HospitalInspections.org

Based on administrative documents review accompanied by the Nursing Supervisor (employee #2) performed on 3/30 and 3/31/15 from 9:00 am thru 5:00 p, it was determined that the facility failed to provide an actualized phone directory where patients can call to place a grievance.

Findings include:

1. During documents review performed on 3/30/15 at 2:30 pm and as part of the admissions process, there is a brochure that is given to the patient and/or representative. In it, is included the management of grievances with some telephone numbers of certain agencies. However, some of these phone call numbers are not updated such as: Medicare direct phone number, Medicare Toll Free phone number and the TTY phone number (for deaf people).

Based on 36 records review (RR), interviews with two patients (#20 and # 26), the Nursing Supervisor (employee #2) and the Registered Nurse (RN employee #3) and policies and procedures (P&P's) review performed during survey process on 3/30 and 3/31/15 from 9:00 am thru 5:00 pm it was determined that the facility failed to ensure that Medicare beneficiaries have knowledge of the appeal process in case of a premature discharge, as observed in 3 out of 36 records review (RR #20, #26 and #28).

Findings include:

1. As part of the appeal process, the facility has the " An Important Message from Medicare " (IM) form that each Medicare patient has to know and sign as part of his/her Rights. During observations performed at the admissions office with the Intaker, the IM is available and is discuss with the patient and representative during the admission's process.

During RR #26, #20 and #28 performed on 3/30/15 at 10:45 am accompanied by the Nursing Supervisor (employee #2) it was found that patients signed the IM during the admission process.

According to interview with the Intaker (employee #4) performed on 3/30/15 at 9:15 am, she stated: " The Important Message is discussed with the patient or family member during the admission's process. It is signed by one of them and I give them a copy. The original form is kept in the clinical record." When the surveyor asked if this form is given to the patient or representative in another moment during the hospitalization the Intaker answered: " You have to ask the nursing staff because they discuss the discharge process to patients and family and I do not remember if this Medicare form is given at the discharge home process".

According to interview performed separately to the Nursing Supervisor (employee #2) and RN (employee #3) on 3/30/15 at 10:00 am and 10:30 am it was determined that the IM is not discussed with the patient or representative at least 48 hours prior to the discharge of the patient. As observed, the IM is not available at the nursing station.

Patients #26 and #20 were interviewed separately on 3/30/15 at 11:00 am and 11:30 am and both patients answered that is the first time that someone explain them the appeal process. Each of them recognize that on the admission's process they signed the IM but if they want to appeal their discharge they do not know the process nor know that have to sign the IM 48 hours prior the discharge home.

2. The facility failed to ensure that Medicare patients know the appeal process and that there is an Important Message Form that has to be discussed at least 48 hours prior to the discharge home.

Based on 36 records review, interviews with the Evaluating Physician (employee #5), Registered Nurse (RN, employee #3) and the Intaker (employee #4) policies and procedures (P&P's) review, performed during survey process on march 30 and 31, 2015, it was determine that the facility failed to have available the Do Not Resuscitate (DNR) Protocol for the medical staff.

Findings include:

1. The Advanced Directives Consent that is discussed to the patient or representative during the admission process establishes patient's desire to prolong life in case that patient's healthcare condition is worsened. The patient has to write a check mark besides his/her desires, such as: I desire:
a. Cardiorespiratory Resucitation
b. Intravenous solutions if they are needed
c. Nutrition by nasogastric tube
d. Blood transfusions or derivates
e. Organ donation

2. If patient writes a check mark besides I do not want cardiorespiratory resuscitation, the Advanced Directives consent has instructions that establish that the DNR protocol has to be documented. However, it was found the following issues:

a. The DNR protocol was not available at the admission office nor the nursing station.

According to interview performed on 3/31/15 at 11:00 am to the Intaker (employee #4), who is responsible of interviewing the patient or representative during the admission process at the registry office, stated: "This Advanced Directives consent is discussed during the admission process to the patient or family member but I don't know about the DNR protocol. Maybe the physician knows about it".

According to interview to the Evaluating Physician (employee #5) performed on 3/31/15 at 10:30 am, she stated : "By my experience here, patients or their representative approve the cardiorespiratory resuscitation procedures if their health condition is worsen during the hospitalization process. I don't know about the DNR protocol or where are the forms. If a patient refuses the CPR I write his/her desire on my progress notes and the nursing staff is notified as well the patient's Psychiatrist". When the protocol was shown to employee #5 she stated: " Is the first time that I see this protocol".

According to interview performed to the RN (employee #3) performed on 3/31/15 at 11:30 am, she stated: " That consent is discussed by the Intaker at the admission's process. I don't have the DNR protocol here at the nursing station. The physician is responsible to discuss and obtain patient's consent". However, it was determined that the physician does not explain the Advanced Directives Consent to the patient or representative.

3. The facility failed to ensure that the Evaluating Physician discuss the Advanced Directives Consent to the patient or representative during the admissions process. The facility does not ensure that the medical staff has knowledge of the DNR Protocol and its implementation.

Based on observations made during the physical environment tour with the two facility's physical plant employee (employee #7) and (employee #8), Facility engineer (employee #6) and Nurseing supervisor (employee #2) performed on 3/30 through 3/31/15 from 9:00 am thru 5:00 pm, it was determined that the facility failed to promote patients' rights related with personal privacy during patient's sleep and dressing time, for 9 out of 35 patients at this unit.

Findings include:

1. During observations at the psychiatric ward with the two facility's physical plant employee (employee #7) and (employee #8), Facility engineer (employee #6) and (employee #2) performed on 3/30 through 3/31/15 from 9:00 am thru 5:00 pm, on rooms # 102, # 108, # 110, # 112, # 113, #114 and # 121 it was observed that the protective paper placed over the windows providing privacy to patients, are broken and damaged and allows that patients activities like sleeping or dressing can be seen by unauthorized people from the outside. The facility failed to ensure patients' privacy during dressing and sleeping time.

Based on interviews to the Evaluating Physician (employee #5), Nursing Director (employee #1), Nursing Supervisor (employee #2), the Registered Nurse (RN, employee #3) and policies and procedures (P&P's) review, performed during survey process on March 30 and 31, 2015, it was determine that the facility failed to establish the chemical restraint observations and interventions in the Institutional Restraint Protocol.

Findings include:

1. During documents review performed on 3/31/15 at 1:00 pm and discussed with the Nursing Director (employee #1), it was found that the Chemical Restraint procedures were not included in this protocol.

a. It was not found a definition for chemical restraint.

b. It was not found observations that the staff of mental health has to do when a patient receives medication to control their aggressive attitude.

c. No interventions were established to manage a patient if shows adverse reactions to a medication.

According to interview to RN (employee #3) performed on 3/30/15 at 10:45 am, she stated: "Before putting the physical restraints on the patient we start the process with less restrictive methods such as: therapeutic communication, sending him/her to the indoor yard so he/she can be calm, or looking for activities that the patient likes and decrease his/her anger. If these methods are not functioning, we call the physician and he/she order medications. They usually order a combo of medications: Haldol, Benadryl and Ativan. There are other medications such as Thorazine with Ativan or Geodon. After administering these medications, we keep the patient in his/her room because the combination of medications can cause sleepiness. We can implement the 1:1 surveillance and every 15 minutes the Mental Health Technician observes and evaluates the patient. If patient continues with a hostile attitude, then the physician considers the physical restraint. If the physician order seclusion we use room number 114 and we keep the direct surveillance, we document our interventions and keep the physician notified".

According to interview performed to the Nursing Supervisor (employee #2) performed on 3/30/15 at 9:30 am, he stated: "We initiate the restraint protocol with less restrictive methods. The physician orders the physical restraints and selects what areas should be restraint (wrists or ankles or both). As per protocol we implement the 1:1 surveillance and the Mental Health Technician is in charge of performing this surveillance. The RN can participate on this surveillance and he/she has to document his/her interventions. If patient turns aggressive, they (nursing staff) call the physician and with a face to face evaluation (the physician) order the medications. We have to observe for allergic reactions and if patient shows it we have to write an incident report. The Evaluating Physician makes a physical check and order medications. As soon a patient has an order for restraint, we have to document an incident report and it is sent to the Quality Program."

According to interview with the Evaluating Physician (employee #5) performed on 3/30/15 at 10:45 am, she stated: "Before ordering the antipsychotics, I call the Psychiatrist to consult the medications for chemical restraint. The nursing staff and I keep observations over the patient and we have to write on the clinical record. If patient shows adverse reactions to a specific medication I order medications that stop the adverse reaction".

2. The facility failed to describe the chemical restraint on the Restraint Protocol with the medications that are recommended by the medical staff and to include the observations and interventions that the mental healthcare personnel has to follow.

2. During interview the X Ray Supervisor (employee #12) on 3/31/15 at 2:00 pm related to the X Ray quality assurance activities plan it was identified that the X Ray department is a contracted services and were not included as part of services to be submitted as quality indicators data in order to evaluate the performance of the services during the year 2014.

According with the X Ray Supervisor (employee #12) she has more functions on this department that include, takes patients ' X Ray, the department did not have secretary, only has three technicians and three contracted technicians that covered with per-diem when as needed.

She referred to identify issues but did not develop quality activities necessary to develop and implement appropriate plans of action to correctly when identify quality deficiencies including monitoring the effects of implemented changes.




33356


Based on administrative documents review accompanied with the Nursing Director (employee #1) and policies and procedures (P&P's) review, performed during survey process on March 30 and 31, 2015, it was determine that the facility failed to ensure that procedures of the Restraint Protocol are included on the surveillance data sheet for the restraint indicator.

Findings include:

1. During the review of the restraint indicator data sheet with the Director of Nursing (employee #1) performed on 3/31/15 at 1:30 pm it was found that some procedures of the restraint protocol were not included on the data sheet, in a manner that the Quality Improvement Program Coordinator can determine if the employees comply with the implementation of the restraint protocol. The steps of the Restraint Protocol that are missing are:

a. Chemical restraint observations and interventions

b. Less Restrictive Methods (1:1 surveillance, therapeutic communication, noise and sensorial incitement limits, encourage patient's participation in recreational activities, to take a bath, time out, etc.)

c. Face to face evaluations by the Physician, RN and the Mental Health Technicians

d. Restraint Method ( Location: at designated room, seclusion room, at Stabilization Unit), if patient is in supine position, restraint points (wrists, ankles or both)

e. To provide passive movements while patient is on restraint and to perform changes positions every 2 hours to avoid circulatory deterioration, to perform massages on restraint points.

f. Physician's reevaluation every hour while patient is kept on restraints.

e. Removal of physical restraints in a diagonal pattern.

f. Documentation of patient's improvement related to his/her attitude.

g. Physician's order for discontinuing the restraint method.

Based on the interview with the Infection Control Officer (Employee #10), it was determined that the facility failed to ensure that the quality program performance improvement activities track adverse patient events related to infection control.

Finding included:

1. On 3/31/2015 at 10:43am on interview Employee#10 state that she did not have evidence of the problems identified on the infection control program are addressed on the QAPI program. The facility did not have minutes for Infection control discussion. No evidence was found related to collaboration between quality program and infection Control Officer to identified and track avoidable health care - acquired infection.
Facility failed to ensure that the quality program performance improvement activities to track adverse patient events related to infection control.

Based on the review of eleven medical staff credential files, it was determined that the facility failed to examine credential files (C.F) to ensure that medical staff have updated Health Certificates, Hepatitis Vaccine, Influenza Vaccine, Mal Practice Insurance and Penalty Antecedent for 3 out of 11credential files reviewed (C.F #5, #6 and #11).

Finding includes:

1. During the review of eleven medical staff credential files on 3/31/15 from 10:30 am till 11:00 am with medical faculty clerk the following was found:

a. Two out of eleven medical staff credential files did not provided evidence of Health Certificates (C.F #5 and C.F #6).

b. One out of eleven medical staff credential files did not provided evidence of Hepatitis Vaccine (C.F #5).

c. Three out of eleven medical staff credential files did not provided evidence of Influenza Vaccine (C.F #5, #6 and #11).

d. One out of eleven medical staff credential files did not provided evidence of Mal Practice Insurance (C.F #6).

e. One out of eleven medical staff credential files the Mal Practice Insurance expired on 2/28/2015 (C.F #5).

f. One out of eleven medical staff credential files did not provided evidence of Penalty Antecedent (C.F #6).

Based on medical record review, policy and procedure review with the Nursing Director (DON) employee #1, it was determined that the facility failed to ensure that nursing staff developed, implemented and keeps current patient care plan accordance to patient needs for 4 out of 36 records review. (R.R. #21, #33, #34, #36)

Finding included:

1. R.R. #21 is a 38 years old female, admitted on 3/25/15 with a diagnosis of Psychosis. During the record review performed on 3/.30/15 at 10:47 am it was found that the registered nurse developed patient plan of care for Falls level I prevention, Developed of suicidal idea or evidence, Anxiety, and Discharge planning on 3/26/15.

The facility policy and procedure for Nursing Plan Of Care (Plan de Cuidado de Enfermería) reviewed on 3/30/15 at 11:00 am refer item #1 that nursing personnel initiated the plan of care in the first 8 hour of admission. (El profesional de enfermería será responsable de iniciar el Plan de Cuidado las primeras 8 horas de la admisión). Items #5 patient plan of care was evaluated daily and compared with the objetive to determine the reaching (Se evaluara diariamente el plan comparándolo con los objetivos para determinar si se alcanzaron). Items #6 the plan of care was modified accordance to patient needs (Se modificara el plan, de ser necesario, de acuerdo a las necesidades del cliente). Items #7 the documentation of intervention of the plan of care was clear, conscious and understood (Las anotaciones en el plan de cuidado serán claras, concisas y fáciles de entender).

Patient plan of care was reevaluated more than daily on 3/29/15, 72 hours after initiated, not accordance to facility policy and procedure.

Accordance to the nursing documentation performed on 3/26/15, 3/27/15, 3/28/15, 3/29/15 and 3/30/15, no evidence was found that nursing personnel implemented the plan of care as developed at admission.

On 3/26/15 at 3-11 shift the nurse documented that patient request a Chaplain (Capellán) and she needs a prayer for her, however no evidence was found the facility effort to satisfy the patient spiritual needs.

2. R.R. #33 is a 35 years old male, admitted on 3/25/15 with a diagnosis of Detox multiple substance. During the record review performed on 3/30/15 at 10:00 am it was found that the registered nurse developed patient plan of care for Falls level I prevention, Developed of suicidal idea or evidence, Anxiety, and Discharge planning on 3/26/15.

Patient plan of care was reevaluated more than daily on 3/28/15, 48 hours after initiated, not accordance to facility policy and procedure.

Accordance to the nursing documentation performed on 3/26/15, 3/27/15, 3/28/15, 3/29/15 and 3/30/15, no evidence was found that nursing personnel implemented the plan of care as developed at admission.

3. R.R. #34 is a 39 years old male, admitted on 3/26/15 with a diagnosis of Mayor Depression. During the record review performed on 3/30/15 at 11:20 am it was found that the registered nurse developed patient plan of care for Falls level I prevention, Developed of suicidal idea or evidence, Anxiety, and Discharge planning on 3/27/15.

Patient plan of care was reevaluated more than daily on 3/29/15, 48 hours after initiated, not accordance to facility policy and procedure.

Accordance to the nursing documentation performed on 3/27/15, 3/28/15, 3/29/15 and 3/30/15, no evidence was found that nursing personnel implemented the plan of care as developed at admission.

4. R.R. #36 is a 50 years old male, admitted on 3/26/15 with a diagnosis of Mayor Depression. During the record review performed on 3/30/15 at 2:41 pm it was found that the registered nurse developed patient plan of care for Anxiety on 3/25/15, Falls level I prevention on 3/26/15, Developed of suicidal idea or evidence, and Discharge planning on 3/27/15.

Patient plan of care was reevaluated more than daily on 3/29/15, 48 hours after initiated, not accordance to facility policy and procedure.

Accordance to the nursing documentation performed on 3/27/15, 3/28/15, 3/29/15 and 3/30/15, no evidence was found that nursing personnel implemented the plan of care as developed at admission.

Based on the observational tour of the medical record department, interview with the Medical Record Director (employee #11), and the incomplete medical record report review it was determined that the facility failed to complete records within 30 days following the patient discharge.

Findings include:

1. The incomplete medical record report was reviewed with the Medical Record Administrator on 3/31/15 at 4:00 pm revealed that the facility did the report for the year 2014 for the month of August and September 2014 and reveal there are 263 incomplete records by the medical staff and 1,727incomplete records by the Nursing staff and Mental health Technicians for those two month. The facility did not have a report for the months of January to July 2014 and for the months of October to December 2014. On 3/31/2015 at 4:10 pm employee # 11 state that they have for the year 2014 only the months of August and September. Facility did not known how many records from the incomplete medical record report were completed.

2. For the year 2015 the incomplete medical record report reveal on January 2015 there are 118 incomplete records by the medical staff and 256 incomplete records by the Nursing staff and Mental health Technicians. For February 2015 there are 35 incomplete records by the medical staff and 133 incomplete records by the Nursing staff and mental health Technicians. Facility did not known how many records from the incomplete medical record report were completed.

3.Facility fails to ensure the prompt completion of the incomplete medical records.

Based on observations during the tour on the record department on 3/31/15 at 2:40 pm with the Medical Record Supervisor (Employee #11), it was determined that the facility failed to ensure that medical records are filed under proper conditions.
Finding includes:
1. During the tour on 3/31/15 at 2:40 pm with Employee #11 four wood pallets were found on the record room floor with multiples medical record boxes stack up. On employee #11 office it was found one wood pallet with medical record boxes. The record boxes from the facility were mixed with the " Centro de Diagnostico y Tratamiento " Diagnostic and Treatment Center (CDT) record boxes.
2. Facility fails to ensure that medical records are filed under proper conditions.

3. R #9 is a 46 years old male admitted on 2/5/15 at 11:30 p.m. with diagnosis of Suicidal Attend, the record was reviewed on 3/31/15 at 3:50 p.m and the following was reveled:
a. The patient was admitted on 2/5/15 and discharge to home on 2/10/15 and the preliminary plan of treatment lacks information related to identified and individualized the patient problems and the goals, the objectives and intervention. Failed to provide evidence of the nursing signature on the patient treatment plan. Lacks of the date when the nurse initiate the treatment plan.
b. The emergency room admission form performed by the nurse lacks of nursing diagnosis, the nursing signature and the nursing professional license.
c. The physician ordered a nutritional consult on 2/6/15 at 1:00 pm. The nutritional estimate risk was performed on 2/6/15 at 9:00 pm by the physician and accordance of the evaluation identified the patient with '' disturbance of nourishment conduct '' and classify on level nutritional risk. The patient was discharge on 2/10/15 and no evidence of nutritional evaluation.
d. The record revealed that the physician ordered vital signs every 8 hours however no evidence was found of vital signs on 2/6/2015, 2/7/15 and 2/8/15 during the three nursing shifts and on 2/9/15 on shift 7:00 am through o 3:00 pm. and 3:00 pm. through 11:00 pm.
e. The evaluation and treatment consent form performed on 2/6/15 lacks of information related to patient name, age, address, secondary effects of medications used per patient, patient representative tutor name and signature and telephone number.
f. The form " Cernimiento de Tuberculosis " Tuberculosis Screening performed on 2/6/15 lacks of information related to if the patient has a diagnostic of tuberculosis previously.
g. The certification form of '' Instrucciones Medicas Anticipa das'' Advance Directives did not have the patient name and lacks information related to if the patient desire or not desire ''impartir'' do advanced instructions.




33356


Based on thirty six records review (RR) performed on 3/31/15 at 4:00 pm during the survey process, it was determined that the facility failed to ensure that the clinical record has all pertinent documentation related to observations and interventions provided to the patients, as observed in 2 out of 36 records review (RR #9 and #10).

Findings include:

1. During RR # 10 performed on 3/31/15 at 4:00 pm it was found that the Registered Nurse (RN) in charge of patient's care did not complete the nursing plan for Discharge Planning. The RN failed to identify the Nursing diagnose on the first column of the plan, failed to individualize the goals and failed to identify the interventions that has to perform.

2. On the New Individualized Treatment Plan the interdisciplinary team that had interventions with the patient has to write his/her goals, interventions and the form allows to write patient's improvement or decline. However, it was found that the interdisciplinary team discussed patient's plan of treatment on January 6th, 2015 but no evidence was found of the participation of the Psychiatrist and the Recreational Therapist.

Based on review of documents with the Director of the Pharmacy Department and interview, it was determined that the facility failed to provide Pharmacy Services in accordance with acceptable professional standards related with lack of mechanisms to ensure that investigational medications are safety controlled and administered, to assess cases who are receiving medications who had the potential of increase its effect and toxicity and to document perceptions of the patients about drug side effects.

Findings include:

1. Written policies and procedures who guide pharmacy services at the facility accordingly with Federal and State laws and regulations, and in accordance with applicable standards of practice were reviewed on 3/30/11 from 1:00 pm though 3:01 pm with pharmacy director (employee #15) the following was identified during the review:

a. Facility did not have in place a mechanism process and policy to ensure that investigational medications are safety controlled and administered. Procedures for the management of cases who are participating on investigational medications and trials were not developed not included as part of pharmacy policy and procedure manual.

b. For the management of cases who are receiving medications that require to asses therapeutic levels of the drug on blood; facility did not have in place a mechanism process and policy.

The Pharmacist (employee # 15) stated on interview on 3/30/15 at 1:00 pm that therapeutic blood /plasma concentration levels are taken only to patients who are using Coumadin and Lithium. A complete assessment or guide to evaluate therapeutic level and status of patients who are using Phenytoin and Phenobarbital or Depakene ( Valproic Acid ) were not developed, not included as part of facility mechanisms to assess in cases who are receiving medications who had a potential of increase its effect and toxicity.

c. Facility had in place a mechanism to educate patients about the medications that are ordered while receiving services and care at the facility. This education was provided by the pharmacist; who give each patient ' s written information related with the medications ordered by the physicians. After the education pharmacist document the information provided in form that are included in the patient medical record. However this form does not include items to be document related with the perceptions of the patient about drug side effects and when appropriate perceived efficacy.

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

Findings include:

1. During the initial observational tour with the pharmacist (employee #15) on 3/30/15 from 10:15 am though 11:58 am the following was found:

a. Facility had a night storage cabinet at the " Centro de Diagnóstico y Tratamiento " Center for Diagnostic and Treatment area who are located on the same building than the hospital. The night storage cabinet contains medication to be used if necessary, on the psychiatric hospital area in the event of a new admission or orders when pharmacy is closed after 5 pm from Monday through Fridays and on Saturdays and Sundays. The cabinet is located on a room near the general nursing supervisor office. On this room it was observed several plastic drawers who contain the medications inside, in the area it was observed a refrigerator who contains medication that need to be refrigerated.

b. A lot of medical surgical materials and paper forms to be used in the medical record documentation were observed storage on the same area. The room was closed by a door that had a lock. However medications located on the area are exposed to persons who are looking for medical surgical materials and medical record paper forms. The facility failed to ensure safe storage of drugs and to protect these medications from non authorized persons.

The Pharmacist (employee # 15) stated on interview on 3/30/15 at 11:40 am that only nursing supervisor personnel are authorized to gain access to this area. However it was explain to her that areas that had storage medications must be kept secure locked and separate and used only for this purpose.

Based on the kitchen observational tour, review of policies/procedures and interviews, it was determined that the facility failed to store, maintain and prepare food in a safe and sanitary manner related to the failure to have in place procedures to ensure the appropriate use of wiping washcloths and scrub sponges on the kitchen area.

Findings include:

1. During the kitchen observational tour performed with the dietitian (employee #14) on 3/30/15 from 3:00 pm till 4:00 pm, the following was observed:

a. Several wiping wash clothes are observed over stainless steal tables in the kitchen and inside a white little bucket of water under the three compartment sink area.

Dietitian (employee #14) stated on interview on 3/30/15 from 3:10 pm that those cloths are use to wipe things up to around the kitchen and were discarded every day.

b. No policies were available to review regarding the use disinfection and management procedures for the cloths in the kitchen as required by the FDA Food Code Chapter 3.

c. Two scrub sponges are observed located at the side of the three compartment sink area.

Dietitian (employee #14) stated on interview on 3/30/15 from 3:15 pm that those sponges are only used to do the big pots and pans that do not go into the dishwashing machine.

d. No policy was available to review regarding the type of material of the sponges and the areas were personnel could use the scrub sponges in the kitchen as required by the FDA Food Code Chapter 3.

Based on observation, interview and review of policies/procedures made during the validation survey for the physical environment with the two facility ' s physical plant employee (employee #7) and (employee #8), Facility engineer (employee #6) and Nursing supervisor(employee #2) performed on 3/30 through 3/31/15 from 9:00 am thru 5:00 pm, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well-being of patients receiving services related to all maintenance closets found unlocked, venopuncture chair broken, night tables, emergency call system, faucets in toilets rooms and, peeling paint was found in patient's rooms, a puddle of water was found under sink on patient ' s bathroom, patient's bed, ceiling acoustic tiles with water damage, window without proper privacy , moldy windows and ceiling in patient's rooms,.

Findings include:

1. Two bathrooms in the admission area were visited on 3/30/15 at 9:50 am and provided evidence that the faucets of the hand sinks do not function well. Only cold water is available. Also, the bathroom accessories are cover with rust and green mold. Both bathrooms do not have emergency call system installed.

2. Water cooler located at the admission area does not have the cover in the nozzle. This missing part can cause an accident. Also this missing part exposed the area where the water crosses and can cause a cross contamination at the moment person is drinking water.

3. All the air conditioning ducts grills located throughout the facility are covered in rusty.
4. The sink located at the triage area does not have hot water.

5. Door frames in the admission and triage area cover with rust.

6. The venopuncture chairs located in the phlebotomy area was observed on 3/30/15 from 10:30 am. The chair was cover with tape and it is starting to crack.

7. All the shelves are wooden in the medical supplies room. Also this room does not have a thermometer to maintain the correct temperature and relative humidity.

8. The night tables and beds in all patients rooms are deteriorated and peeling off.

9. The emergency call system located in patients bathrooms are covered with rust. Test was performed and nurse has problems to turn it off.

10. The bathrooms located in patient's rooms #3 and #6 in the nursing unit were observed on 5/13/09 from 1:45 pm till 1:55 pm and provided evidence that they did not have toilet seats and the toilet in room #3 did not work.

11. The dirty and clean linen closet does not have exhausted fan, smoked detector and fire extinguisher. All the shelves are wooden.

12. The nursing station was visited on 3/30/15 at 11:50 am and it was found rubber base were detached from the walls. Walls covered with dirt and peeling paint. The sink located in counter on front the medication room with old soap stuck.

13. Peeling paint was observed on 3/30/15 from 11:00 am through 2:00 pm in patients ' rooms #101, #102, #105, #106, #107, #108, #110 and # 115. Peeling paint in side wall from the hallway area A.

14. A puddle of water was found next to the toilet in patient's room #110 on 3/30/15 at 11:57 am water comes out from the bottom of the toilet. Also an uncovered hole on the ceiling was observed. This hole is from the exhausted fan. Missing exhaust fan.

15. Exhaust fan cover from bathroom of patients room # 104 is broken.

16. Faucets of the sink in patients ' room # 101 it is not functioning properly cause do not have enough water pressure and do not comes out. Room #106 left handle of the faucet does not work. Patients do not have hot water in the wash basin. Room #109 is loose from the hand sink. #111, #114 and # 122 faucets do not function. Room #115 it was observed that water was running from the hand sink faucet because it cannot close.

17. Kitchen area was observed on 3/30/15 at 11:50 am and the following was found:

a) The rubber around the miscellaneous freezer door is broken and loose.
b) Floor tiles under the 3 compartment sink have rust and white scum.
c) Wall tiles are covered with old dirt and mold on the grout.
d) Floor tiles beside the stoves with dirty embedded.
e) The food line service has all the insulation broken.
f) Missing and broken acoustical ceiling tile in kitchen employee bathroom.
g) Missing rubber base and dirt embedded on floor tiles in the Dry storage.

18. The ceiling acoustic tiles in the locker room, pantry, medical office, stabilizer area " Sala Estabilizadora " and kitchen were observed on 3/30/15 from 11:00 am until 2:00 pm with water damage and broken ceiling tile.

19. During the physical environment on 3/30/15 at 9:50 am it was observed in the admission area bathrooms do not have emergency call system.

20. The intercom in front room #114 is broken. This room is use for patients in seclusion.

21. On the stabilized room " Sala Estabilizadora " bathroom does not have emergency call system installed.

22. The door lock of patient room # 110 is loose.

23. All patients room entrance door was observed with dirt and peeling paint.

24. The windows in patient's room #102, #110, #112, #113, #114, #119, #121 and #122 was observed on 3/30/12 at 11:30 am through 1:30 pm that the paper providing privacy to the windows patients are broken and damaged and allows the patient was look from the outside. On room # 117 windows has an old white spot of glue from a sticker. The window from room #102 was observed scrapping and written.

25. The windows frames in the patients ' room #102 through #124 at the bottom it is covered with green mold and yellow spots cause by the sitting water and humidity.

26. All patients bathroom doors and frame was observed rusty and peeling paint.

27. Electric generator located at the back of the hospital is installed on a concrete pad but it is not protected or isolate by a fence to prevent accidents. Employee cars were observed parking at least 30 feet near to the generator. The area lacks of signs indicating caution, smoking etc.
28. All patients room ceiling was observed with black mold on it.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the two physical plant employee (employee #7) and (employee #8) , it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed from 3/30/15 through 3/31/15 from 9:00 am until 5:00 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0027, K0046, K0048, K0050, K0051, K0075, K0104, K0106, K0130, K0144 and K0147).

Based on tests performed on equipment and observations made during the survey for the physical environment with physical plant employees (employee #7 and #8), facility's Engineer( employee #6) , it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff related to the bathroom in the admission area, " Sala Estabilizadora " , the nursing counter of the treatment area and in the medication area is not appropriately designed, the patients rooms and bathroom requires cleaning and maintenance, dirty linen closets do not have extractors, medical record department is not protected from fire the facility is not performing annually bacteriological tests to the cistern.

Findings include:

1. The maintenance closet was found dirty, mops and brooms were placed with the mop and broom up against the wall and the poles on the floor, the door was found unlocked and no exhaust fan was found in this room.

2. In the clean and dirty linen storage closet, wooden shelves and two electrical panels were found and this closet did not have an extractor, extinguisher and smoke detector.

3. The walls in patient's room were found with peeling paint.

4. The floor tiles in patients ' rooms were found chipping and dirty.

5. The medical record department was visited on 03/31/15 at 2:05 pm and the following was determined:
a. The records are stocks on wooden pallets.
b. Lacks of smoke detectors, extinguishers and Emergency lights.
c. The area where patients or visitors enter to ask for copies of records is not organized to provide privacy during interview if other persons are in this area.

6. Written evidence about bacteriological tests and water cisterns was requested on 3/30/15 at 3:05 pm. No evidence was found that cistern is tested on a monthly basis. The facility provided evidence that the cistern was clean yearly. The facility failed to be in accordance with state law requirements (Chapter XXV, Article #1, from November 7, 1999).

7. Written evidence about maintenance record, equipment tests and record for temperature in patients ' rooms was requested on 3/30/15 at 11:15 am. No evidence of register was provided. Facilities just provide " Conduces" job order of maintenance and repairs performed to the equipment ' s.

8. Kitchen area was observed on 3/30/15 at 11:50 am and the following was found:

a) The rubber around the miscellaneous freezer door is broken and loose.
b) Floor tiles under the 3 compartment sink have rust and white scum.
c) Wall tiles are covered with old dirt and mold on the grout.
d) Floor tiles beside the stoves with dirty embedded.
e) The food line service has all the insulation broken.
f) Missing and broken acoustical ceiling tile in kitchen employee bathroom.
g) Missing rubber base and dirt embedded on floor tiles in the Dry storage.

Based on observations made during the validation survey for the physical environment with the physical plant employee (employee #7) and (employee #8) facility's engineer ( employee #6) and Nursing supervisor (employee #2), it was determined that the physical structure and care areas failed to provide proper temperature and relative humidity control in patients rooms.

Findings include:

1. During the physical environment tour performed on 3/30/15 through 3/31/15 from 9:00 am until 5:00 pm it was found that the room ' s temperatures are cold.
Patients on room # 122, #121, # 120 and #114 were observed sleeping and with a quilt tucked up, the eyes and nose are the only part exposed.
Surveyor asked to employee #8 is the temperature at this moment monitored and how they controlled the temperature and humidity. He stated " the temperature in every room at this moment is 65 degrees " . Surveyor asked if someone monitor the temperature every day and he said no.
Temperature was taken in room #114, #120, #121 and #122 with a laser thermometer "Raynger ST " and reveals the following:
Room #114- 65 degrees
Room #120- 63 degrees
Room#121-63 degrees
Room #122-64 degrees
2. On 3/31/15 at 10:15 am during an observational tour, two patients were observed sitting on the backyard sleeping under the light of the sun and jacket.
Surveyor asked (patient #22) at 10:15 am why she is under the sun sleeping and she refers: "it is too cold inside and I already took a shower and the water was not hot " .
Interviewing patient #26 at 9:40 am he indicates:" the temperature in the room is too cold. The cold makes me uncomfortable and it is painfully".
Surveyor asked to (employee #7) and (employee #8) about a temperature record and indicates they do not have record of temperature and humidity of patients' rooms. Surveyor asked about a policy and procedure about room temperature and they indicate they do not know anything about it.

Based on the observational tour with the DON (employee #1) it was determined that the facility failed to promote sanitary and safe care through its infection control program in the patients rooms, emergency cart, clean linen storage and use linen storage related to improper infection control procedures and failed to follow infection control standards of practice.

Findings include:

1. The following was observed in the patients rooms on 3/30/2015 from 9:30 am till 10:30 am with the DON (employee #1) related to infection control:

a. During the tour it was fond that the rooms 102, 105, 106, 107, 108, 109, 110, 113, 115, 117, 119, 117, 121, and 122 have peeling paint, on the walls, strong musty smell and the air conditioning vents dirty.

The facility failed to maintain a sanitary hospital environment to control infection and communicable disease.
2. On 3/30/15 at 10:49 am during the emergency cart inspection with the employee #1 the following was found:
a. Six blue blood sampling tubes expired on February 2015, two suction catheters expired on July 2014, two suction catheters expired on August 2014, two suction catheters expired on September 2014, two sterile latex surgical gloves expired on April 2014, two sterile latex surgical gloves expired on October 2014 and four sterile latex surgical gloves expired on February 2015.
The facility failed to ensure that the medical surgical materials are up to date to prevent possible cross contamination.
3. On 3/31/2015 at 9:18 am during a blood sampling observation with Nursing Supervisor (Employee #2) one sharp container was observed without a security base. The unsecure sharp container was on top of a full sharp container on the security based.

The facility failed to ensure that all sharp containers are secure to prevent possible blood pathogen exposure
4. On 3/ 31/2015 at 10:15 am during observation of the clean laundry storage room with the DON the surveyor observe a wheelchair inside the clean laundry room storage.
The facility failed to ensure procedures related to prevent cross contamination.

Based on administrative documents review accompanied by the Nursing Supervisor (employee #2) and policies and procedures (P&P's) review and performed on 3/31/15 at 9:45 am it was determined that the facility failed to include the time frame for each patient's screening category at the Triage.

Findings include:

1. The Conductual Room triage has three screening categories which the nursing staff will use as a reference according to patient's signs and symptoms. These categories are: red for emergency, green for urgent and blue for non urgent. According to P&P's review performed on 3/31/15 at 9:45 am, the procedures mention the three screening categories but there are no descriptions of the time frame for the green and blue categories.

2. The nursing staff uses a Triage/screening documentation sheet where is written demographic information of the patient, vital signs, pain management, main complaint, among other important information. At the top of the screening sheet, the nurse has to write a check mark on one of the screening categories: emergency, urgent or non urgent. However, this screening sheet mentions only two categories, such as: emergency and not emergency. The urgent category is not mentioned. This issue allows that the nursing staff does not identify the patient's category leaving a blank space and putting a colored sticker (red, green or blue) according to patient's signs/symptoms.

a. Backwards of this screening sheet, there are general criteria that the nursing staff uses as reference when performing the patient's screening. However, signs and symptoms related to a non urgent category, such as: crying, sadness and death ideas without structure are not included.

3. The facility failed to ensure that the Triage screening categories policies and procedures include the time frame and signs and symptoms for each screening category.