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Based on complaint investigation survey PR00000595, tests performed on equipment and observations made during the survey for the physical environment with the facility's Assistant Director of Nursing (employee #1) on 4/6/17, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner.

Findings include:

1. The maintenance closet of emergency room was visited on 4/6/17 from 9:00 am until 3:45 pm. This closet was found with chemicals to clean the facility and equipment and was found unlocked and accessible to non-authorized persons.

2. 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.

3. Patient's bathrooms were observed with peeling off paint in wall tiles. A lot of graffiti were observed on the walls.

4. On patient's bathroom in the emergency room the nursing call was observed without pull cord.

5. Both bathrooms were observed in need of cleaning with strong urine odor.

Based on complaint investigation survey PR00000595 performed on 04/06/17 , observations made during the survey for the physical environment with the Assistant Director of Nursing (employee #1), it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality.

Findings include:

1. Maintenance cart was observed on 4/6/17 from 9:45 am until 11:40 am with cleaning chemicals on top and in the middle of the carts and did not have a cabinet on these carts where personnel can lock these cleaning solutions to limit its accessibility to non-authorized persons.

2. Maintenance cart with one drill, two cans of paints and other tools was observed from 4/6/17 at 9:15 am beside a stretcher with one patient waiting for the physician evaluation.

Based on complaint investigation survey PR00000595 performed on 04/06/17, tests performed on equipment and observations made during the survey for the physical environment , it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff.

Findings include:

1. Emergency staff does not have a key or a special device readily accessible to open bathroom doors if patients activate the emergency call system and the door is locked from the inside as observed on 4/6/17 at 9:45 am.

2. On 4/6/17 at 9:00 am two patients were observed in the hallway in front of the cubicles 1 thru 11 in a stretchers. The patients were connected to an I.V. solution which reduced the width of this exit passage to less than three feet.

"Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on complaint investigation survey PR00000595 performed on 04/06/17, it was determined that the facility failed to promote sanitary and safe environment through its infection control program as evidenced by housekeeping maintenance cart that was found unattended in the hallway and the MSDS was not available in Spanish or English.

Findings include:

1. Material Safety Data Sheets (MSDA) was not found 4/6/16 at 1:50 pm in the storage area where solutions and disinfectants are used in the housekeeping area of the Emergency room. The MSDS detailed information prepared by the manufacturer of a hazardous chemicals with useful information such as flash point, toxicity, procedures for spills and leaks, and storage guidelines was not available in Spanish and English posted in the area in case of and exposition to any of these solution to provide fist aid.

Based on complaint investigation survey PR00000595 and fifty Record Review R.R. it was determined that the facility failed to ensure that medical record information is legible, are complete with dates and times by the person responsible for providing the service consistent with hospital policies and procedures. This deficient practice was identified on six out of fifty cases reviewed ( R.R. # 6,# 12, # 30,# 35, # 36 and # 40 ).

Finding include:

1. R. R. #12 is a 81 years old female who visit the emergency room on 11/4/16 with a principal diagnosis of Cyst Pelvic Mass. During the Record review performed on 4/7/17 at 9:25 am it was found the following:

a. The Transfer sheet lack of reason, risk and benefit to transfer the patient.

2. R. R. #17 is a 76 years old female who visit the emergency room on 11/16/16 with a principal diagnosis of Suicidal Attempt. During the Record review performed on 4/7/17 at 10:25 am it was found the following:

a. The Emergency Treatment Consent sheet lack of the patient or relative signature.

3. R. R. #30 is a 69 years old female who visit the emergency room on 1/6/17 to be evaluated for a medical clearance. During the Record review performed on 4/7/17 at 9:00 am it was found the following:

a. The Transfer sheet lack of reason, risk and benefit to transfer the patient

4. R. R. #40 is a 77 years old female who visit the emergency room on 2/27/16 with a principal diagnosis of Urinary Retention, Moderate Dehydration and Dementia. During the Record review performed on 4/7/17 at 1:00 pm it was found the following:

a. An consult was requested to the Urologist, the consult was answered by the physician on 3/1/17 at 12:30 pm. However consult request, findings and recommendation was illegible. The physician that request the consult failed to write the date and hour when the consult was performed, no evidence was document that the urologist was notified.

b. A consult was requested to Social Worker on 2/28/17, however no evidence was found that the social worker evaluate the patient.

c. The patient instruction sheet was left in blank, only have the physician signature documented.

d. The Certification of Medical Necessity for Ambulance Transport sheet was left in blank, only have the admission diagnosis, condition of patient at discharge and the sign of the physician.


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5. R. R. # 6 is an 86 years old female, who visited the Emergency Room on 10/11/16. The patient was diagnosed with Abdominal Pain. During the record review performed on 4/7/17 at 8:45 am it was found the following:

a. The sheet used for rejection of treatment and abandonment against medical advice (AMA) is not completed. It only has the signature of the relative of the patient.

6. R. R. #35 is a 35 years old female, who visited the Emergency Room on 2/3/17. The patient was diagnosed with acute viral disease. During the Record review performed on 4/7/17 at 2:25 pm it was found the following:

a. The discharge sheet lack of patient status at the moment of discharge.

7. R. R. #36 is an 80 days old male, who visited the Emergency Room on 2/4/17. The patient was diagnosed with laceration arm. During the Record review performed on 4/7/17 at 10:00 am it was found the following:

a. The assessment performed by the nurse in the emergency room says that the integumentary system is normal. The patient visit the emergency room because he cut his arm with a saw.

Base on a complaint investigation survey PR00000595, review of sixteen emergency room (ER) registered nurse (RN) credential file (CF) and twenty eight ER physician credential file it was determined that the facility failed to ensure that ER personnel maintain updated their credential file for Advance Cardiac Life Support (ACLS) and Pediatric Advance Life Support (PALS), cardio pulmonary resuscitation (CPR) certification, health certificate, hepatitis B vaccine, and state narcotic license for seven out of sixteen RN credential File (RN, CF #4, #6, #8, #11, #14, #15 and #16) and twelve out of twenty eight Physician Credential File (Physician CF #2, #3, #4, #8, #10, #12, #15, #17, #20, #24, #26 and #28).

Findings include:

1. During the review of sixteen ER Nursing Credential File on 4/7/17 at 1:00 pm with Institutional Program Director (employee # 11) it was found the following:

a. Four out of sixteen RN credential file no provide evidence of updated ACLS certification ( CF #4, #6 #14 and #15).

b. Five out of sixteen RN credential file no provide evidence of updated PALS certification ( CF #8, #11, #14, #15 and #16)

2. During the review of twenty eight ER Physician Credential File on 4/7/17 at 2:00 pm with Institutional Program Director (employee #11) it was found the following:

a. Four out of twenty eight ER Physician credential file no provide evidence of updated Health certificate (Physician CF #4, #8, #15 and #24).

b. Six out of twenty eight ER Physician credential file no provide evidence of hepatitis B vaccine ( CF #4, #10, #17, #20, #24 and #26).

c.One out of twenty eight ER Physician credential file no provide evidence of updated State Narcotic License
( CF #12).

d. Three out of twenty eight ER Physician credential file no provide evidence of updated ACLS certification (CF #2, #3 and #28).

e. One out of twenty eight ER Physician credential file no provide evidence of updated CPR certificate (CF #28).