulin Registration Sheet lack of the sign of the RN.
g. The RN Discharge summary was left in blank.
h. No evidence was found related to Do Not Resuscitate (DNR) consent, the physician place the DNR order on 3/11/17.
i. No evidence was found related to physician death progress note.

4. R.R. #5 is a 54 years old female admitted on 2/12/17 with a diagnosis of Sepsis, Diabetes Mellitus during the record review performed on 5/11/17 at 10:54 am it was found the following:

a. The summary Sheet no provide evidence of the diagnosis at discharge and the physician not sign the sheet.
b. The Physiatrist (PMR) Consult was performed on 2/23/17 and be notified 2/23/17 at 1:40 pm, the Physiatrist perform the evaluation on 2/28/17 at 11:50 am 5 days later, not accordance to facility policy and procedure.
c. The physician Telephonic order performed on 2/12/17 at 10:20 am ordered an Dextrose cover with Regular Insulin Subcutaneous (SQ), the order lack of the physician counter-sign and the date and hour when counter sign.
d. The physician Telephonic order performed on 2/13/17 at 7:00 pm ordered Vancomycin 1 gram (gm) Intravenous (IV) per one, Blood culture (B/C) every 15 minute (min.) per 3 occasion, Urine Culture (U/C), Nasogastric tube (NGT) to Lis, Calcium Gluconate 1 ampoule (Amp) IV per one, Hypertonic Dextrose 50 milliliter (ml) IV per one, Regular Insulin 10 unit IV per one, the physician counter sign the order, however lack of the date and hour when counter sign.
e. The physician Telephonic order performed on 2/14/17 at 3:20 pm ordered Vasotec 0.625 milligram (mg) Intramuscular (IM) stat lack of the date and hour when physician counter sign.
f. The physician Telephonic order performed on 2/14/17 at 4:45 pm ordered Demerol 50 mg IM stat, lack of the date and hour when physician counter sign.
g. The physician Telephonic order performed on 2/14/17 at 10:00 am ordered Abdominal Pelvic Computerized Tomography (CT) Scan with contrast by NGT lack of the date and hour when physician counter sign.
h. The physician Telephonic order performed on 2/14/17 at 11:45 pm ordered ordered Demerol mg IM every 6 hour (hr) as needed (PRN) for pain lack of the date and hour when physician counter sign.
i. The physician Telephonic order performed on 2/15/17 at 12:30 pm ordered Electrocardiogram (EKG) immediately (stat), Arterial Blood Gases (ABG'S) stat lack of the date and hour when physician counter sign.
j. The physician Telephonic order performed on 2/15/17 at 1:15 pm ordered Digoxin 0.50 mg IV stat per one dose, Troponina Stat every 8 hr per 3, Complete Metabolic Panel (CMP) stat, B-type natriuretic peptide (BNP) stat, Chest X Ray (CXR) plus ABG'S stat, Cardiology, Nephrology, Pneumology Evaluation, Result of 2D'Ecocardigraphy (2DECO), lack of the date and hour when physician counter sign.
k. The physician Telephonic order performed on 2/15/17 at 3:30 pm ordered decrease fraction of inspired oxygen (FiO2) 70%, lack of the date and hour when physician counter sign.
k. The physician Telephonic order performed on 2/15/17 at 5:30 pm ordered Complete Blood Cell (CBC) stat, Vasotec Hold, Blood Pressure (B/P) 1 hr, Flagyl 500 mg IV every 6 hour, lack of the date and hour when physician counter sign.
l. The physician Telephonic order performed on 2/15/17 at 9:00 pm ordered CBC in the morning (AM), lack of the date and hour when physician counter sign.
m. The physician Telephonic order performed on 2/17/17 at 1:45 pm ordered Lovenox 20 mg subcutaneous (SQ) every 12 hr lack of the date and hour when physician counter sign.
n. The physician Telephonic order performed on 2/17/17 at 6:50 pm ordered Demerol 50 mg IM every 6-8 hr PRN for dolor, Phenergan 50 mg IM every 6-8 hr PRN, lack of the counter sign of the physician and date and hour when physician counter sign.
o. The physician Telephonic order performed on 2/27/17 at 1:00 am ordered B/C per 3 every 15 minutes, U/C, lack of the date and hour when physician counter sign.
p. The physician ordered on 2/27/17 at 6:00 pm get portable result, lack of the Registered Nurse (RN) sing and date and hour.
q. The physician Telephonic order performed on 2/28/17 at 11:35 am ordered Discontinue Foley, lack of the date and hour when physician counter sign.

5. R.R. #12 is a 77 years old female admitted on 2/28/17 with a diagnosis of Pneumonia, during the record review performed on 5/11/17 at 12:00 am it was found the following:

a. The summary Sheet no provide evidence of the diagnosis at discharge and the physician not sign the sheet
b. Cardiologist Consult performed on 2/28/17 at 5:10 pm, was notified to the cardiologist on 3/1/17 and was answered on 3/9/17, 8 days later after notification, not accordance to facility policy and procedure.
c. The physician ordered on 3/6/17 at 10:00 am ordered Cephulac 30 ml, Oil mineral 30 ml, Magnesium Milk 30 ml per mouth (PO)stat, lack of the physician sign and date and hour when physician counter sign.
d. The physician Telephonic order performed on 3/10/17 at 9:45 am ordered FiO2 50%, lack of the physician sign and date and hour when physician counter sign.
e. The physician Telephonic order performed on 3/10/17 at 11:30 am ordered Physician Consult for central line, lack of the physician sign and date and hour when physician counter sign.
f. The physician Telephonic order performed on 3/15/17 at 10:00 am ordered Lasix 40 mg IV after each transfusion units, lack of the physician sign and date and hour when physician counter sign.
g. The Dextrose and Insulin Registration Sheet lack of the sign of the RN.
h. The RN initial assessment was incomplete, lack of Past pain management history, Ethic and psychosocial aspect, System assessment, Nutritional assessment, Social and Spiritual assessment.
i. No evidence was found related to Do Not Resuscitate (DNR) consent.

6. R.R. #11 is a 94 years old female admitted on 3/30/17 with a diagnosis of Septicemia, Bronchopneumonia, Myocardial infarct and Ischemic Heart Disease during the record review performed on 5/11/17 at 10:09 am it was found the following:

a. The summary Sheet no provide evidence of the diagnosis at discharge and the physician not sign the sheet.
b. The RN initial Assessment was incomplete, lack of Health history,Present History, Psychosocial aspect, Neurological system assessment.
c. No evidence was found of the DNR Consent. The physician place the order on 3/29/17.
d. Evidence was found that patient death on 4/3/17 at 1:39 pm, however no evidence was found related to Physician death progress note. No evidence was found RN death note. No evidence was found of the physician order to discontinue treatment.
e. No evidence was found of the discharge evaluation, accordance to facility policy and procedure.

7. R.R. #13 is a 67 years old male admitted on 1/22/17 with a diagnosis of Congestive Heart Failure(CHF) during the record review performed on 5/10/17 at 1:30 pm it was found the following:

a. The surgery Consent performed on 1/27/7 at 10:40 am the letter of the surgeon was illegible.
b. The physician Telephonic order performed on 1/22/17 at 2:25 pm ordering consult was not taken by the Registered Nurse (RN), lack off the RN sign.
c. The physician Telephonic order performed on 1/27/17 at 8:08 pm ordering Oxygen (FiO2) at 50% lack of the date and hour when the physician counter sign the order.
d. Physician Telephonic order performed on 1/30/17 at 10 am , 1/30/17 at 9:50 pm, 1/31/17 at 3:10 am and 1/31/17 at 5:45 am, lack of the physician counter sign, date and hour of counter sign.
e. The physician telephonic order performed on 2/10/17 at 11:00 am, lack of the physician counter sign, date and hour of counter sign.
f. The physician telephonic order performed on 2/12/17 ordering Blood culture (B/C), Urine Culture (U/C), Vancomycin 1 gram (g) stat, lack of the physician counter sign, date and hour of counter sign.
g. The Dextrose and Insulin Registration Sheet lack of the sign of the RN on 1/25/17 at 12:00 pm, at 6:00 pm, on 1/26/17 at 6:00 pm, on 1/27/17 at 6:00 am, at 6:00 pm, on 2/6/17 at 9:00 am, at 5:00 pm.
h. The Intake and Output sheet lack of the sign of the nurse on 1/25/17 at 2-10 shift and on 1/26/17 at 6 am-2 pm shift.
i. The RN initial Assessment performed on 1/23/17 at 4:20 pm, lack of patient diagnosis and chief complaint and the activities of daily living was left in blank, The RN lack of sign, license number and dated the assessment.
j. The Authorization of delivery of Cadaver, lack of the Funeral home to be delivered.
k. No evidence was found of the copy of the Death certificate.
l. No evidence was found related to physician death progress note.
m. No evidence was found physician order to discontinue treatment after death.
n. No evidence was found of the Final Diagnosis.

8. R.R. #14 is a 68 years old female admitted on 5/8/17 with a diagnosis of Osteoarthritis left Knee during the record review performed on 5/10/17 at 9:45 am it was found the following:

a. The anesthesia consent was sign by the patient on 5/8/17 at 10:05 am, however not was legible the name of the physician under whom the anesthesia is supervised and the physician who certifies the explanation to the patient.

9. R.R. #15 is a 62 years old female admitted on 5/8/17 with a diagnosis of Osteoarthritis Right Knee during the record review performed on 5/10/17 at 10:15 am it was found the following :

a. The anesthesia consent was sign by the patient on 5/8/17 at 7:30 am, however lack of type of anesthesia that was administered.

10. R.R. #16 is a 72 years old female admitted on 4/26/17 with a diagnosis of Acute Renal Failure during the record review performed on 5/10/17 at 10:45 am it was found the following :

a. The Consult with physician #10 performed on 4/26/17 at 1:15 pm, not was answered.
b. The Hematologist/ Oncologist Consult performed on 5/4/17 at 6:20 pm, not was answered.
c. The neurologist Consult lack of the date and hour when was performed.

11. R.R. #17 is a 39 years old male admitted on 4/25/17 with a diagnosis of Right Knee Septic Arthritis, DM type II, Hypertension (HTN) during the record review performed on 5/10/17 at 11:00 am it was found the following:

a. The surgery consent was sign by the patient on 5/1/17, however, lack of the benefits of surgery.
b. A telephonic physician order performed on 5/5/17 at 3:45 pm ordered Discontinue Morphine 5 mg and administer Morphine 4 mg every 12 hour for pain, lack of the route of administration and lack of physician counter-signature and the date and time counter-signature.

12. R.R. #19 is an 85 years old male admitted on 5/5/17 with a diagnosis of Bronchopneumonia by aspiration, Alzheimer during the record review performed on 5/10/17 at 1:30 pm it was found the following:

a. The nursing initial assessment performed on 5/5/17 at 1:46 pm left in blank the discharge planning assessment, evidence was find the patient has gastrostomy at admission process. No evidence was found that the nurse referred patient to discharge planning services.

13. R.R. #57 is a 66 years old male admitted on 2/4/17 with a diagnosis of Epileptic Status, during the record review performed on 5/11/17 at 3:42 pm it was found the following:

a. The medical History and Physical Examination, the physician performed on 1/4/17 at 5:10 pm 28 days previous to admitting and not reevaluation was performed.
b. The Surgery and procedure consent was sign by patient relative on 2/5/17, however the consent was left in blank and lack of surgeon sign.
c. The Transfusion consent was sign by the patient relative and the physician on 2/11/17 and 2/12/17, however lack of the name of the physician that oriented and do not specified if patient consent or not to be transfuse.
d. The physician Telephonic order performed on 2/4/17 at 5:00 pm ordered discontinue Pepcid, Protonix 80 mg in 0.9% normal saline solution (NSS) 250 ml at 11 ml, and CBC, lack of the dated and hour when physician counter sign the order.
e. The physician Telephonic order performed on 2/4/17 at 7:25 pm ordered Plavix 75 mg PO in hold, lack of the dated and hour when physician counter sign the order.
f. Evidence was found that patient was restraint started on 2/7/17 at 4:00 pm until 2/12/17 at 9:30 am, however the physician Restraint order sheet performed on 2/7/17 at 4:00 pm, lack of the the time patient was restraint and lack of the RN sign and no was re-evaluated in the next 5 days.
g. No evidence was found related to physician progress note evaluation to justified the restraint order.
h. No evidence was found related to Patient Restraint Assessment every 15 minute on 2/8/17.
i. On 2/9/17, on 2/10/17, on 2/11/17, on 2/12/7 until 9:20 am the patient be restraint accordance to patient restraint assessment and RN progress note without an physician order.
j. The patient restraint assessment performed on 2/7/17 provide evidence that the patient not was assess every 15 min, as protocol. The 830: pm , 8:45 pm, 10:00 pm, 10:15 pm, 11:45 pm, on 2/8/17, 12:00 am, 1:15 am, 1:30 am 3:00 am, 3:15 am, 4:30 am, 4:45 am, 6:00 am and 6:15 am was left in blank.
k. The patient restraint assessment performed on 2/9/17 and on 2/10, the RN left in blank the Step II Factors influencing behavior and did not sign the sheet.
l. The patient restraint assessment performed on 2/11/17 provide evidence that from 5:15 pm till 7:00 pm the patient not was asses and no evidence was found in the nurses note that patient was release of restraint and no evidence was found that the physician re -ordered restraint the patient again.
m. The RN progress note from 2/7/17 did not justified the reason to restraint the patient.
n. No evidence was found patient restraint assessment on 2/12/17 from 6:45 am till 9:30 am that the RN documented in the nursing progress not that patient was release from restraint.


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14. R.R. #39 is a 66 years old female admitted who visit the emergency room on 04/01/17 at 12:23 am with a diagnosis of Chest pain. , during the record review performed on 5/11/17 at 11:16 am the following was found:

On 04/01/17 at 6:13 am RR#39 was transfer to another institution. No evidence of the discussion of risk and benefits of the transfer were found on the medical record however the transfer sheet have the benefits and risk of transfer but they were left in blank.

Based on validation survey and fifty seven record reviewed (RR) with medical record manager (employee #8), on 5/9/17 till 5/12/17, it was determined that the facility failed to ensure that medical record document the results of all consultative evaluations of the patient by clinical and other staff involved in the care of the patient for 2 out of 57 record review (R.R. #16 y # 30)

Findings include:

1. R.R. #16 is a 72 years old female admitted on 4/26/17 with a diagnosis of Acute Renal Failure during the record review performed on 5/10/17 at 10:45 am it was found the following :

a. The Consult with physician #10 performed on 4/26/17 at 1:15 pm, not was answered.

b. The Hematologist/ Oncologist Consult performed on 5/4/17 at 6:20 pm, not was answered.


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2. RR #30 was performed on 5/11/17 at 9:36 am with a diagnosis of ruled out (R/O) of Cerebrovascular Accident (CVA), Hemiplegia, Hypertensive Crisis, Encephalopaty, Suspected Aspiration Pneumonitis and Diabetes Mellitus. During RR it was found that the Nephrologist answered the consult on 3/10/17 but the head physician failed to write date and hour when he placed the consult in the clinical record.

Base on validation Survey and fifty seven record review with medical record manager (employee #8), on 5/9/17 till 5/12/17, it was determined that the facility failed to ensure that medical record document properly executed informed consent forms for procedures and treatments for 9 out of 57 record review (R.R. #3, #4, #14, #16, #17, #21, #30, #54 and #57)

Findings include:

1. R.R. #3 is a 51 years old female admitted on 3/3/17 with a diagnosis of Suspected Obstructive Jaundice, during the record review performed on 5/1/17 at 10:30 am it was found the following:

a. The human immunodeficiency virus (HIV) test consent performed on 3/11/17 at 10:10 pm, lack of the patient sign.

2. R.R. #4 is a 77 years old female admitted on 3/3/17 with a diagnosis of Stage 4 sacral Pressure Ulcer, during the record review performed on 5/11/17 at 3:28 pm it was found the following:

a. The Consent for the use of railings in bed, lack of patient or relative sign.
b. The anesthesia consent, lack of type of anesthesia to administered to the patient and date and hour when patient sign

3. R.R. #14 is a 68 years old female admitted on 5/8/17 with a diagnosis of Osteoarthritis left Knee during the record review performed on 5/10/17 at 9:45 am it was found the following:

a. The anesthesia consent was sign by the patient on 5/8/17 at 10:05 am, however not was legible the name of the physician under whom the anesthesia is supervised and the physician who certifies the explanation to the patient.

4. R.R. #15 is a 62 years old female admitted on 5/8/17 with a diagnosis of Osteoarthritis Right Knee during the record review performed on 5/10/17 at 10:15 am it was found the following :

a. The anesthesia consent was sign by the patient on 5/8/17 at 7:30 am, however lack of type of anesthesia that was administered.

5. R.R. #17 is a 39 years old male admitted on 4/25/17 with a diagnosis of Right Knee Septic Arthritis, DM type II, Hypertension (HTN) during the record review performed on 5/10/17 at 11:00 am it was found the following:

a. The surgery consent was sign by the patient on 5/1/17, however, lack of the benefits of surgery.

6. R.R. #57 is a 66 years old male admitted on 2/4/17 with a diagnosis of Epileptic Status, during the record review performed on 5/11/17 at 3:42 pm it was found the following:

a. The Surgery and procedure consent was sign by patient relative on 2/5/17, however the consent was left in blank and lack of surgeon sign.
b. The Transfusion consent was sign by the patient relative and the physician on 2/11/17 and 2/12/17, however lack of the name of the physician that oriented and do not specified if patient consent or not to be transfuse.


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7. R.R. #21 is a 44 years old male admitted on 3/12/17 with a diagnosis of Acute Apendicitis and Colitis Infecciosa, during the record review performed on 5/10/17 at 2:40 p. m. it was found the following:

a. The Consent for admission and treatment lacks of the date and the hour when the patient admitted.

b. The Consent for the use of railings in bed, lack of patient or relative sign, date and hour.

8. R.R. #54 is a 77 years old female admitted on 5/9/17 with a diagnosis of Syncope Head Trauma, Unstable Angina Pectoris, Right Elbow Trauma and Diabetes Mellitus Type II during the record review performed on 5/11/17 at 9:30 a. m. it was found the following:

a. The Consent for Admission and Treatment, Important Mesage of Medicare, Living Will and Education and Falls Prevention lacks of the identification label.

b. The Physical Assessment performed by the physician on 5/9/17 lacks of identification label and the physician signature was ilegible.

c. The Physicians order short acting Insulin Suplemental Sub Q Coverage lacks of identification label only written the patient name.


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9. RR #30 was performed on 5/11/17 at 9:36 am with a diagnosis of ruled out (R/O) of Cerebrovascular Accident (CVA), Hemiplegia, Hypertensive Crisis, Encephalopaty, Suspected Aspiration Pneumonitis and Diabetes Mellitus. During RR it was found that the Nephrologist failed to sign and date the consent form for the hemodialysis treatment. The physician's order for hemodialysis treatment was on 3/29/17 at 5:46 pm but it was not determined when the physician signed and discussed the treatment with the patient.

Base on validation survey and fifty seven record review with medical record manager (employee #8), on 5/9/17 till 5/12/17, it was determined that the facility failed to ensure that medical record document orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient's condition for 13 out of 57 record review (R.R. #2, #3, #4, #5, #11, #12, #13, #15, #17, #19, #30, #54 and #57 )

Findings include:

1. R.R. #2 is a 78 years old male admitted on 3/29/17 with a diagnosis of End Stage Renal Disease (ESRD), Diabetes Mellitus during the record review performed on 5/11/17 at 9:15 am it was found the following:

a. The RN initial assessment lack of the hour when arrive to the ward.
b. During the hospitalization the surgeon put a Quinton quimio port, the discharge instruction sheet lack of evidence of instruction to care the Quinton.

2. R.R. #3 is a 51 years old female admitted on 3/3/17 with a diagnosis of Suspected Obstructive Jaundice, during the record review performed on 5/1/17 at 10:30 am it was found the following:

a. The physician consult performed on 3/4/17 at 7:50 am, lack of the date and hour when answered.
b. The human immunodeficiency virus (HIV) test consent performed on 3/11/17 at 10:10 pm, lack of the patient sign.
c. The Summary Clinical and Examination at discharge performed on 3/16/17 at 11:20 am lack of patient or relative sign and RN sign.
d. The Internal patient transfer sheet performed on 3/4/17 at 1:51 pm, was incomplete, lack of Vital sign (S/V) and how the patient was transferred.
e. The RN initial assessment performed on 3/4/17 was incomplete, the RN left in blank the General information, Vital Sign, Functional assessment, Nutritional Assessment, Social assessment, Discharge planning assessment Spiritual Assessment.

3. R.R. #4 is a 77 years old female admitted on 3/3/17 with a diagnosis of Stage 4 sacral Pressure Ulcer, during the record review performed on 5/11/17 at 3:28 pm it was found the following:

a. The summary Sheet provide evidence of the diagnosis at discharge and the physician not sign, date the sheet.
b. The infectology consult lack of the date and hour when consult was placed.
c. The Consent for the use of railings in bed, lack of patient or relative sign.
d. The anesthesia consent, lack of type of anesthesia to administered to the patient and date and hour when patient sign
e. The physician Telephonic order performed on 3/11/17 at 5:30 am ordered Increase Intropin at 24 ml and transfuse unit of packet Red Blood Cell (PRBC), lack of the physician sign and date and hour when physician counter sign.
f. The RN Discharge summary was left in blank.
g. No evidence was found related to Do Not Resuscitate (DNR) consent, the physician place the DNR order on 3/11/17.
h. No evidence was found related to physician death progress note.

4. R.R. #5 is a 54 years old female admitted on 2/12/17 with a diagnosis of Sepsis, Diabetes Mellitus during the record review performed on 5/11/17 at 10:54 am it was found the following:

a. The summary Sheet no provide evidence of the diagnosis at discharge and the physician not sign the sheet.
b. The physician Telephonic order performed on 2/12/17 at 10:20 am ordered an Dextrose cover with Regular Insulin Subcutaneous (SQ), the order lack of the physician counter-sign and the date and hour when counter sign.
c. The physician Telephonic order performed on 2/13/17 at 7:00 pm ordered Vancomycin 1 gram (gm) Intravenous (IV) per one, Blood culture (B/C) every 15 minute (min.) per 3 occasion, Urine Culture (U/C), Nasogastric tube (NGT) to Lis, Calcium Gluconate 1 ampoule (Amp) IV per one, Hypertonic Dextrose 50 milliliter (ml) IV per one, Regular Insulin 10 unit IV per one, the physician counter sign the order, however lack of the date and hour when counter sign.
d. The physician Telephonic order performed on 2/14/17 at 3:20 pm ordered Vasotec 0.625 milligram (mg) Intramuscular (IM) stat lack of the date and hour when physician counter sign.
e. The physician Telephonic order performed on 2/14/17 at 4:45 pm ordered Demerol 50 mg IM stat, lack of the date and hour when physician counter sign.
f. The physician Telephonic order performed on 2/14/17 at 10:00 am ordered Abdominal Pelvic Computerized Tomography (CT) Scan with contrast by NGT lack of the date and hour when physician counter sign.
g. The physician Telephonic order performed on 2/14/17 at 11:45 pm ordered ordered Demerol mg IM every 6 hour (hr) as needed (PRN) for pain lack of the date and hour when physician counter sign.
h. The physician Telephonic order performed on 2/15/17 at 12:30 pm ordered Electrocardiogram (EKG) immediately (stat), Arterial Blood Gases (ABG'S) stat lack of the date and hour when physician counter sign.
i. The physician Telephonic order performed on 2/15/17 at 1:15 pm ordered Digoxin 0.50 mg IV stat per one dose, Troponina Stat every 8 hr per 3, Complete Metabolic Panel (CMP) stat, B-type natriuretic peptide (BNP) stat, Chest X Ray (CXR) plus ABG'S stat, Cardiology, Nephrology, Pneumology Evaluation, Result of 2D'Ecocardigraphy (2DECO), lack of the date and hour when physician counter sign.
j. The physician Telephonic order performed on 2/15/17 at 3:30 pm ordered decrease fraction of inspired oxygen (FiO2) 70%, lack of the date and hour when physician counter sign.
k. The physician Telephonic order performed on 2/15/17 at 5:30 pm ordered Complete Blood Cell (CBC) stat, Vasotec Hold, Blood Pressure (B/P) 1 hr, Flagyl 500 mg IV every 6 hour, lack of the date and hour when physician counter sign.
l. The physician Telephonic order performed on 2/15/17 at 9:00 pm ordered CBC in the morning (AM), lack of the date and hour when physician counter sign.
m. The physician Telephonic order performed on 2/17/17 at 1:45 pm ordered Lovenox 20 mg subcutaneous (SQ) every 12 hr lack of the date and hour when physician counter sign.
n. The physician Telephonic order performed on 2/17/17 at 6:50 pm ordered Demerol 50 mg IM every 6-8 hr PRN for dolor, Phenergan 50 mg IM every 6-8 hr PRN, lack of the counter sign of the physician and date and hour when physician counter sign.
o. The physician Telephonic order performed on 2/27/17 at 1:00 am ordered B/C per 3 every 15 minutes, U/C, lack of the date and hour when physician counter sign.
p. The physician ordered on 2/27/17 at 6:00 pm get portable result, lack of the Registered Nurse (RN) sing and date and hour.
q. The physician Telephonic order performed on 2/28/17 at 11:35 am ordered Discontinue Foley, lack of the date and hour when physician counter sign.

5. R.R. #12 is a 77 years old female admitted on 2/28/17 with a diagnosis of Pneumonia, during the record review performed on 5/11/17 at 12:00 am it was found the following:

a. The summary Sheet no provide evidence of the diagnosis at discharge and the physician not sign the sheet
b. The physician ordered on 3/6/17 at 10:00 am ordered Cephulac 30 ml, Oil mineral 30 ml, Magnesium Milk 30 ml per mouth (PO)stat, lack of the physician sign and date and hour when physician counter sign.
c. The physician Telephonic order performed on 3/10/17 at 9:45 am ordered FiO2 50%, lack of the physician sign and date and hour when physician counter sign.
d. The physician Telephonic order performed on 3/10/17 at 11:30 am ordered Physician Consult for central line, lack of the physician sign and date and hour when physician counter sign.
e. The physician Telephonic order performed on 3/15/17 at 10:00 am ordered Lasix 40 mg IV after each transfusion units, lack of the physician sign and date and hour when physician counter sign.
f. The Dextrose and Insulin Registration Sheet lack of the sign of the RN.
g. The RN initial assessment was incomplete, lack of Past pain management history, Ethic and psychosocial aspect, System assessment, Nutritional assessment, Social and Spiritual assessment.
h. No evidence was found related to Do Not Resuscitate (DNR) consent.

6. R.R. #11 is a 94 years old female admitted on 3/30/17 with a diagnosis of Septicemia, Bronchopneumonia, Myocardial infarct and Ischemic Heart Disease during the record review performed on 5/11/17 at 10:09 am it was found the following:

a. The summary Sheet no provide evidence of the diagnosis at discharge and the physician not sign the sheet.
b. The RN initial Assessment was incomplete, lack of Health history, Present History, Psychosocial aspect, Neurological system assessment.
c. No evidence was found of the DNR Consent. The physician place the order on 3/29/17.
d. Evidence was found that patient death on 4/3/17 at 1:39 pm, however no evidence was found related to Physician death progress note. No evidence was found RN death note. No evidence was found of the physician order to discontinue treatment.
e. No evidence was found of the discharge evaluation, accordance to facility policy and procedure.

7. R.R. #13 is a 67 years old male admitted on 1/22/17 with a diagnosis of Congestive Heart Failure(CHF) during the record review performed on 5/10/17 at 1:30 pm it was found the following:

a. The physician Telephonic order performed on 1/22/17 at 2:25 pm ordering consult was not taken by the Registered Nurse (RN), lack off the RN sign.
b. The physician Telephonic order performed on 1/27/17 at 8:08 pm ordering Oxygen (FiO2) at 50% lack of the date and hour when the physician counter sign the order.
c. Physician Telephonic order performed on 1/30/17 at 10 am , 1/30/17 at 9:50 pm, 1/31/17 at 3:10 am and 1/31/17 at 5:45 am, lack of the physician counter sign, date and hour of counter sign.
d. The physician telephonic order performed on 2/10/17 at 11:00 am, lack of the physician counter sign, date and hour of counter sign.
e. The physician telephonic order performed on 2/12/17 ordering Blood culture (B/C), Urine Culture (U/C), Vancomycin 1 gram (g) stat, lack of the physician counter sign, date and hour of counter sign.
f. The Dextrose and Insulin Registration Sheet lack of the sign of the RN on 1/25/17 at 12:00 pm, at 6:00 pm, on 1/26/17 at 6:00 pm, on 1/27/17 at 6:00 am, at 6:00 pm, on 2/6/17 at 9:00 am, at 5:00 pm.
g. The Intake and Output sheet lack of the sign of the nurse on 1/25/17 at 2-10 shift and on 1/26/17 at 6 am-2 pm shift.
h. The RN initial Assessment performed on 1/23/17 at 4:20 pm, lack of patient diagnosis and chief complaint and the activities of daily living was left in blank, The RN lack of sign, license number and dated the assessment.
i. The Authorization of delivery of Cadaver, lack of the Funeral home to be delivered.
j. No evidence was found of the copy of the Death certificate.
k. No evidence was found related to physician death progress note.
l. No evidence was found physician order to discontinue treatment after death.
m. No evidence was found of the Final Diagnosis.

8. R.R. #15 is a 62 years old female admitted on 5/8/17 with a diagnosis of Osteoarthritis Right Knee during the record review performed on 5/10/17 at 10:15 am it was found the following :

a. The anesthesia consent was sign by the patient on 5/8/17 at 7:30 am, however lack of type of anesthesia that was administered.

9. R.R. #17 is a 39 years old male admitted on 4/25/17 with a diagnosis of Right Knee Septic Arthritis, DM type II, Hypertension (HTN) during the record review performed on 5/10/17 at 11:00 am it was found the following:

a. The surgery consent was sign by the patient on 5/1/17, however, lack of the benefits of surgery.
b. A telephonic physician order performed on 5/5/17 at 3:45 pm ordered Discontinue Morphine 5 mg and administer Morphine 4 mg every 12 hour for pain, lack of the route of administration and lack of physician counter-signature and the date and time counter-signature.

10. R.R. #19 is a 85 years old male admitted on 5/5/17 with a diagnosis of Bronchopneumonia by aspiration, Alzheimer during the record review performed on 5/10/17 at 1:30 pm it was found the following:

a. The nursing initial assessment performed on 5/5/17 at 1:46 pm left in blank the discharge planning assessment, evidence was find the patient has gastrostomy at admission process. No evidence was found that the nurse referred patient to discharge planning services.

11. R.R. #57 is a 66 years old male admitted on 2/4/17 with a diagnosis of Epileptic Status, during the record review performed on 5/11/17 at 3:42 pm it was found the following:

a. The medical History and Physical Examination, the physician performed on 1/4/17 at 5:10 pm 28 days previous to admitting and not reevaluation was performed.
b. The Surgery and procedure consent was sign by patient relative on 2/5/17, however the consent was left in blank and lack of surgeon sign.
c. The Transfusion consent was sign by the patient relative and the physician on 2/11/17 and 2/12/17, however lack of the name of the physician that oriented and do not specified if patient consent or not to be transfuse.
d. The physician Telephonic order performed on 2/4/17 at 5:00 pm ordered discontinue Pepcid, Protonix 80 mg in 0.9% normal saline solution (NSS) 250 ml at 11 ml, and CBC, lack of the dated and hour when physician counter sign the order.
e. The physician Telephonic order performed on 2/4/17 at 7:25 pm ordered Plavix 75 mg PO in hold, lack of the dated and hour when physician counter sign the order.
f. Evidence was found that patient was restraint started on 2/7/17 at 4:00 pm until 2/12/17 at 9:30 am, however the physician Restraint order sheet performed on 2/7/17 at 4:00 pm, lack of the the time patient was restraint and lack of the RN sign and no was re-evaluated in the next 5 days.
g. No evidence was found related to physician progress note evaluation to justified the restraint order.
h. No evidence was found related to Patient Restraint Assessment every 15 minute on 2/8/17.
i. On 2/9/17, on 2/10/17, on 2/11/17, on 2/12/7 until 9:20 am the patient be restraint accordance to patient restraint assessment and RN progress note without an physician order.
j. The patient restraint assessment performed on 2/7/17 provide evidence that the patient not was assess every 15 min, as protocol. The 830: pm , 8:45 pm, 10:00 pm, 10:15 pm, 11:45 pm, on 2/8/17, 12:00 am, 1:15 am, 1:30 am 3:00 am, 3:15 am, 4:30 am, 4:45 am, 6:00 am and 6:15 am was left in blank.
k. The patient restraint assessment performed on 2/9/17 and on 2/10, the RN left in blank the Step II Factors influencing behavior and did not sign the sheet.
l. The patient restraint assessment performed on 2/11/17 provide evidence that from 5:15 pm till 7:00 pm the patient not was asses and no evidence was found in the nurses note that patient was release of restraint and no evidence was found that the physician re -ordered restraint the patient again.
m. The RN progress note from 2/7/17 did not justified the reason to restraint the patient.
n. No evidence was found patient restraint assessment on 2/12/17 from 6:45 am till 9:30 am that the RN documented in the nursing progress not that patient was release from restraint.


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12. R.R. #54 is a 77 years old female admitted on 5/9/17 with a diagnosis of Syncope Head Trauma, Unstable Angina Pectoris, Right Elbow Trauma and Diabetes Mellitus Type II during the record review performed on 5/11/17 at 9:30 a. m. it was found the following:

a. The Physicians order short acting Insulin Suplemental Sub Q Coverage lacks of identification label only written the patient name.

b. The triage performed on Emergency Room on 5/8/17 was incomplete, the RN left in blank the Initial Intervention and lacks of nurses note.

c. No evidence of physician progress note for 5/10/17.



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13. RR #30 was performed on 5/11/17 at 9:36 am accompanied by the Nursing Supervisor from the Intensive Care Unit. This belongs to a female patient of 67 years old who was admitted to this unit with a ruled out (R/O) of Cerebrovascular Accident (CVA), Hemiplegia, Hypertensive Crisis, Encephalopaty, Suspected Aspiration Pneumonitis and Diabetes Mellitus. She was admitted on 2/27/17 and the rehabilitation services documentation was reviewed with the following findings:

a. The physical therapist (PT) performed the initial evaluation on 3/6/17 after the Physician from the rehabilitation services answered a consult on 3/5/17 at 3:00 pm. It was found that the PT failed to establish the frequency of treatment after planning the activities she will performed with the patient. She established AAROM -Left extremities to AROM, Core strength, PROM 4 extremities and transfers. However, failed to determine for how long the patient will be doing the exercises.

b. The PT progress notes form does not have a daily pain assessment section. This documentation form has a subjective section where the PT can write what patient refers. However, there is not a structure for pain assessment that can help the PT to identify patient's needs. No pain scale is observed, no characteristics and management of pain were included in this form.

c. In one of the progress notes from 5/11/17 says the following: "Patient has edema on her right superior extremity". However, there is no evidence documented by the PT telling the intensity of patient's pain, characteristics of pain and there is no evidence if patient took medication before participating on the physical therapy.

d. According to the PT documentation review, in a period from 3/8 thru 5/10/17, it was determined that the PT was providing the rehabilitative services on a frequency of 3 times a week. Due to lack of documentation in the initial assessment and plan of treatment related to the frequency of the physical therapies to be provided, it couldn't be determined if the PT was in compliance with the plan of what she established with this patient.

e. According to the review of the frequency of progress notes performed by the PT, it was found that on April 2017 the PT provided treatment on days 18 and 19. No evidence of a third therapy was provided between April 20 and 21, 2017.

The patient received physical therapy on May 1, 4 and 5, 2017. Then a progress note from May 10, 2017 reveals that patient is pending for reevaluation by the Physician of the Rehabilitation Services. However:

No documentation between May 5 thru May 10, 2017 was found on the clinical record with an explanation why the physical therapy was not provided between this periods.

According to interview with the Nursing Supervisor from the Intensive Care Unit (employee # 21) performed on 5/11/17 at 11:00 am, she stated the following: "This patient showed respiratory distress which required intubation. She remained with the tracheal respiratory tube since May 9 thru May 10, 2017. Thus, the physical therapy was hold until the patient feels better. It has to be mentioned that this patient receives acute hemodialysis treatment 3 times per week. According to the PT, they do not provide therapy to patients the same days that they receive the hemodialysis".

The P&P for not providing physical treatment the same day when hemodialysis is given was requested. After the Nursing Supervisor (employee # 21) looked for the information, she stated: " The PT told me that the Physician of the Rehabilitation Services decided to not provide physical treatment the same days that hemodialysis patient's receive treatment because they feel weakness after hemodialysis treatment."

The surveyor tried to perform an interview to the Physical Therapist Assistant (PTA) on 5/11/17 at 11:35 am as soon as she arrived the Intensive Care Unit. However, the PTA was dodging the questions that were asked.

When the surveyor requested her to answer some questions related to her documentation on the clinical record of patient #30, she stated: "If progress notes are not in the clinical record on those days, mean that the physical therapy was not provided because patient received hemodialysis".

It was showed to her that on some days on April and May, 2017 no evidence of treatment provided by her were written on the clinical record. For example: April 20 was Thursday but it was not determined if patient received physical therapy due to lack of documentation. The PTA stated: "If there is no documentation the treatment was not provided and maybe the patient refused due to feeling weak".
However, that explanation was not written in the clinical record.

The Physical Therapy staff failed to write in the clinical record all procedures related to pain management and to explain the reasons of why treatment was not provided. These deficient practices do not comply with rules and regulations for keeping an actualized and well documented the clinical record.

Base on validation Survey and fifty seven record review with medical record manager (employee #8), on 5/9/17 till 5/12/17, it was determined that the facility failed to ensure that medical record document final diagnosis with completion of medical records within 30 days following discharge for 11 out of 57 record review (R.R. #5, #11, #12)

Findings include:

1. R.R. #5 is a 54 years old female admitted on 2/12/17 with a diagnosis of Sepsis, Diabetes Mellitus during the record review performed on 5/11/17 at 10:54 am it was found the following:

a. The summary Sheet no provide evidence of the diagnosis at discharge and the physician not sign the sheet.

2. R.R. #11 is a 94 years old female admitted on 3/30/17 with a diagnosis of Septicemia, Bronchopneumonia, Myocardial infarct and Ischemic Heart Disease during the record review performed on 5/11/17 at 10:09 am it was found the following:

a. The summary Sheet no provide evidence of the diagnosis at discharge and the physician not sign the sheet.

3. R.R. #12 is a 77 years old female admitted on 2/28/17 with a diagnosis of Pneumonia, during the record review performed on 5/11/17 at 12:00 am it was found the following:

a. The summary Sheet no provide evidence of the diagnosis at discharge and the physician not sign the sheet.

Based on a Validation survey, observational tour at the Medical Surgical Unit A accompanied by the Nurse Leader (employee #18) at 9:30 am on 5/10/17, policies and procedures (P&P's) review and interview with the patient's family member, it was determined that the facility failed to ensure that nursing staff complies with the uses of bedside medications in a manner to avoid risk of drug adverse reactions, as observed in 1 out of 56 patients (RR#19).

Findings include:

1. During observational tour at the Medical Surgical A Unit on 5/10/17 at 9:30 am it was observed a bag of multiple medications put over the side table. These medications belongs to patient # 19 who was admitted due to Bronchopneumonia, is bedridden and disoriented due to Alzheimer's. During the visit at his room, he was sleeping and it was observed that he is using soft restrictions on both hands. The patient was alone.

a. The medications that patient brought from home were: Candesartan (Atacand) 4 milligrams (mg) 1 tablet (tab) by gastrostomy daily, Lorazepan 0.5 mg 1 tab by gastrostomy daily in am, Clonazepan 0.5 mg by gastrostomy daily: 1 tab in am, 1 tab in pm, Galantamine ER 8 mg capsule 1 tab daily by gastrostomy.
The medication administration record (MAR) was reviewed and the same medications were provided by the facility's pharmacy.

During interview with the Nurse Leader (employee #18) performed at 9:30 am on 5/10/17 she stated: "If the patient arrives through the Emergency Room, the nursing staff tells the family to bring at the hospital the medications that the patient is taking at home. This is the way that the nursing staff writes on the reconciliation form the actual medications. As soon as the patient arrives at the unit, the nurse gives orientation to the patient and family members that they have to take back home the medications that they brought".

b. On 5/11/17 at 1:30 pm the patient's son was interviewed and he stated the following: "I'm in charge of my father. When we arrived at the emergency room I received instructions from the nurse that I have to bring father's medications. I did it. When we arrived to this unit, I do not remember when the nurse told me to take them back home. I am sorry that I can tell you at this moment. I have been struggling with both parents, (he began to cry). I'm losing my memory due that I am tired. I will take home the bag of those medications".

The surveyor asked patient's #19 son if he administered medications that he brought from home during his father hospitalization, he stated: "No, I did not do it because the nurses are giving him the same medications".

c. The P&P for uses of bedside medications establishes that the nursing staff is responsible to give orientation to patient and family members to take back home all mediations that were brought to the hospital. If family members are not present, the pharmacy service is responsible to keep the medications in a safety place until family members request the medications or until the patient is discharged home.

The facility failed to ensure that bedside medications were delivered to patient's son in a manner to avoid drug adverse reactions.

The nursing staff and the pharmacy services failed to follow the P&P for the uses of bedside medications.

Based on a Validation survey observational tour at different clinical units, such as: Medical Surgical Unit A, Intensive Care Unit, Pediatrics Unit, Delivery Room/OB GYN Unit and Nursery Unit, performed from 5/10 thru 5/12/17 accompanied by the nursing staff, P&P's review and interview to the Pharmacy Services Director (employee #20), it was determined that the facility failed to ensure that the Pharmacy Services supervises the procedures related to drug storage, identification of medicine stocks and labeling of medications.

Findings include:

1. During the IJ situation identified on 5/09/17 at 10:15 am at the storage room located on the ground floor, it was found IV solutions, ulcer/wound medications and medical surgical materials that are used in ulcer care procedures that were put over dirty shelves and mixed with office materials and other equipment.

a. The room temperature was over 80 degrees Fahrenheit which is not adequate for these IV's and materials as recommended by their manufacturers. The adequate temperature for the IV solutions is 75 degrees Fahrenheit as well for the ulcer/wound medications and care materials.

b. During interview with the Nurse Leader (employee #18) of the Medical Surgical A Unit performed on 5/10/17 at 10:30 am she stated the following:

"The IV solutions come directly from the general storage that is located at HIMA Caguas. We perform the request once a week and the person that is in charge of this storage bring us the IV's. We have in our unit a storage for the IV's and at the General Nursing Supervisor's office, some boxes of IV solutions are kept there. If we are out of stock with the IV solutions, we request them to the Nursing Supervisor or to the General Nursing Supervisor. I think that the Pharmacy is not in charge of the IV's. The instructions are to request the IV's and the person at the storage room goes to Caguas and bring them to our hospital."

c. During interview with the Wound and Ulcer Care Nurse (employee #6) on 5/10/17 at 10:00 am, she stated: "I request to the employee that works in the storage room to provide the medications and ulcer care materials according to the inventory that I usually perform. He calls me to deliver what I ordered. If he cannot find me, he can leave the box with the order at the Nursing Department."

The surveyor told employee #6 the findings of two boxes full of medications and ulcer care materials under an inappropriate environment where dust and high temperatures were affecting these materials. Employee # 6 stated: "I did not know that the employee of the storage room was leaving boxes of wound care medications and materials there. He knows that if he cannot find me at the hospital he has to leave the boxes at the Nursing Department."

d. During interview with the Pharmacy Services Director performed on 5/11/17 at 11:00 am, she stated:
"I do not have control of the IV solutions storage nor the wound/ulcer medications. I do not have an inventory of those items. I know that the IV solutions and ulcer care medications come from HIMA Caguas. Nobody notifies me when those items are requested and when arrive to the facility. I have identified a space for storage of the IV solutions with adequate room temperature as requested by the manufacturers. I have suggested on administrative meetings this idea but I did not receive notifications to do what I suggested. Sometimes, I receive phone calls from clinical units requesting me some IV solutions to prepare medications because their inventory is empty. I help them giving the IV's that I have in stock but my services can be affected because if I continue giving the available IV's that I have, then I could be having less IV's for dilution of some medications that my staff prepare every day."

The facility failed to establish a mechanism where the Pharmacy Services will be in charge of requesting, delivering and keeping in a safety place and under their supervision the IV solutions and wound/ulcer medications.

2. During observational tour at the Pediatrics unit on 5/11/17 at 1:24 pm it was observed that two skin medications known as Extra Protective cream and a lubricant tube were opened and used on patients. However, these medications were not labeled with date, hour and signature of the staff member that opened them.

3. At the Pediatric Unit medications room, there is a cabinet where the Labor Room/OB GYN storage has stock medications. However, it was not identified.

4. At the labor Room/OB GYN stock medications cabinet it was found an expired medication known as Brethine 1 mg/ml. The expiration date was on 7/16. It was discussed with the Registered Nurse from OB GYN (employee #23) and she stated: "I don't understand why this medication was kept here. We are always with the pharmacy staff verifying these medications. Also, Brethine is a medication that has not been in use for long time ago."

The pharmacy services failed to perform with the nursing staff monitoring and tracking activities to identify expired medications.

5. During stock medications cabinet's inspection performed at the Intensive Care unit on 5/11/17 at 8:49 am it was found that the order form to request medications is used as a medications lists to evidence
the availability of medications that are in the stock cabinet. However, it was observed that the presentation of some medications are different to the information that appears on the list.

a. On the cabinet there is Hydrazaline (Apresoline) 20 mg/ml but is not included in the medications list /order form.

b. On the medications list appears Physostigmine 1mg/ml but is not available at the Pharmacy stock.

The Pharmacy Services failed to establish a mechanism to ensure that the medications that are physically present at the stock cabinet appears on the medications/list form, in a manner that the nursing staff can identify accurately when performing surveillance activities.

Base on validation Survey and review of equipment maintenance record with X Ray interine supervisor (employee # 11) on 5/12/17 from 9:30 am till 11:30 am, it was determined that the facility failed to ensure that periodic inspection of equipment and preventive maintenance must be made and maintenance by the hospital and be available for review.

Findings include:

During the review of equipment maintenance record it was found that the facility lack of equipment maintenance documentary since December 2016. No evidence was provide relate to equipment maintenance from 2017.

Interview with the Interine Supervisor (employee #11) on 5/12/17 at 10:30 am stated that he is the interin supervisor since October or November 2016, he was helping in some area of the administrative task as Square the nominate, perform the work program, order the contrast and material needed. The employee of the company that performed that maintenance to the equipment send the maintenance resume sheet direct to HIMA San Pablo Caguas.

Based on a validation survey, observations, review of policies and procedures and routine equipment testing with the acting supervisor of the X-ray department (employee #11) and interview, it was determined that the facility failed to ensure that the physicist periodically verifies the badge exposure for radiation exposure.

Findings include:

On 5/12/17 at 10:00 am the acting supervisor of the X-ray department (employee #11) provided evidence of the bi monthly radiation dosimeter report revision of badges used by X-ray department personnel from August 2016, October 2016 and March 2017. However, no written evidence was found of routine inspections of the dosimeters for radiation by the physicist. The X-Ray supervisor (employee #11) stated during an interview on 5/12/17 at 10:30 am that the badge reports are reviewed by the physician, it suppose that I call the physicist to evaluate the result but I forget. On Wednesday the physicist came to the unit I'm going to give him the result to evaluate by him.

Based on a validation survey, observation performed on 5/2/17 through 5/10/17 from 8:00 am until 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 which makes this condition "Not Met" (cross reference Tag A724)

Based on a validation survey, tests performed to equipment, observations and interviews made during the survey of the physical environment , 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:

During the kitchen tour performed on 05/09/17 from 9:15 until 10:10 am with the Kitchen Director (employee #13) the following was found:

1. Trays drying on top of each other.

2. Rack drying trays with mold.

3. The washing area the paint on the roof peeling off.

4. 3-compartment sink:
a. A black hose running over the dirty pots to the second compartment of clean water.
b. Sanitizer sink compartment with a hole and it is covered with aluminum foil.
c. Sink faucets with continuous liquids and full of white spots.

5. Broken floor tile under the table where dirty pots and pans are placed.

6. Tiles on the walls are observed with dirty old encrusted on the walls.

7. Hand washing area broken wall tiles.

8. Small hood
a. Bulb without cover
b. Does not have ANSUL system
c. Two 1/2 "rigid steel tubes cut uncovered.

9. Wall extractor off; the base and the blades are full of mold, screen dirty and very dusty.

10. Sink area (2 compartments)
a. Cracked floor slabs under hose.
b. Grout of the floor tiles with mold.

11. Next to the fire extinguisher is a metal cover with a hole where the wires are observed and they are filled with dust.

12. Skylights above where they are preparing foods filled with green mold.

13. Slabs around stoves with dirty inlay.

14. Cream colored cart where they place condiments is observed with black and old spots.

15. Steam table of 4 compartments is observed with white spots (white mold) around.

16. Broken slabs between 2 compartment sink and fridge # 2.

17. Broken slabs between 2 compartment sink.

18. Steam table area of the line with mold and white mold.

19. Warehouse area
a. Dirty floor with black spots.
b. No fire extinguisher
c. Slabs on the wall with dirty inlay

20. Fourth tray wash:
a. Floor slabs in the entrance with dirty inlay.
b. Wall slabs with dirty and old stains.
c. Table where trays are placed is observed with white spots (white mold)

21. Tiles on the wall of the housekeeping room are broken.

22. Housekeeping room has no door.

23. Detergent room:
a. Missing 2 tiles on the wall.
b. Detergent pans are located on a wooden base.

24. In front of Pharmacy, there are missing baseboard and others are broken.

During the physical environment in the Emergency Room performed on 5/9/17 from 3:00 pm until 4:30 pm the following was found:

1. Nursing station where samples are placed is broken ceiling tile and tubes with dust filled wires.

2. Intensive Care I:
a. Sink faucet does not work is flushing water all the time.
b. In cubicle # 4 loose floor tile.

3. Man bathroom:
a. Extractor does not work properly as there is strong urine odor. Floor slabs are dirty.
b. Cover of call system in front of the bathroom does not have it

4. All stretchers in all sections of the emergency room with mold.

5. Dirty and mold-filled on drug cart.

6. Dirty utility room do not had exhaust fan.

7. Intravenous Medication Room:

a. Bathroom with bathtub has no faucet to open water. You are missing tiles in the area where the water faucet goes. Has no nurse call system and does not comply with ADA law.

8. Ladies Observation Area:
a. The cord of lamps shorts.
b. All the walls with the painting peeling off.

9. Environmental Control Room:
a. There is no exhaust fan

10. Minor surgery:
a. Camilla cover broken and full of mold.
b. Area reading plate clocks and oxygen with mold around.

11. Fourth MD # 1
a. Cracked floor slabs in the concave area.
b. Curtain rail fastened with tape.
c. Written wooden lid loose and dusty.

12. Triage # 1
a. Entrance with exposed cement.

13. Cubicle # 2 & # 3
a. There was mold on the floor below the sink.

14. Cubicle # 4
a. Several broken floor slabs.
b. Railings on the wooden walls are porous.

15. Acute Medical Assessment
a. Ceiling slabs with water filtration stains.
b. Walls with water bubbles in the paint by filtration.
c. Lack of floor area, sink area (exposed cement).
d. Cover of broken stretcher.

17. Pediatric Emergency Room
a. Cubicles # 7 without label.
b. A / C grill broken duct.
c. Top Outlet does not have.
d. Stretcher with mold.
e. Loose thermostat box
f. Visitor bathroom with mold stains on the wall.

During the physical environment in the Area of Radiology performed on 5/10/17 from 1:35 pm until 2:40 pm the following was found:

1. Area of Radiology:
A. Woman Bathroom
1. Continuously dripping faucet of the hand washing sink
2. One of the two sinks has no water faucet.
3. Floor slabs with dirty inlay

B. Radiology area main entrance
1. Slabs are missing from the floor and others are broken.
2. Loose rubber base.

C. Sonography Room # 2
1. Ceiling tiles out of places

D. X-Ray Room # 1
1. Missing ceiling tiles

E. Mammography Room
1. Broken ceiling tiles
2. Duct air cover with dust
3. Cover of the ceiling lamp broken
4. The bathroom do not has nurse call system
5. Painting of the walls peeling off

F. Nuclear Medicine Room
1. Ceiling lamp in the area of cannulate patients without cover.

G. Sonography Room
1. Floor tiles with old dirty stains.

H. CT Scan Room
1. Floor tiles with mold and old stains
2. The cover of the Air Conditioner unattached and covered with dust
3. Broken ceiling tile
4. Ceiling tiles out of place and bended

I.In the entrance of the X-Ray area the push bottom to open the doors do not function.

During the physical environment in the Outside front hospital tour performed on 5/10/17 from 10:45 am until 11:20 am the following was found:

A. Emergency exit (Stairs)
1. The ladders are full of green slime and much debris accumulated in the last step.
2. Debris and wet garbage making the sidewalk become slippery.

B. Outside Ladies' Bath
1. It has not extractor. The hole of the exhaust fan visible and uncovered.
2. Wall tiles with dirty embedded.
3. Metal plate on the wall filled with mold and the surface is sharp.
4. Two ceiling tiles broken and one folded.

C. Outdoor men's bath
1. Floor tiles are observed with stains of mold and dirty.
D. On the way between the cafeteria and medical building there is unevenness of floor can cause fall. In front of the OPD (Out Patient building), it is observed that the tree roots have raised the sidewalk. They have two barriers to prevent a fall but with everything and that an area of 3 linear feet has been left unidentified and this can cause a fall.
E. Opposite the OPD building there is an area with black slime due to the continuous leak of water from the drainage pipe that is out of place. The floor is wet at all times.
F. Ranch of Cyclone Fence behind Emergency room was observed with 19 oxygen tanks and 12 nitrogen tanks they are direct to the floor and the storage has no roof.
G. The entire structure of the hospital is observed with lack of paint, walls with black mold and the masonry of the walls falling out.
H. Poor cleanliness is observed in the emergency room parking area.

During the physical environment in the Physical Therapy Area performed on 5/10/17 from 2:45 pm until 3:20 pm the following was found:

A. Hydrotherapy Area
1. Ceiling lamps without covers.

B. Third cubicle

1. Wall with yellow stains and peeling paint.

2. Hand washing sink in front of the three cubicles with mold in the bottom of the floor.

3. Walls with water leaks.

C. Environmental Control Room is observed with running water since the water shut off key does not work.

During the physical environment in the second floor performed on 5/11/17 from 8:45 pm until 3:20 pm the following was found:

1. The Ice machine of the second floor out of service
2. In the ice machine room is the floor full of trash.

Medico Quirurgico A

1. Mixed visitors bathroom the hand washing sink is leaking.

Soiled Linen Room
1. The hand sink had the hot water faucet is not functioning.

Employee's bathroom

1. Floor tiles stained with white mold.
2. Ceiling tiles with water lick marks.
3. Exhaust fan does not work. Strong smell of urine.

Room # 201
1. Ceiling tiles raised.
2. The cord of the night lamp of the A side is short.
3. Window has not decorative trim and has the cement exposed.
4. Intravenous stand with rust and it lacks a wheel.
5. Bed board side B is broken.

11. General Archive Area:
a. Loose cap with exposed communications cable.
b. Acoustic missing
c. Missing bases

12. Slabs under hand washing sink in the rooms of 201-220 with dirty old mops and fungus.
13. The towel rails in the bathrooms of the 201-220 rooms do not have the cover.
14. The locks of the bathrooms in rooms 201-220 do not meet in case a patient falls, it is difficult the entrance to be able to provide help.
15. Bathroom of room # 203 the border wall of the shower lacks of tiles.
16. The closets do not have ceiling tiles exposing the air conditioning ducts in rooms 201-220.
17. Side rails of beds in rooms 201-220 are observed with mold.

d. Room #204
1. Broken wall tile under hand washing sink.
2. Exposed cement on the around window.

18. The frames of the Bathroom doors from rooms #201-#220 was observed rusty.

e. Room #214
1. The walls of each space for the patients' beds are without labeling.
2. The night lamp of the side B do not had the pull cord.
3. The faucet of the hand washing sink do not close well and always is running water.

f. Bathroom
1. It was found wall tiles broken in the shower.
2. Faucets of the toilet with tape holding a piece.

19. No evidence was found on 5/9/17 at 3:45 pm of a record for the test and maintenance weekly and monthly of the negative pressure for the Isolation rooms in the second floor.

20. Patient's bathrooms in the emergency room area can be locked from the inside and personnel do not have readily accessible keys or a device to open the door.

21. A lot of mold in the bathroom accessories was observed; this condition repeats thru all the bathrooms on this floor and all the bathrooms on the floor.

22. In room #215 the night lite lamp on side B is attach with tape.

23. Pediatric Ward

Room # 112
a. Side rails on the bed rusty.
b. Ceiling tile in the closet broken.
c. Slab under sink with white mold.
d. Mirror over the hand washing sink with bulb and cover.

Room # 118
a. Beds with siderails rusty.
b. Bedboard from side B is broken.
c. The lamp on top of the hand washing sink without cover
d. Floor slab area A with pink spots.

Room #131
a. Light switch without cover.

Room #132
a. Unattached rubber base.

Room # 133
a. No closet
b. There is not the frame for sharp container
c. The door does not close since it has tape in the gap of the lock.

Room # 134
a. Vertical Blinds Broken
b. No closets
c. Dirty and peeled walls
d. The bathroom lacks a slab and can be seen hollow with the keys of the toilet.

Room#135
a. Missing rubber base

24. The diesel tanks used to store and provide diesel to the ambulance in front of the emergency room entrance was found out in the open and not separated or protected by a fence as observed on 5/10/17 at 1:30 pm. The diesel tanks are located in an area that makes it accessible to non-authorized persons.

25. Morgue
a. Loose door lock.
b. Gypsum board wall with a hole.
c. Wall with exposed cement

26. During the 4 days of inspection at the facility the main hospital entrance door was observed open and in the afternoons the security guard was observed by opening and closing it manually.

In interview with employee #22 Engineer of facility on 5/9/17 at 3:00 pm revealed that the door was damaged for couple of weeks; who had already sent it to quote a new one. At the moment of requesting evidence, he informs me that he has not yet been sent. However on 10/17/17 at 9:10 am I delivered evidence of the quotation for the installation of a new door.

Based on a validation survey, observation with Director of Nursing (DON) (employee # 1) on 5/10/17 at 9:15 am it was determined that the facility failed to prevent patients from harm. This constitute an Immediate Jeopardy to 5 out of 5 patients admitted at the facility.

Findings include:

During the observational tour performed on 5/10/17 at 9:15 am it was observed in the ER Department the following:

1. A room in the back of the ER Depatment identify in the wall Intravenous Medication Room "Cuarto de Medicamentos Intravenosos".
2. It was observed with 6 lounge chairs with less of separation between of 12 inches.
3. The room does not have nurses call system installed.
4. The room also had a bath room without nurses call system too.

It was determined that the facility failed to prevent patients from potential harm related to failure to provide care and supervision related to the lack of nurses call system on a treatment area.

On interview with the DON, Medical Director and ER nurse supervisor on 5/10/17 at 10:49 am until 11:10 am revealed that the intravenous medication area has less that one year. They did know that the bathroom did not have nurses call system. But they knew that the chairs did not have the nurses call system.

The facility's correction plan (POC) was received on 5/10/17 at 4:40 pm.

Immediate Jeopardy Situation Identified 05/10/2017

Specific Corrective Actions

1. Intravenous Medication Room will be closed for changes until 5/12/2017
2. Immediate elimination of three (3) lounge chairs in the Intravenous Medication room to allow for the required separation of at least 12 inches between patients. Support Services Director will be in charge of this movement and should be completed by 05/10/2017.
3. Installation of a nurse call notification system in the Intravenous Medication Room besides each lounge chair. Support Services Director will be in charge of the installation of the electric nurse alert system by 5/12/2017.
4. Immediate acquisition of manual bells to established a manual nurse alert system. Nurse Director will be in charge of providing manual bells and should be available at site by 05/10/2017. Manual bells will be available as an alternate measure.
5. Bathroom electric alert system will be install by 5/12/2017. Support Services Director will be in charge of this installation.

The facility's correction plan (POC) was evaluated and accepted on 5/10/17 at 4:45 pm.

Based on a validation survey, observation of delivery of care, review of medical records, dietary department round, policies and procedures (P&P's), official documents, and interviews from 05/09/17 to 05/12/17 it was identified that the facility failed provide a sanitary environment to avoid sources and transmission of infections and communicable diseases accordantly to the 42 CFR 482.42 which makes this condition, Not Met (Cross reference Tags A0749).

Based on a validation survey, observation tour at the General Storage room and interview with administrative dietitian (employee # 13) and Infection Control Officer (employee #12) on 5/9/17 at 10:15 am it was determined that the facility failed to prevent patients from harm. This constitute an Immediate Jeopardy to 30 out of 30 patients admitted at the facility.

Findings include:

Observational tour at the General storage room perform on 5/9/17 at 10:15 am until 10:45 am, it was found that the facility failed to establish effective infection control precautions to avoid widespread nosocomial infections.

This storage room is located at the ground floor of this facility.

During the observational tour it was found the following:
1. Medical surgical equipment's
2. Office equipment's
3. Medical records
4. Radiology films
5. Credential files
6. Temperatures of this room out of rage. Temperature was 79 degrees Fahrenheit (79º F) bellow the middle of the wall and 81º F from the middle of the wall toward the roof.
The medical surgical temperatures recommendation, according to the Manufacture is 77 º F (as maximum temperature).
7. Flying insects were observed inside the storage room.
8. Dead lizard were found in this area, suggesting of poor pest control measures.
Since January 2016, this storage room has been used as a receiving area of medical surgical equipment, which no evidence was found of who is in charge to keep it clean and to follow the administrative instructions for the dispatch of materials received from Caguas storage room.
No infection Control measures were implemented before the IJ was notified at 2:00 pm, it was observed that boxes containing medical surgical equipment were placed in a van that belongs to the HIMA San Pablo Hospital Corporation.

According to interview with the engineer employee #22, these boxes are taken to HIMA San Pablo Hospital at Caguas.

It was requested inventory list of these materials but it was not provided.

It was requested evidence of the decommission procedures.

A Statement of Deficiency was provided to the facility on 5/9/2017 at 2:05 pm notifying the IJ and requesting a Plan of Correction (POC).

The facility provided a POC on 5/9/17 at 5:00 pm as follow:

General instruction and corrective Actions:

1. Hospital Executive Director, through the hospital Directors, Managers and supervisors, will be enforcing the compliance with the directives given on January 22, 2016, regarding the closing of the old warehouse area for storage purpose and current procedures for receiving and storage medical surgical materials, medical supplies. An official communication will be distribute to all personnel (see attachment) (05/09/2017)

2. Directors, Managers and Supervisors of each operational area will be responsible of discussing the official communication with their personnel and provide evidence of such (05/26/2017)

3. Hospital Epidemiologist will be in charge of verifying compliance with the establish procedures by weekly inspections.

Corrective actions for specific findings:

1. Access and control to the old warehouse will be immediately assigned only to the Materials Management clerk and to an authorized general supervisor.
2. All signs designating the area as a storage warehouse "Almacen" will be immediately removed.
3. Medical surgical equipment and supplies were immediately removed from the area and prepared for transportation to the centralized warehouse for further decommission.
4. Inventory list of medical supplies to be disposed was immediately prepared and submitted to survey officials (05/09/2017-see attachment).
5. IV fluids was immediately discarded.
6. Temperature requirements do not apply since the warehouse was closed and not to be used as a storage since January 2016.
7. Medical records were immediately relocated to the Information Management Department.
8. Radiology films were taken to the Radiology Department for appropriate filing.
9. Credential files were immediately taken to the Medical Director Office.
10. Pest control and cleaning measures. Ing Guadalupe will contact Pest Control subcontractor on 5/10/2017 for fumigation services before 5/13/2017. Hospital Housekeeping department started cleaning and disinfecting procedures today (5/9/2017)
11. Training personnel on Corporate Policies: Policy 068 Disposal of syringe and sharp objects and Policy 071- Biomedical Material Disposal.
12. Development of Corporate Policies to manage medications and medical surgical supplies disposition procedures.

An onsite visit was performed on 5/9/2017 at 5:10 pm to the storage room.

The POC was accepted by the surveyors on 5/9/2017 at 5:20 pm.


36632


Based on validation survey, observational tour, review of the infection control program, interviews, and policies and procedures (P&P's) with the Infection Control Officer (employee #12) performed from 5/9/17 thru 5/12/17 it was determine that the facility failed to ensure and promote an ongoing hospital-wide infection prevention and control program that identifies, report and prevent the spread of infections and communicable diseases.

1. During dietary department observational tour with the administrative dietitian (employee #13) and Infection Control Officer (employee #12) it was observed the following:

a. On 5/9/17 at 9:15 am was observed that the shelves for placing food trays after being washed for drying were filled with rust.

b. On 5/9/17 at 9:20 am it was observed in the dietary department that the one of the cooks (Employee #14) was beating eggs without wearing disposable gloves. The administrative dietitian (employee #13) approaches to the cook and then he performed a hand wash and used the disposable glove.

During Interview with the administrative dietitian (employee #13) on 5/9/17 at 9:20 am she stated: ''Our policy states that they have to use disposable glove when managing food."

2. During observation of the medication refrigerator located in the office of the infection control officer on 5/9/17 at 9:40 am was found that there was no evidence of a temperature log. In the refrigerator were 6 vial of influenza vaccine.

During interview with the Infection Control Officer (employee #12) on 5/9/17 at 9:40 am, she stated: "I do not usually keep medicines in this refrigerator, but since I was in the process of getting the influenza vaccine I had to keep them here. It was a box of 10 shots and 6 shots left."

During review of the "Cotejo de Temperature de la Nevera de Medicamentos" (Medication Fridge Temperature Check) Policy # 070 on 5/9/17 at 9:45 am was found the following evidence in item #2 thru #6:

a) (2.) The refrigerator should have a thermometer in a visible area.
b) (3.) The person responsible for reading and recording the temperature of the refrigerator will be assigned by the supervisor of the unit.
c) (4.) The refrigerator temperature will be taken at 7:00 am every day.
d) (5.) The record will be documented on sheet # 353.
e) (6.) The temperature of the refrigerator should be between 35 and 45 degrees Celsius.

However, these steps were not followed.

3. During review of the temperature log of the mortuary room used for the storage of human corpses on 5/12/17 at 8:55 am provided evidence that on 2/4/16, 2/5/16, 2/8/16, 6/30/16, 7/15/16,7/26/16, 10/29/19, and 10/30/16 the temperature was not evaluated and documented. The back door of the mortuary has a space between the bottom of the door and the floor that allows the access for pest (insects and rodents) to go in.

During interview with the Infection Control Officer (employee #12) on 5/12/17 at 8:55 am related of this situation and she stated: "The staff in charge of this area should have documented those temperatures every day, if the space is in blank and there is no temperature documented is because they did not performed it. I will work with that."

4. During the review of the infection control program manuals with the infection control Officer (Employee #12) on 5/9/17 at 2:40 pm evidence was found that the manual establish that they were revised on 2015, approved on 2015 and next revision on 2017. However the 2015 revision of the manuals has not been approved and signed by the executive director, epidemiologist, chair of the infection control committee and the medical director. The infection control program has been using from 2015 thru 5/9/17 unauthorized infection control manuals.

5.During visit to room 217 with the infection control Officer (Employee #12) on 5/10/17 at 9:43 am to observe a wound care process perform by the registered nurse skin care specialist (RN) (Employee #6) and assisted by RN (Employee #16), it was found the following:

a. It was observed in three occasions the RN skin care specialist (Employee #6) poured liquid soap over her dried right hand and then opened the faucet with the left hand and wet her hands.

b. It was observed on 5/10/17 at 9:43 am that the RN skin care specialist (Employee #6) shakes the hands to remove excess of water from the hands and then continued to dry with the disposable towel.

c. The RN skin care specialist (Employee #6) did not follow hand hygiene accordingly with Center of Disease Control (CDC) Hand Hygiene in Health Care Settings October 25, 2002/Vol.51/RR-16, guidelines.


d. The RN skin care specialist (Employee #6) was observed on 5/10/17 at 9:43 am to use a scissor to cut the adhesive tape and the medication dressings for the ulcer care; however she failed to clean and disinfect the scissors before using it which increases the risk of cross-contamination.

The facility failed to ensure that nursing staff follows the Centers for Disease Control and Prevention (CDC) establish for cleaning and disinfection of non-critical items guidelines.

e. It was observed that the RN (Employee #16) assisting the skin care specialist on 5/10/17 at 9:47 am took two disposable gloves and put them on without performing hand hygiene and began to assist in the care of the ulcer.

During review of the hand wash policy #012 perform on 5/10/17 at 3:00 pm was found:

a. On item #1 the policy establishes to wash hand: "before starting work".
b. The policy does not include washing hands after glove removal.

Agency failed to ensure that all nursing staff performs hand hygiene during ulcer care following established guidelines by Center of Disease Control (CDC) Hand Hygiene in Health Care Settings October 25, 2002/Vol.51/RR-16.

f. It was observed that the RN (Employee #16) assisting the skin care specialist on 5/10/17 at 9:50 am performed a hand wash, however the RN(employee #16) shakes the hands to remove excess of water from the hands and then dried with the disposable towel.

g. It was observed that the RN skin care specialist (Employee #6) on 5/10/17 at 9:52 am performed the ulcer care applying wound cleanser spray on the ulcer and then with a clean gauze in a circular motion from the edges of the ulcer outwards three times, then placing a gauze over the left side of the ulcer and pressing and continued placing another gauze over the right side of the ulcer and pressing.

The facility failed to assure that the nursing staff maintains appropriate infection control measures and standards of nursing for the intervention of ulcer care procedure and to prevent cross contamination establish in National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.

6. During the tour on the first floor in the Intensive area on 5/10/17 at 10:20 am with the infection control officer (Employee #12) it was found:

a. The storage of intravenous fluids and medical and surgical materials had not registered the temperature and humidity for the day 5/7/17.

7. During the tour on the Radiological area on 5/10/17 at 1:45 pm with the infection control officer (Employee #12) it was found:

a. Return vents of the air conditioning unit filled with dust.
b. Mammography machine filled with dust.
c. Horizontal surfaces with dust.
d. Two broken ceilings tiles.
e. X-ray machines filled with dust.
f. The emergency crash cart # 13 of the nuclear medicine area had 5 epinephrine 1 / 10,000 packs with an expiration date of 5/1/17.
g. The emergency crash cart # 13 of the nuclear medicine area was filled with dust and hair.
h. In the nuclear medicine area was observed a used infusion bag of 100 ml 0.9% (piggy back) on the desk of medicine administration site.
i. In the area of computed tomography (CT) the air conditioning unit had the area of the filters filled with dust.
j. The return vents of the central air conditioning unit were filled with dust.

During interview with the Nuclear medicine staff (employee #17) on 5/10/17 at 1:50pm, she stated: "The pharmaceutical department come and verify the emergency crash car monthly. I use that piggyback to flush the IV site of my patients after the administration of the medication."

During interview with the Infection Control Officer (employee #12) on 5/10/17 at 1:50pm, she stated: "All those surfaces on the radiological department should be clean and free of dust. The emergency crash car is verified monthly. I'll have that expired medication change and the car will be cleaned. We do not promote the practice of flushing IV site of our patients."

8. During the tour on the Physical therapy area on 5/10/17 at 2:50 pm with the infection control officer (Employee #12) it was found:

a. The clean sheets were beside the dirty sheets.
b. There were open bandage hanging from a string.

During interview with the Infection Control Officer (employee #12) on 5/10/17 at 2:55pm, she stated: "Those clean sheets are not supposed to be so close to de dirty ones. The bandages are not supposed to be used on more than one patient."


17959


During observational tour, P & Ps reviewed and interviews with the Nursing Director (DON) (employee # 1) on 05/09/17 through 05/11/17 at 9:30 a. m. till 3:00 p. m. the following was observed:

9. The Medicine and Surgery Department on the second floor was visit on 5/9/17 at 9:50 a. m. with the nurse supervisor (employee #5) was observed:

a.On patient room #201B was observed a 82 year old female patient admitted to this facility on 5/4/17 with Respiratory distress, Sacral Ulcer Stage III and Left Hip Ulcer Stage IV. The patient was accompanied with her daughter and she refer that her mother did not received her IV antibiotics at 9:00 a.m.

The nurse supervisor was notified related to this situation immediately. At 10:10 a. m. the register nurse (employee #7) goes to the patient room with a canalization cart he enters the cart at the patient room then enters his hand into his right pocket and takes two gloves puts them on his hand then enter again his right hand on his right pocket takes a gauze and then removed the patient angio catheter and discard the IV lines and IV fluids. The nurse takes an angio catheter and a sterile solution of the canalization cart, puts it directly on the patient bed, prepared the IV solution and initiated the canalization on the right arm however during the canalization procedure the nurse touch the area in all occasions but failed the canalization, then he tried on the left hand and canalized the patient. When the nurse removed the angio and during performed the canalization the nurse did not wash his hands, puts a pair of gloves and used same gloves all the time and when finished he wash his hand not according with hand washing protocol.

During performed the canalization procedure did not explain the procedure to the patients' daughter and he maintain uncommunicative. The nurse used his pocked to put the medical surgical materials gauzes, gloves, adhesive tape and the keys. The canalization catr was maintain on the interior of the patient room at all time.

b. The register nurse (employee #7) failed to establish effective infection control precautions to avoid widespread nosocomial infections.

c. The R.N #7 failed to follow agency's policies and procedures related to the patient canalization. Did not clean his hands according with appropriate standards of infection control, which pose risk of cross contamination.

d. The R.N #7 failed to follow agency's policies and procedures related to hand washing and failed to adequately set up the materials that he was going to use according with appropriate standards of infection control.

e. This patient room has three glass windows the base of the second windows lacked of tiles and the cement wall was exposed, small pieces of cement was observed and expose the patient to cross contamination.

f. On 5/11/17 at 9:10 a. m. it was observed on patient room #210 that a register nurse was administrating the medications however, she introduce the medication cart in the interior of the patient room.

g. On 5/09/17 at 2:55 p.m. on patient room #218 was observed opened and full biohazards trash can with exposed IV lines, gauzes, gloves and other biohazards materials which expose the patient, families and personnel with cross contamination.

10. The Operating Room Department was visit on 5/10/17 from 9:20 a. m. till 11:58 a. m. with Nurse Supervisor (employee #3), during the initial tour for infection control it was determined that the facility failed to ensure a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice for infection control (IC) related to the following observations:

a. During observations of the operating room area was observed that the Operating Room Department lacks of '' women 's and men's dresser " area for ambulatory patient's.

The Nurse Supervisor (employee #3) was interviewed and she stated: '' The department has a waiting room used to ambulatory patients and families, the day of the surgery the nurse enters the ambulatory patient from a door located in front of the waiting room, this door provide access to the '' women's and men's dresser '' used for the operating room personnel, however the same '' women's and men's dresser used for the operating room personnel were used for ambulatory patient's. The nurse supervisor stated that the area designated to ambulatory patients was not used approximately one year because they did not have personnel to cover this area. All of the operating room personnel and all of the ambulatory patient's used the same women's and men's dresser.''

a. Ten blood samples tubes of blue plug was identified expiated date was on April 30/ 2017.

b. On 5/10/17 from 9:20 a. m. till 11:58 a. m. according of the facility's policies and procedures establish that the relative humidity stay between 30 % and 60 % and the temperature stay between 68.0 ºF and 73.0 ºF. The daily temperature and humidity register log was reviewed from January to April of 2017 and reveled the following evidence:

- The daily temperature of the '' Operating Room '' from January to April of 2017 reveled that on suite #1, suite #2, suite #4, suite #5, medical surgical storage and central supply the daily temperature was maintain 30.0 to 79.2 ºF and was maintain twenty (20) to thirty one (31) days.

- The daily Humidity of the '' Operating Room '' from January to April of 2017 revealed that the humidity was maintain under the established parameters of 22 % or exceeded the established parameters up to 75%.

d. The facility provide evidence of the daily temperature and humidity log of the '' Operating Rooms, Medical Surgical Storage and Central Supply '' for year 2017, the form used on the facility department has a '' legend '' and established that if the personnel identified changes on the establishes parameters of temperature or humidity write the number two for temperature and number three for humidity and number four notify the engineer department and number five notify the Epidemiology nurse, however the daily temperature and humidity log provide evidence of the designated classification numbers but the facility did not provide evidence of the interventions which contains the date, the hour, the name of employee who intervenes to resolved the problem and if the employee verified the relative humidity and the temperature post intervention.

e. During observations of the Operating Room Department on 5/10/17 from 9:20 a. m. till 11:58 a. m. was observed that on the Operating Room Suite #1 at 10:10 a. m. the Temperature was on 67.1 ºF and the Humidity was on 63%, on Suite #2 the Temperature was on 65.5 ºF and the Humidity was on 54%.

On the Surgical room the Temperature was on 69.8 ºF and the Humidity was on 33% at 10:13 a. m. On the Medical Surgical Storage Room #3 at 10:15 a. m. the Temperature was on 65.3 ºF and the Humidity was on 64%. On the Operating Room Suite #4 at 10:18 a. m. the Temperature was on 67.1 ºF and the Humidity was on 60%. The temperature and humidity taken of all of the operating rooms suites, medical surgical room and medical surgical storage provide evidence that the daily temperatures and humidity exceeded the established parameters or was maintain under the established parameters.

11. The Intensive Care Unit was visit on 5/11/17 from 9:30 a. m. till 11:59 a. m. with Nurse Supervisor (employee #9) the following was observed:

The '' Utility Room '' located on the corridor near the patient's cubicles #4 and #5 lacks of identification label (rotulo de identificacion).


20423


12. During observation tour to the X-Ray Department with the acting supervisor (employee #11) on 5/12/17 from 9:30 am through 11:00 am it was found the following:

a. The floor near CT equipment area was observed with stains on the floor.
b. The area where the patient lies to perform the CT, has a transparent plastic cover that is broken and glued with tape, not allowing the cleaning between patients.
c. The mattress of the bed of the sonogram room # 1 was observed with the broken vinyl and tape in the area of the sonogram machine.

During interview with the acting supervisor of the X- Ray Department (employee #11) on 5/12/17 at 10:00 am he responded to the question if the mattress was cleaned after each procedure? " they cover the mattress with Stretcher paper but do not disinfected between patients".

Interview performed to the infection Control officer (employee #12) related to policy and procedure to disinfected the X-Ray (stretcher), they only have policy and procedure "protected with Stretcher paper between patient".



33356


13. During observational tour performed on 5/10/17 at 9:30 am accompanied by another surveyor, it was found that patient #19 was receiving an intravenous (IV) antibiotic. The medication was Clindamycin but it was observed that besides the spike that is introduced on the IV tubing port, the nurse introduced a needle in a manner that room air was in contact with the IV medication.

During interview with the Registered Nurse (employee # 19), she stated the following:
"The Clindamycin has to be administer with an IV line with filter but we do not have that (IV) line. I put the needle because it helps to take out air that is inside the vial and it allows that the medication falls to the drip chamber and it won't stop."

According to interview with the Pharmacist performed on 5/11/17 at 11 am, she stated the following: "The company that distributes the Clindamycin doesn't has available the IV line with filters. I ordered the medication through other company".

On 5/12/17 at 9:30 am an observational tour was performed to observe the administration of this IV medication and the IV line with filter was in use.

The facility failed to monitor the administration of this medication according to the manufacturer's guidelines.

The nursing staff failed to implement best practices of infection control to avoid cross contamination.

14. On patient's #19 room, it was observed on 5/12/17 at 9:30 am, an opened suction catheter inside the plastic cover hanging over the oxygen meter outlet. The secretions canister has content of a previous suction performed to the patient.

During interview with the Registered Nurse (employee #19), she stated: "The respiratory therapist is in charge of performing patient's suction. If he/she left that catheter there that means that the catheter will be reused. The Licensed Practical Nurse can empty the content of the canister, usually at the end of the work shift."

It was requested to see the availability of suction catheters at the unit medical surgical storage, accompanied by the Nurse Leader (employee #18) of the Medical Surgical A Unit.

During interview performed on 5/12/17 at 10:30 am, she stated: "We have availability of suction catheters. I do not understand why the therapist put that catheter behind the patient. In case that we do not have availability of any medical surgical materials we request it to the Nursing Director, the Nursing General Supervisors from 3pm/11 pm shifts or calling to the general storage staff at HIMA Caguas."

The nursing staff failed to monitor infection control measures used by other professional staff members.

15. During observational tour at the Medical Surgical A unit performed on 5/10/17 at 10:00 am accompanied by the Nurse Leader (employee # 18) it was found at the medications room that there are 4 medications carts and a refrigerator for medications. During inspection of these equipment's it was found that they were not clean. The medications carts were with dried residues of medications and pieces of transpore tape in different areas of these carts. Also it was observed, dark spots and rust.

The medications cart that serves medications at section B of the Medical Surgical A unit, has a back cover that is fixed with transpore tape.

During interview with employee #18 performed on 5/10/17 at 10:30 am, she stated the following: "The registered Nurses are in charge of cleaning the carts. They are supposedly to do it frequently. The facility has ordered new medications carts but we are waiting their arrival."

During the inspection of the medications refrigerator located at the medication room at the medical surgical A Unit accompanied by employee #18 it was observed dust and dark particles inside it.

It was requested to clean the 4 carts and the refrigerator immediately. However, a follow up inspection was performed on 5/11/17 at 2:00 pm and 3 of 4 carts were observed that were not completely clean.

The same situation was observed on 5/11/17 at 3:30 pm at the Nursery unit. They have a medications refrigerator and a breast milk refrigerator. Both were observed with dust and dark spots.

Policies and procedures (P&P's) were requested to determine the frequency of cleaning the refrigerators and who of the staff is in charge. However, the P&P's were not available to determine compliance.

16. The medications room at the Medical Surgical A Unit, it was observed an environmental thermometer hanging on the wall. However, it was not functioning. The Nurse Leader (employee #18) was not aware of the malfunction of this equipment, as observed during the observational tour.

The facility failed to develop a mechanism that watches compliance with the professional guidelines that rules the maintenance of the environmental temperature to keep medications and biological in good condition, according to the specifications established by the manufacturers. The nursing staff failed to perform surveillance and do the arrangements necessary to avoid cross contamination or damage to the medications.

17. On 5/11/17 at 10:00 am it was observed at the Intensive Care Unit that the medication cart was with residues of medications, dust and dark spots. In the medications room, below the sink, the surface of the cabinet was covered with dust and a huge brownish /dried water spot. No evidence was found of a cleansing and disinfection schedule to ensure a safety environment, avoiding cross contamination.

18. On 5/11/17 at 1:24 pm, during observational tour at the Pediatric Unit it was observed that it has available a transport case. It has medications and medical surgical equipment that are used to intervene with pediatric emergencies when a transfer to other facility is carried out. However, during inspection of the transport case, it was found the following:

a.Intravenous (IV) solution of 0.9 % Normal saline 250 milliliters (ml) has expired on February 2016
b. IV solution of 0.9 % Normal Saline 500 ml has expired December 2015
c. IV solution of Dextrose/0.45 Normal saline of 500 ml has expired on November 2015
d. Travel IV has expired on May 20125
e. Medical Surgical equipment, such as: feeding tubes of 5 and 8 frame (Fr), tracheal tubing of different sizes (2.0, 3.0, 3.5, 5.0 and 6.0), secondary IV lines, laryngoscope blades, 10 and 20 ml syringes;
their plastic covers were observed with brown and yellow spots indicating that time has passed an no one of the nursing staff changed that equipment for new ones.

It was reviewed the 2017 monthly registry for the medications and the medical surgical equipment where each month or as needed, the nursing staff has to write a check mark besides the item indicating if it is present or not. Since year 2016, the nursing staff has been identifying that the medical surgical equipment is present but they failed to open the case to verify the expiration dates or the conditions of the plastic covers of these items. If an emergency occurred, the nursing staff and the physicians were performing procedures with expired equipment.

The P&P for the uses of transport case was requested on 5/11/17 at 3:30 pm and it says the following:
a. step #2 indicates: The Registered Nurse that accompanies the patient is responsible of the transport case and when returns to the facility will verify that it is complete.

b. step #3 indicates: A monthly inspection will be performed for the medical surgical equipment , medications and intubing equipment using the Monthly Inspection Form for the Transport Case.

c. step #4 indicates: the Pharmacy services is in charge to verify the medications and the Registered Nurse will verify the intubation and medial surgical equipment.

The facility failed to perform an ongoing monitoring and surveillance activities to ensure that medical surgical equipment are secure and ready to be used if an emergency transfer is performed.

The nursing staff failed to follow the P&P's for the Uses of the Transport Case

Based on a validation survey, fifty seven active and close records reviewed, review of policies and procedures related to the Discharge Planning Program with the Social Worker/Discharge Planning (employee #9), it was determined that the facility failed to ensure that discharge planning personnel complete an evaluation and reassess the patients' needs on a timely basis for post-hospital care and are made before discharge to avoid unnecessary delays with the discharge for 6 out of 57 records reviewed (R.R #4, #11, #12, #13, #19 and #57).

Findings include:

1. A mechanism to ensure that the discharge planning process is complete assess and evaluated on a timely basis was not performed nor followed as found on 5/10/17 from 9:30 am till 4:00 pm: 9 out of fifty seven clinical record reviews the initial evaluation and assessment of Discharge planning was not performed during the first 48 hour of admission as described in the facility policies and procedure.

a. R.R #4 is a 77 years old female admitted to the facility on 3/3/17 with a diagnosis of Stage 4 Sacral Pressure Ulcer. During the record review performed on 5/11/17 at 3:28 pm, it was found that the patient died on 3/12/17 at 9:37 am and no evidence was found related to discharge planning evaluation.

b. R.R #11 is a 94 years old female admitted to the facility on 3/30/17 with a diagnosis of Septicemia, Bronchopneumonia and Myocardial Infart, Ischemic Heart Disease. During the record review performed on 5/11/17 at 10:09 am, it was found that the patient died on 4/3/17 at 1:39 pm and no evidence was found related to discharge planning evaluation.

c. R.R #12 is a 77 years old female admitted to the facility on 2/28/17 with a diagnosis of Pneumonia and Sepsis. During the record review performed on 5/11/17 at 12:00 pm, it was found that the patient died on 3/25/17 at 7:23 am and no evidence was found related to discharge planning evaluation.

d. R.R #13 is a 67 years old male admitted to the facility on 1/22/17 with a diagnosis of Right Leg Cellulitis, Congestive Heart Failure (CHF). During the record review performed on 5/10/17 at 3:55 pm, it was found that the patient died on 2/13/17 at 8:30 pm and no evidence was found related to discharge planning evaluation.

e. R.R #19 is a 85 years old male admitted to the facility on 5/5/17 with a diagnosis of Bronchopneumonia (BKP) by aspiration. During the record review performed on 5/10/17 at 1:30 pm, it was found that the patient was not evaluated by discharge planning. The record provide evidence that the registered nurse perform the initial assessment and history on 5/5/17 at 1:46 pm, the patient has gastrostomy, However this is one of the criteria to refer to discharge planning, No evidence was found that the RN notified or refer the case to the discharge planner services.

On 5/11/17 at 2:00 pm was the first intervention that the employee #9 had with patient son, after days of admission, not accordance to facility policy and procedure that state that discharge planning initial evaluation be performed between the first 24-48 hour of admission.

f. R.R #57 is a 66 years old male admitted to the facility on 2/4/17 with a diagnosis of Epileptic Stats. During the record review performed on 5/11/17 at 3:42 pm, it was found that the patient was discharge home and no evidence was found related to discharge planning evaluation.

Based on a validation survey, fifty seven active and close medical records reviewed (R.R) with the Social Worker/ Discharge Planning (employee #9) and review of policies/procedures and interview, it was determined that the facility failed to ensure that ongoing reassessments are performed and documented for patient's needs for factors that may affect continuing care for 2 out of 57 patients admitted to the facility (R.R #17 and #20).

Findings include:

1. A mechanism to ensure that the discharge planning process is reassessed on an on-going basis was not performed nor followed as found on 5/10/17 from 9:30 am till 4:00 pm; 2 out of fifty seven clinical record reviews did not reveal a re-assessment before discharge (R.R #17 and #20).

a. R.R #17 is a 39 years old male admitted to the facility on 4/25/17 with a diagnosis of Right Knee Septic Arthritis. During the record review performed on 5//10/17 at 11:00 am, it was found that the initial Discharge Planning assessment was performed on 4/26/17 at 11:30 am, the discharge planning identified need of physical therapy and need an walker. The next reassessment was performed on 5/2/17 six days later and the discharge planning documented that patient be evaluated by the physiatric and verificate if patient was continue with physical Therapy at home or in physician office. The discharge planning coordinate equipment service to a walker. The reevaluate in 5/5/17 the discharge planning documented that no have date to discharge, pending result of cultive, patient need a walker when the order was completed, the services was coordinated.
However the discharge planing not met with facility policy and procedure of discharge planning reevaluation that state that the reassessment was performed 72 hour after initial evaluation.

b. R.R #20 is a 82 years old female admitted to the facility on 5/4/17 with a diagnosis of Sepsis. During the record review performed on 5//10/17 at 2:00 pm, it was found that the initial Discharge Planning assessment was performed on 5/5/17 at 1:00 pm, the discharge planning identified need of home care with nursing service due to an ulcer. However, no evidence was found that the discharge planing performed re-assessment follow up.

Based on a validation survey, the review of facility policies/procedures and interview with the Discharge planning/ Social 'Worker (employee #9), it was found that the facility failed to include a complete list of Home Care (HHA), Hospice and Skilled Nursing Facilities (SNFs) that are available to the patient, in a geographic area in which the patient resides and failed to provide to patients with Advantage medical insurance a list of available Home Cares post-hospital extended care services that have a contract with the Advantage medical insurance and failed to document in the patient's medical record that the list was presented to the patient or to the individual acting on the patient's behalf for 57 of 57 active and closed records reviewed.(RR #1 through #57)

Findings include:

1. During interview with the Social Worker/ Discharge Planning (employee #9) she state on 5/11/17 at 2:00 pm that "I perform a discharge planning for all patients with Medicare and Medicare Advantage, through consult or by diagnosis, we prioritize patients with diagnostic of Cerebrovascular Accident (CVA), Ulcers and others. The referrals are seen in a 24-hour period; on weekends if patient need some coordination, the personnel call me to my personal phone. The facility do not pay me to stay in on call but the patient need the services. I'm the only one that performed the discharge planning and as Social Worker too.

After identifying the needs of the patient in the initial assessment we discuss the findings with the referring physician and the patient's medical insurance plan. The reassessment is performed 72 hour after the initial assessment. If the patient's need some service either Home Care / Hospice the patient is asked if he/she has any agency of their choice or had previously services. If the patient is a Medicare Advantage, the health plan is the one who assigns the agency that will provide services unless the patient wants a specific agency. I do not have a list of facilities contracted by the Medicare Advantage. But if the patient chooses a specific agency I write the patients choice on the Medicare Advantage referral so they can consider the patients ' choice.

2. The facility policies and procedure provided evidence related to a list of home cares, Skill Nursing, medical equipment companies and Hospices that provides post-hospital care services to patient with traditional Medicare medical insurance. However, no evidence was found that this list was provided to the patient. No evidence was provided on 5/11/17 at 2:30 pm related to a list of Home Care, Hospice and medical equipment company that have contract with the different Advantage medical insurance. The facility lack of a list of Home Care, Hospice, Medical Equipment and Skilled Nursing Facilities that the patient or their relatives can choose the preferred agency for them. No evidence was found on 57 out of 57 close record reviewed who choose the agency that is going to provide services to the patient.

Based on a validation survey, the review of documents and policies/procedures and interview with the Social Worker/ Discharge Planning (employee #9), it was determined that the facility failed to ensure that its discharge planning process is reassessed on an on-going basis.

Findings include:

1. The hospital's discharge planning process is integrated into its Quality Assessment and Performance Improvement Program as reviewed on 5/11/17 at 2:30 p.m, however, they only report statistic related to percent of patient referred to home care, hospice and skilled nursing facilities.

2. No evidence was found on 5/11/17 at 2:30 p.m., of an ongoing mechanism to reassess its discharge planning process.

Based ona validation survey, fifty seven records review (RR) and the review of policies and procedure performed during recertification survey from 05/09 thru 05/12/17 it was determined that the facility failed to follow the policies and procedure for notifications of patients death as required for Organ, Tissue and eye Procurement Program as evidence on 3 out of 57 records reviewed (RR#42, RR#43 and RR#51)

Findings include:

1. RR #51 is a 68 year old male patient with a diagnostic of cardiorespiratory arrest. On 5/11/17 at 1:45 pm it was identified that the patient was pronounced dead on 12/12/16 at 7:30 pm, at 7:31 pm the ward clerk call the for Organ, Tissue and eye Procurement agency and notified the patient death, no Register nurse signature was found on the for Organ, Tissue and eye Procurement refer as required by the facility policy and procedure 001item 3 letter c.

The facility fail to follow their policies and procedure for notifications of death.

2. RR #42 is a 22 year old male patient with a diagnostic of drug intoxication and cerebral trauma. On 5/11/17 at 1:55 pm it was identified that the patient was pronounced dead on 06/11/16 at 12:00 pm, at 12:00 pm in Organ, Tissue and eye Procurement refer is written that the hospital notified the patient death, no name of the person notifying the death or Register nurse signature was found on the for Organ, Tissue and eye Procurement refer as required by the facility policy and procedure 001item 3 letter c.

3. RR #43 is a 71 year old male patient with a diagnostic of Trauma. On 5/11/17 at 2:15 pm it was identified that the patient was pronounced dead on 01/07/16 at 10:00 pm, at 10:03 pm the ward clerk call the for Organ, Tissue and eye Procurement agency and notified the patient death, no Register nurse signature was found on the for Organ, Tissue and eye Procurement refer as required by the facility policy and procedure 001item 3 letter c.

Based on a validation survey, observation Director of Nursing (DON) (employee # 1) on 5/10/17 at 9:15 am it was determined that the facility failed to prevent patients from harm. This constitute an Immediate Jeopardy to 5 out of 5 patients admitted at the facility.

Findings include:

During the observational tour performed on 5/10/17 at 9:15 am it was observed in the ER Department the following:

1. A room in the back of the ER Depatment identify in the wall Intravenous Medication Room "Cuarto de Medicamentos Intravenosos".
2. It was observed with 6 lounge chairs with less of separation between of12 inches.
3. The room does not have nurses call system installed.
4.The room also had a bath room without nurses call system too.

It was determined that the facility failed to prevent patients from potential harm related to failure to provide care and supervision related to the lack of nurses call system on a treatment area.

On interview with the DON, Medical Director and ER nurse supervisor on 5/10/17 at 10:49 am until 11:10 am revealed that the intravenous medication area has less that one year. They did know that the bathroom did not have nurses call system. But they knew that the chairs did not have the nurses call system.

The facility's correction plan (POC) was received on 5/10/17 at 4:40 pm.

Immediate Jeopardy Situation Identified 05/10/2017

Specific Corrective Actions

1. Intravenous Medication Room will be closed for changes until 5/12/2017
2. Immediate elimination of three (3) lounge chairs in the Intravenous Medication room to allow for the required separation of at least 12 inches between patients. Support Services Director will be in charge of this movement and should be completed by 05/10/2017.
3. Installation of a nurse call notification system in the Intravenous Medication Room besides each lounge chair. Support Services Director will be in charge of the installation of the electric nurse alert system by 5/12/2017.
4. Immediate acquisition of manual bells to established a manual nurse alert system. Nurse Director will be in charge of providing manual bells and should be available at site by 05/10/2017. Manual bells will be available as an alternate measure.
5. Bathroom electric alert system will be install by 5/12/2017. Support Services Director will be in charge of this installation.

The facility's correction plan (POC) was evaluated and accepted on 5/10/17 at 4:45 pm.

Based on a validation survey, observation tour at the emergency on 5/10/17 at 09:40 am it was determined that the facility failed to post the EMTALA signs in the entering of the emergency department.

Findings include:

On 5/10/17 at 9:40 am during the observational tour of the emergency rooms it was observed that the facility did not have EMTALA signs on the entrance of the emergency room as required by EMTALA regulation