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Based on the review of hospital licenses/certifications, it was determined that the facility failed to ensure that it is in compliance with Federal and State laws related to an expired Fire Department Endorsement and two expired elevators licenses.

Findings include:

During the review of the facility's licenses/certifications on 7/13/12 at 11:30 am, it was identified that the facility's two elevator licenses expired on July 5, 2012 and the Fire Department Endorsement expired on May 5, 2012. The facility provided evidence that they submitted and paid for the fire department inspection, but they have not arrived to perform the inspection and give them the endorsement. The elevator company was also notified and were planning to visit the facility on 7/13/12.

Based on the review of documents, observations, tests and interviews from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm, it was determined that the Governing Body failed to carry out its responsibility for the operation and management of the hospital. The hospital has an organized Governing Body (G.B) but failed to meet on a regular basis, the last meeting to discuss quality of care issues was in October of 2011. In May of 2012 the G.B met but only discussed census statistics. No evidence was found that other members such as the Medical Director, Director of Finances, Director of Human Resources, Faculty Representatives, etc are invited as needed considering the multitude of changes happening at this facility, for example the new administrator, renovations of the the physical plant and recent inspection findings (State Law inspection and Joint Commission). The facility failed to ensure that the hospital's surgical department provides services in accordance with acceptable standards of practice and complexity of services provided, failed to ensure that surgical services maintains a high standard of medical practice and patients' care, failed to execute complete surgery informed consents, failed to ensure that the operating room log registry is complete, failed to ensure that the anesthesia services are provided in a well organized manner and comply with all the requirements, failed to meet the needs of its patients in accordance with acceptable standards of practice, perform post-assessment, patient's assessment after respiratory therapy treatment, patient's estimated initial respiratory therapy treatments, in-services training for the department, sufficient personnel available, sign posting for those patients using oxygen, labeled with the date and hour when started on the equipment, and the respiratory therapy staff pattern, facility failed to ensure that Rehabilitation services is organized and staffed to ensure the health and safety of patients, no evidence was found policies and procedures, credential files, the organizational chart to indicate lines of authority and delegation of responsibilities within the department, Physical therapy staffing and schedules, implemented and maintained on an ongoing Quality Assessment and Performance Improvement (QAPI) program, quality indicators related to patient's goals being met during their treatment and when discharge. The Governing Body failed to provide the necessary oversight and leadership as evidenced by the lack of compliance with: Governing Body (42 CFR 482.12), Quality Assessment and Performance Improvement Program (QAPI) (42 CFR 482.21), Nursing Services (42 CFR 482.23), Physical Environment (42 CFR 482.41), Infection Control (42 CFR 482.42), Surgical Services (42 CFR 482.51), Anesthesia Services (42 CFR 482.52), Emergency Services (42 CFR 482.55), Rehabilitation Services (42 CFR 482.56) and Respiratory Services (42 CFR 482.57).

Based on the review of institutional plan documents, it was determined that the facility failed to ensure that the institutional plan provides for capital expenditures for at least a three year period including the operating budget year.

Findings include:

The facility's institutional plan was reviewed on 7/13/12 at 9:00 am and provided evidence of the annual operating budget. However, no evidence was provided of a plan for capital expenditures for at least a 3-year period which includes anticipated income and expenses.

Based on nine medical records reviewed (R.R) and review of protocols and policies/procedures and interview, it was determined that the facility failed to ensure that notice of rights are provided to patients and patient's relatives during admission to the hospital for 7 out 7 of records reviewed (R.R #1, #3, #4, #5, #6, #13 and #14).

Findings include:

1. R.R #3 is a 46 years old female who was admitted on 7/8/12 with a diagnosis of Cellulitis Abscess Lumbar Area and Asthma and was reviewed with the director of nursing (employee #10) on 7/10/12 at 10:12 am. The medical record included documentation that the patient was provided with a notice of rights during admission to the facility and the patient has the information package, however during interview on 7/10/12 at 10:27 am, the patient's relative stated when the package was given to them it was not explained, they were only given a piece of paper to sign.

2. R.R #4 is a 78 years old male who was admitted on 7/7/12 with a diagnosis of Chronic Liver Disease and Diabetes Mellitus Type II and was reviewed with the director of nursing (employee #10) on 7/10/12 at 1:12 pm. The medical record included documentation that the patient's relatives was provided with a notice of rights during admission to the facility and the patient has the information package, however during interview on 7/11/12 at 9:00 am, the patient's relative stated when the package was given to them it was not explained, they were only given a piece of paper to sign.

3. R.R #5 is a 63 years old female who was admitted on 6/1/12 with a diagnosis of Diverticulitis and was reviewed with the director of nursing (employee #10) on 7/10/12 at 1:42 pm. The medical record did not include documentation that the patient was provided with notice of rights during admission to the facility and the patient has the information package. During interview 7/11/12 at 10:47 am, the patient's relative stated when the package was given to them it was not explained, they were only given a piece of paper to sign.

4. R.R #13 is an 89 years old female who was admitted on 7/9/12 with a diagnosis of Cerebro Vascular Accident and was reviewed with the director of nursing (employee #10) on 7/11/12 at 11:32 am. The medical record included documentation that the patient's relatives was provided with a notice of rights during admission to the facility and the patient has the information package, however during interview on 7/11/12 at 11:23 am, the patient's relative stated when the package was given to them it was not explained, they were only given a piece of paper to sign.

5. R.R #14 is a 62 years old male admitted on 6/26/12 with an Ulcer, Cellulitis Left Leg and Diabetes Mellitus and was reviewed with the director of nursing (employee #10) on 7/11/12 at 11:50 am. The medical record included documentation that the patient was provided with a notice of rights during admission to the facility and the patient has the information package, however during interview on 7/11/12 at 11:33 am, the patient's relative stated when the package was given to them it was not explained, they were only given a piece of paper to sign.

6. R.R #6 is a 67 years old female admitted on 7/1/12 with Cellulitis Left Leg Ulcer and was reviewed with the director of nursing (employee #10) on 7/11/12 at 10:24 am. The medical record included documentation that the patient's relatives were provided with a notice of rights during admission to the facility and the patient has the information package, however during interview on 7/11/12 at 10:15 am, the patient's relative stated when the package was given to them it was not explained, they were only given a piece of paper to sign.

7. R.R #1 is a 10 years old male admitted on 7/8/12 with Acute Gastroenteritis and was reviewed with the director of nursing (employee #10) on 7/10/12 at 9:10 am. The medical record included documentation that the patient's relatives (mother) was provided with a notice of rights during admission to the facility and the patient has the information package, however during interview on 7/10/12 at 9:25 am, the patient's relative stated when the package was given to them it was not explained, they were only given a piece of paper to sign.

Based on four clinical records reviewed (R.R) and facility DNR protocol, it was determined that the facility failed to ensure that policies and procedure related to advance directives for "Do Not Resuscitate" (DNR) orders are followed for 4 out of 4 records reviewed (R.R #7, #8, #9 and #34).

Findings include:

1. Four out four records reviewed #7, #8, #9 and #34) on 7/12/12 from 9:00 am till 12:00 pm with the director of nursing (employee #10), identified with do not resuscitate, the witness signature, Consent patient name, name of the physician who oriented physicians' orders did not have progress notes and physician's orders related to the patients' clinical condition:

a. R.R #7 is an 88 years old female who was admitted on 7/1/12 with a diagnosis of Congestive Heart Failure(CHF) and Pneumonia. During the record review on 7/11/12 at 10:50 am, with the director of nursing (employee #10) a consent form for "Do Not Resuscitate" was found in the clinical record, signed by her relatives on 6/19/12 and no evidence was found that the witness signed the form. The physician's order for DNR was signed on 6/19/12. No evidenced was found of a physician's progress notes about the reason for this decision. No evidence was found that the patient was re-evaluated by the physician in charge to justify continuing with the DNR order. No evidence was found of the re-evaluation of the DNR according to the patient's clinical condition.

b. R.R #8 is a 93 years old male who was admitted on 7/8/12 with a diagnosis of Acute Coronary Syndrome. During the record review on 7/12/12 at 9:10 am, with the director of nursing (employee #10) a consent form for "Do Not Resuscitate" was found in the clinical record, signed by his relatives on 7/9/12 and no evidence was found that the witness signed the form. The physician's order for DNR was signed on 7/9/12. No evidence was found of a physician's progress note about the reason for this decision.

c. R.R #34 is a 78 year old female was admitted on 6/26/12 with a diagnosis of Pneumonia. The record was reviewed on 7/12/12 at 9:30 am with the director of nursing (employee #10), a consent form for Do Not Resuscitate (DNR) says DNR and do not intubate (DNI) and was signed by her relative on 6/29/12 and no evidence was found that the witness signed. No evidenced was found on the consent of the patient's name and name of the physician who oriented. The physician's order for "Do Not Resuscitate" was signed on 6/29/12 at 8:20 am. However, it does not say do not intubate it only says DNR and its signed. No evidenced was found of a physician's progress notes about the reason for this decision. Evidence was found that the patient was re-evaluated by the physician but did not justify continuing with the DNR order.

d. R.R #9 is a 77 years old female who was admitted on 6/21/11 with a diagnosis of Hyperkalemia, Anemia and BKP. The record was reviewed on 7/12/12 at 11:00 am with the director of nursing (employee #10), a consent form for Do Not Resuscitate (DNR) say DNR and do not intubate (DNI) was signed by his relative on 6/22/12 and no evidence was found that the witness signed. The physician's order for "Do Not Resuscitate" was signed on 6/22/12. However, it does not say do not intubate it only says DNR and its signed. No evidenced was found of a physician's progress notes about the reason for this decision. Evidence was found that the patient was re-evaluated by the physician but did not justify continuing with the DNR order.

2. During the review of the facility's "Do Not Resuscitate Protocol" on 7/12/12 at 8:15 am with the Director of institutional programs (employee #10), it was determined that the facility failed to have policies and procedures in place related to:

a. Do Not Intubate (DNI).
b. Nursing participation.
c. Other measure to patient identified
d. The physician authorized to place on the DNR or DNI order.
e. The chemical code was not considered.
f. The patient record identification.
g. If "Do Not Resuscitate" (DNR) order will be reviewed by the physician in charge whenever a significant change in the patient's condition occur or when a specific request from the patient, the family is made.
3. No evidenced was found of quality improvement for DNR and DNI on 7/12/12 at 12:00 noon.

Based on closed records reviewed (R.R) with the director of nursing (employee #10), it was determined that the facility failed to promote the patient's right to be free of restraints and failed to continually assess and monitor 4 out of 4 records reviewed (R.R #16, #17, #18 and #19).

Findings include:

1. R.R #16 is a 66 years old female who was admitted on 5/4/12 with a diagnosis of Severe Gastritis, Severe Dehydration, Hypertension and Diabetes Mellitus). The record review was performed on 7/12/12 at 3:05 pm with the nursing Director (employee #10) and provided evidence that the physician placed a telephone order on 6/27/12 at 5:15 am for restrictions. No evidence was found of the consent by family members to place the patient on restrictions. No evidence was found of restraints education to the patient or her relative. No evidence was found of the information in the physician's progress notes related with the patients restrictions orders and justification for the restriction. No evidence was found of the patient's plan of care related to the restraints.

2. R.R #17 is a 79 years old female who was admitted on 5/23/12 with a diagnosis of Acute Diverticulitis, Diabetes Mellitus and Bronchopneumonia. The record review was performed on 7/12/12 at 1:05 pm with the nursing director (employee #10) and provided evidence that the physician placed a telephone order on 5/24/12 at 11:20 pm for restrictions. No evidence was found of restraint education to the patient or her relative. No evidence was found of the information in the physician's progress notes related with the patients restriction orders and justification for the restriction.

3. R.R #18 is a 73 years old male who was admitted on 5/23/12 with a diagnosis of Pneumonia and Congestive Heart Failure. The record review was performed on 7/12/12 at 2:00 pm with the nursing director (employee #10) and provided evidence that the physician placed a telephone order on 5/24/12 at 9:00 pm for restrictions. No evidence was found of restraint education to the patient or his relative. No evidence was found of the information in the physician's progress notes related with the patients restrictions orders and justification for the restriction.

4. R.R #19 is a 66 years old female who was admitted on 5/2/12 with a diagnosis of BKP and Cerebrovascular Accident (CVA). The record review was performed on 7/12/12 at 2:30 pm with the nursing director (employee #10) and provided evidence that the physician placed a telephone order on 5/3/12 at 2:50 am for restrictions. No evidence was found of restraint education to the patient or his relative. No evidence was found of the information in the physician's progress notes related with the patients restrictions orders and justification for the restriction.

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

Findings include:

1. The facility's restraint policies and procedure reviewed on 7/13/12 at 9:55 am states that the restriction will be soft including from the restriction of an extremity or restriction of four extremities.

2. The facility's restraint policies and procedure reviewed on 7/13/12 at 9:59 am states that the professional of nursing initiates a restriction the doctor will have to provide a telephone order or written in the first twelve hours to have initiated the restriction. The facility requires the physician order is obtained immediately (within a few minutes) after application of the restraint.(this policy does not meet with the restraint regulation at 482.13 (e)(6)).

3. The facility's restraint policies and procedures reviewed on 7/13/12 at 10:05 am states that if the patient has no alteration of behavior after an order is placed, shall not exceed 24 hours and the nurse may discontinue the restriction. If the patient returns to relapse behavior, the restriction can be placed back within 24 hours and this is covered by the medical order (this policy does not meet with the restraint regulation at 482.13 (e)(5)).

Based on the review of the Quality assessment and performance improvement program, interviews accompanied by the facility's Quality Improvement Officer (employee #11) on 7/12/12 from 1:15 am till 3:30 pm, it was determined that the facility failed to ensure an effective on going hospital wide data driven Quality assessment and performance improvement activities that is implemented, maintained and reflects the complexity of hospital's organization and services, involves all hospitals departments and services (including those services furnished under contract or arrangement) and focuses on indicators related to improve health outcomes.

Based on review of quality assurance activities with the quality assurance officer (employee
#11), it was identified that the facility failed to ensure that the quality assurance program requirements are met.

Findings include:

1. A mechanism to ensure that facility quality assurance and performance improvement program indicators information are available and reflects the patterns and tendencies identified after analysis of the information, were not followed, nor promoted. The following findings were identified during the review of the quality assurance program activities with the quality assurance officer (employee #11) on 7/12/12 at 1:45 pm:

a. Infection control program collects, analyze and present quality assurance indicators to the quality assurance program. During the first trimester of year 2012 (January, February and March 2012) and based on percent and outcomes attained, the program must follow process surveillance in order to address deficient practices and develop improvement. However information and indicator data collected for the second trimester of year 2012 (April, May and June 2012) were not presented to the quality assurance program. The facility failed to identify potential quality concerns and select areas that need further investigation and track changes over time.

b. Information management program collects, analyze and present quality assurance indicators to the quality assurance program, related with the compliance by the facility to notify Medicare beneficiaries about their hospital discharge rights. During the first trimester of year 2012 (January, February and March 2012) and based on percent and outcomes attained, the program must follow process surveillance in order to address deficient practices and develop improvement. However information and indicator data collected for the second trimester of year 2012 (April, May and June 2012) were not presented to the quality assurance program. The facility failed to identify potential quality concerns and select areas that need further investigation and track changes over time.

c. Medication irregularities report showed by the Pharmacist on 7/11/12 at 9:50 am for the first two trimester of natural year 2012 (from January /2012 through June/ 2012) only include statistical information, identification of patterns, trends and tendencies were not include as part of the report. Outcomes attained by patients as result of medication irregularities were not included as part of the reports. The facility failed to identify potential quality concerns and select areas that need further investigation.

Based on the review of quality assurance activities with the quality assurance officer (employee #11), it was identified that the facility failed to include all hospital services and contracted services in the Quality Assessment and Performance Improvement (QAPI) program activities.

Findings include:

1. During the review of the facility's hospital-wide quality assurance activities master plan with the quality assurance officer (employee #11) on 7/12/10 at 1:10 pm, it was identified that
nuclear medicine failed to provide the quality assurance activity plan to evaluate performance, processes of care and services provided to patients and operations.

2. During the review of the facility's hospital-wide quality assurance activities master plan with the quality assurance officer (employee #11) on 7/12/10 at 1:10 pm, it was identified that the laundry is a contracted service and were not included as part of services to be submitted as quality indicators data in order to evaluate the performance of the services.

3. Radiologic services, food and dietetic services quality assurance plan did not include indicators to evaluate processes of care and the appropriateness of services offered to patients as reviewed on 7/12/12 from 1:25 pm till 3:30 pm.

4. The facility was providing enteral feeding in bolus to patients, due to the lack of enteral feeding machines, to provide enteral feeding continuously. However the process of administration was not reviewed in order to ensure that it follows acceptable standards of practice, infection control guidelines and improves patient health nutritional outcomes as reviewed on 7/12/12 from 1:25 pm till 3:30 pm.

Based on the review of quality assurance activities with the quality assurance officer (employee #11), it was identified that the facility failed to measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that assess processes of care, hospital services and operations.

Findings include:

1. Quality assurance committee meeting minutes and activities for the natural year of 2012 were reviewed on 7/12/12 from 1:25 pm till 3:30 pm, with the quality assurance officer (employee #11) who is the person in charge of coordinating quality assurance activities. The following was found in relation with the review of these documents and discussion:

a. Minutes and quality assurance activities did not provide evidence of current improvement areas or the analysis by the facility leadership on an ongoing basis. Data reviewed discussion in areas which need improvement based upon reports and information collected and presented to the committee were not evidenced during the survey for the program of infection control or for the services of nuclear medicine, pharmacy and emergency department.

b. According with information provided by the Pharmacist on 7/11/12 at 9:50 am in the medication error monthly report (from January /2012 through June/ 2012) the omissions were the highest percent of incidents found. However, investigations of the circumstances where the omissions occurred were not performed on an ongoing basis, in order to determine reasons for the omissions and implement corrective actions to improve the medication administration process. The facility failed to identify and take actions in response to medication administration irregularities.

c. Information management program collect, analyze and present quality assurance indicators to the quality assurance program, related with the compliance by the facility to notify Medicare beneficiaries about their hospital discharge rights. During the first trimester of year 2012 (January, February and March 2012) and based on the percent and outcomes attained, the program must follow process surveillance in order to address deficient practices and develop improvement. However information and indicator data collected were not analyzed in order to establish corrective measures to improve the process.

Based on the review of patient care outcome results, quality assurance activities with the medical director (employee #24), emergency room medical director (employee #36) and the infection control officer (employee #16) and records reviewed (R.R), it was identified that the facility failed to track adverse patient events as part of the performance improvement activities for R.R #33.

Findings include:

1. A mechanism to ensure that the facility examines systems and processes of patient care was not promoted according with the following findings:

a. R.R #33 is a 42 years old male who visited the emergency room (ER) on 1/28/12 at 3:58 pm with Fever and Viral Syndrome. The triage was performed at 3:58 pm and the patient was categorized as "non urgent" with the following vital signs (V/S): temperature-38.5ºC, pulse-91, respiration-17 and blood pressure-131/70 and complaint with generalize pain, fever, nauseas and vomits. The record was reviewed on 7/12/12 at 2:30 pm and provided evidence that the E.R physician evaluated the patient for fever as of four days ago with vomits and the patient's mother died about 2 to 3 weeks ago. The physician ordered treatment at 4:30 pm of .9% Normal Saline to run full drip, Pepcid 20 mg IV, Tigan 2 ml IM, Tylenol 500 mg stat, laboratory samples and chest X ray. The results of the laboratory taken on 1/28/12 at 5:30 pm provided evidence that the white blood cell (WBC) count was 11.72 ul, platelets on 293.0 ul and low sodium 134 mmol/l. On 1/29/12 at 12:05 pm the physician's discharge progress notes refers that the patient denies systemic disease, cough with sputum, diarrhea, melena, dysuria, cephalea and dyspepsia. The chest X-Ray provided evidence of no infiltrates seen, laboratory evidence of bacteria infection and grief reaction over mother's death.

b. On 1/29/12 at 12:05 pm, the patient was discharged home (20 hours later) with the following recommendations: Regular diet, look for reactions and friends support to avoid depression, psychologist or psychiatric ambulatory evaluations, repeat (CBC) on 24-48 hours, observed for bleeding, hematomas, high fever, no aspirin or derivatives and only to take acetaminophen.

c. On 1/31/12 at 9:04 am the patient returned to the ER (45 hours later) and the triage was performed at 8:52 am and was categorized as "urgent" with the following vital signs (V/S): temperature-39.1ºC, pulse-117, respiration-25 and blood pressure-95/60, oxygen saturation 99% and complaint with generalize malaise and fever. The ER physician evaluated the patient for fever, nauseas and cough with blood and a provisional diagnosis of Viral Syndrome, Fever and possible BKP. The physician ordered treatment at 9:30 am of .9% of Normal Saline to run 250 ml, Tylenol 500 mg stat, laboratory samples and chest X ray. The results of the laboratory taken on 1/31/12 at 10:00 am provided evidence that the (WBC) count was 6.91 ul, platelets on 183.0 ul, low sodium 132 mmol/l and low chloride 96 mmol/l. On 1/31/12 at 3:00 pm nursing progress notes were found that the patient was "observed in isolation and a vomited blood on the floor and the physician was notified". On 1/31/12 at 4:00 pm the CBC was repeated and type/cross was taken, PT-PTT sample and the WBC of CBC was taken and was notified by the laboratory as a "panic result" of .80 ul and platelets of 147.0 ul and prothrombin time of 16.4 sec. At 7:00 pm the respiratory therapist placed a ventury mask at 50% for respiratory difficulty with blood gas ph of 7.365, low pCO2 of 20.7, low pO2 of 57.1, low BE of 11.2, low HCO3 of 11.6 (mmol/L) and low O2 saturation of 87.1%. The X-rays' findings on 1/31/12 was "right lung lobe ill defined patchy consolidation with suggestions of air bronchogram's in favor of pneumonia". The physician tries to transfer the patient 1/31/12 a 7:00 pm due to a Bronchopneumonia and to rule out T.B.

d. On 1/31/12 at 8:20 pm the nurse notified "code green" and began cardiorespiratory resuscitation and the patient was pronounced dead at 9:00 pm. The facility failed to ensure that the patient's was given a psychological evaluation during his first admission, no evidence was found that this cases was evaluated by the emergency room medical director related to the patient's death, transfer or return to the E.R within 48 hours. No evidence was found that the case was notified or evaluated by the Infection control officer related to personnel handling of this case during the first and second visits related to possible T.B infection. No evidence was found that facility follows mechanisms for peer review of patient care and death.

Based on review of patient care outcome results, quality assurance activities with the medical director (employee #24) emergency room medical director (employee #36) and infection control officer (employee #16) and records reviewed (R.R), it was identified that the facility failed to ensure that adverse patient events are analyzed and discussed as part of the performance improvement activities for R.R #33.

Findings include:

1. A mechanism to ensure that the facility examines systems and processes of patient care was not promoted according with the following findings:

a. R.R #33 is a 42 years old male who visited the emergency room (ER) on 1/28/12 at 3:58 pm with Fever and Viral Syndrome. The triage was performed at 3:58 pm and the patient was categorized as "non urgent" with the following vital signs (V/S): temperature-38.5ºC, pulse-91, respiration-17 and blood pressure-131/70 and complaint with generalize pain, fever, nauseas and vomits. The record was reviewed on 7/12/12 at 2:30 pm and provided evidence that the E.R physician evaluated the patient for fever as of four days ago with vomits and the patient's mother died about 2 to 3 weeks ago. The physician ordered treatment at 4:30 pm of .9% Normal Saline to run full drip, Pepcid 20 mg IV, Tigan 2 ml IM, Tylenol 500 mg stat, laboratory samples and chest X ray. The results of the laboratory taken on 1/28/12 at 5:30 pm provided evidence that the white blood cell (WBC) count was 11.72 ul, platelets on 293.0 ul and low sodium 134 mmol/l. On 1/29/12 at 12:05 pm the physician's discharge progress notes refers that the patient denies systemic disease, cough with sputum, diarrhea, melena, dysuria, cephalea and dyspepsia. The chest X-Ray provided evidence of no infiltrates seen, laboratory evidence of bacteria infection and grief reaction over mother's death. On 1/29/12 at 12:05 pm, the patient was discharged home (20 hours later) with the following recommendations: Regular diet, look for reactions and friends support to avoid depression, psychologist or psychiatric ambulatory evaluations, repeat (CBC) on 24-48 hours, observed for bleeding, hematomas, high fever, no aspirin or derivatives and only to take acetaminophen.

b. On 1/31/12 at 9:04 am the patient returned to the ER (45 hours later) and the triage was performed at 8:52 am and was categorized as "urgent" with the following vital signs (V/S): temperature-39.1ºC, pulse-117, respiration-25 and blood pressure-95/60, oxygen saturation 99% and complaint with generalize malaise and fever. The ER physician evaluated the patient for fever, nauseas and cough with blood and a provisional diagnosis of Viral Syndrome, Fever and possible BKP. The physician ordered treatment at 9:30 am of .9% of Normal Saline to run 250 ml, Tylenol 500 mg stat, laboratory samples and chest X ray. The results of the laboratory taken on 1/31/12 at 10:00 am provided evidence that the (WBC) count was 6.91 ul, platelets on 183.0 ul, low sodium 132 mmol/l and low chloride 96 mmol/l. On 1/31/12 at 3:00 pm nursing progress notes were found that the patient was "observed in isolation and a vomited blood on the floor and the physician was notified". On 1/31/12 at 4:00 pm the CBC was repeated and type/cross was taken, PT-PTT sample and the WBC of CBC was taken and was notified by the laboratory as a "panic result" of .80 ul and platelets of 147.0 ul and prothrombin time of 16.4 sec. At 7:00 pm the respiratory therapist placed a ventury mask at 50% for respiratory difficulty with blood gas ph of 7.365, low pCO2 of 20.7, low pO2 of 57.1, low BE of 11.2, low HCO3 of 11.6 (mmol/L) and low O2 saturation of 87.1%. The X-rays' findings on 1/31/12 was "right lung lobe ill defined patchy consolidation with suggestions of air bronchogram's in favor of pneumonia". The physician tries to transfer the patient 1/31/12 a 7:00 pm due to a Bronchopneumonia and to rule out T.B. On 1/31/12 at 8:20 pm the nurse notified "code green" and began cardiorespiratory resuscitation and the patient was pronounced dead at 9:00 pm. The facility failed to ensure that the patient's was given a psychological evaluation during his first admission, no evidence was found that this cases was evaluated by the emergency room medical director related to the patient's death, transfer or return to the E.R within 48 hours. No evidence was found that the case was notified or evaluated by the Infection control officer related to personnel handling of this case during the first and second visits related to possible T.B infection. No evidence was found that facility follows mechanisms for peer review of patient care and death.

Based on the review of documents, observations, tests and interviews, it was determined that the Governing Body failed to be accountable, to ensure the appropriateness and effectiveness of patient care provided in the hospital setting.

Findings include:

A mechanism to ensure that the Governing Body provides oversight of the facility operations and of the quality of care, treatment and services provided to patients were not promoted, nor followed according with the non compliance of the following conditions of participation from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm: Governing Body (42 CFR 482.12), Quality Assessment and Performance Improvement Program (QAPI) (42 CFR 482.21), Nursing Services (42 CFR 482.23), Physical Environment (42 CFR 482.41), Infection Control (42 CFR 482.42), Surgical Services (42 CFR 482.51), Anesthesia Services (42 CFR 482.52), Emergency Services (42 CFR 482.55), Rehabilitation Services (42 CFR 482.56) and Respiratory Services (42 CFR 482.57).

Based on observations, records reviewed (R.R) and review of documents, policies/procedures and interviews from 7/10/12 through 7/13/12 from 8:30 am till 4:30 pm, it was determined that the facility failed to ensure that the hospital has a well-organized nursing service related to the lack nursing developed nursing care plans, assignments, patient's categories, the medication cart was observed unattended while the nurse was in patient's rooms, all drugs and biologicals must be administered, failed to ensure that nursing personnel provide necessary care to patients as needed, sufficient nursing staff are available all times, drugs administration procedure and the lack of nursing documentation related to the patient's status in the medical record makes the Nursing Condition of Participation "Not Met".

Based on observations made during the observational tour of the facility, patients interview, interview with the director of nursing (D.O.N.) (employee #10) and review of policies and procedures and records reviewed (R.R), it was determined that the facility failed to ensure that nursing personnel provide necessary care to patients as needed for 7 out of 10 records review (R.R #3, #4, #5, #7, #24, #25, #34) and 2 out of 2 patients interview (IV), (IV # 1 and # 2).

Findings include:

A. A mechanism to ensure that nursing personnel provide assistance to patients and relatives who request help was not promoted according with the following findings:

1. The IV #1 during an interview on 7/10/12 at 10:05 am said that she calls the nurses and it takes them a long time to arrive, around 20 to 30 minutes. She stated that the venous puncture area of the intra venous fluid hurts a lot when the area was canalized, when the nurse arrived she removed the IV and it had an edematous area.

2. R.R #3 is a 46 years old female who was admitted on 7/8/12 with a diagnosis of Cellulitis Abscess Lumbar Area and Asthma. The patient stated during an interview on 7/10/12 at 10:27 am that last night she activated the nursing call system and told them that she had a lot of pain and they never came, and it is not until the 7-3 shift that she was given Demerol. During the record review it was found that it did not have nursing progress notes shifts for the 7-3 and 3-11 shifts. The nursing progress notes of the 11-7 shift were found with no evidence of the pain estimate. The skin care nursing notes, documents that the patient has cellulitis on 7/9/12 of the lower lumbar area with radiation into the left buttock. Cellulitis with bloody drainage exudates is less. Erythema, hardened to the touch and pain. The facility failed to ensure that nursing care and procedures are performed according with patient needs, facility policies and standards of practice.

3. R.R #4 is a 78 years old male who was admitted on 7/7/12 with a diagnosis of Chronic Liver Disease and Diabetes Mellitus Type II. During The record review on 7/11/12 at 9:00 am, a medical order for dextrostix every 8 hours was found. On 7/8/12 a DXT was not performed during the 3-11 shifts and on 7/9/12 a DXT was not performed for the 3-11 and 11-7 shifts. The facility failed to ensure that nursing care and procedures are performed according with patient needs, facility policies and standards of practice.

4. R.R #5 is a 63 years old female who was admitted on 6/1/12 with a diagnosis of Diverticulitis. During interview on 7/11/12 at 10:47 am, the patient said she activated the nursing call system and nobody responded. She called because she has a colostomy and it is draining all the time and she can not move. When her husband is around he cleans her all the time. The nurses come into the room a few times a day. During the record review on 7/11/12 at 9:40 am it was found without nursing progress notes on 7/8/12 shift 7-3. On 7/9/12 no nursing progress notes for the 3-11 and 11-7 shifts. On 7/10/12 no nursing progress notes for the 3-11 and 11-7 shifts. The facility failed to ensure that nursing care and procedures are performed according with patient needs, facility policies and standards of practice.

5. The IV #2 is a 71 years old female who was admitted on 7/6/12 with Right Lower Extremity Cellulitis and Diabetes Mellitus. During interview on 7/10/12 at 10:05 am she said that she activated the nursing call system and someone told her they were coming to help her and they arrived two hours later. She called because they left her food on a table far away and she could not reach it and she couldn't stop looking at the food.

6. During the observational tour on 7/12/12 on 3:00 pm, in the intermediate ward with the DON employee #10 and supervisor (employee #12) and it was found that the telemetry has 16 patients. They are evaluated by licensed practical nurse (LPN) for the three shifts. During the evaluation of job assignments, it was observed that the area of telemetry is assigned to the nurse (LPN).

7. During interview with the DON employee #10 on 7/12/12 on 3:10 pm she said that she has identified this situation and has submitted it the administrator. There are only three licensed practical nurses that perform this function. In the hospital they offered a one-day course by the supervisor in charge of intensive care unit of the hospital and in-service trainer. She said that today they are making arrangements so that registered nurse are providing surveillance in the telemetry area.

8. During interview with licensed practical nurse (employee #13) on 7/12/12 on 3:20 pm, she said that there are 12 patients in the telemetry area, and she is in charge of drawing paths by turn twice. She said that she is aware that the Telemetry order is renewed every 72 hours, monitoring the patient's bone rhythm monitor tracings and for any abnormal changes. If she finds that there are irregular shapes then she notifies the nurse immediately. If necessary the patient is evaluated and the physician is called. If the patient is discontinued from telemetry orders she writes it in the log.

9. Two out of ten medical records were reviewed on 7/11/12 at 11:20 pm with the DON employee #10 and nursing supervisor employee #12 provided evidence that licensed practical nurses failed to write out-put of irrigation and residue of gastric content of the patients with nasogastric tube on the nursing progress notes (R.R #7 and #34).



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10. A mechanism to ensure that supportive nursing interventions of the process of enteral feeding by bolus are included in the progress notes to ensure that dietitian recommendations and standards of practice was not performed. The following was identified during review of two out of five records (R.R #24 and #25) who had ordered enteral feeding with the clinical dietitian (employee #15) on 7/10/12 at 11:40 am:

a. R.R #24 is a 78 years old female admitted to the facility on 6/26/12 with a diagnosis of Pneumonia. The patient was admitted with a nasogastric tube and the physician was ordered to remain NPO until 6/27/12. On 6/27/12 at 11:46 am the dietitian evaluated the patient and recommended to begin with Diabetic source enteral formula at 30 ml/hour for 16 hours; to reach a goal of 67ml/hour. Instead of being continuously administered it has to be administered in a bolus, due to the lack of enteral feeding machines in the hospital. Clinical dietitian (employee # 14) include in the nutritional orders recommendations and the process to follow during bolus administration of enteral feeding on 6/27/12 . This recommendations include the quantity of supplement to be provided during breakfast ,lunch and dinner, the quantity of water, that personnel must be used to irrigate the enteral feeding before and after the bolus administration and precautions to be taken in order to prevent aspiration. There are no evidence on the nursing progress notes from 6/27/12 through 7/5/12 that those recommendations to be followed during the procedure were addressed and performed. The facility failed to monitor and evaluate bolus feeding recommended by the dietitian on 6/27/12 in order to ensure appropriate standards of practice to prevent resident's complications.

b. R.R #25 is a 74 years old male admitted to the facility on 7/7/12 with a diagnosis of Sacral Ulcer, R/O Sepsis, Hx of Alzheimer and Dehydration. The patient was admitted with a PEG tube and gastrostomy. On 7/8/12 at 8:30 am the dietitian evaluates the patient and recommends to begin with Peptamen 1.0 enteral formula at 30 ml/hour for 16 hours; to reach a goal of 80ml/hour. Instead of being continuously administered it was started as a bolus, due to the lack of enteral feeding machines in the hospital. Clinical dietitian (employee # 14) include in the nutritional orders recommendations and the process to follow during bolus administration of enteral feeding on 7/8/12. This recommendations include the quantity of supplement to be provided during breakfast ,lunch and dinner, the quantity of water, that personnel must be used to irrigate the enteral feeding before and after the bolus administration and precautions to be taken in order to prevent aspiration. There are no evidence on the nursing progress notes from 7/8/12 through 7/10/12 that those recommendations to be followed during the procedure were addressed and performed. The facility failed to monitor and evaluate bolus feeding recommended by the dietitian on 7/8/12 in order to ensure appropriate standards of practice to prevent resident's complications.

Based on observations made during the observational tour of the facility, interview with patients and relatives, interview with the director of nursing DON (employee #10) and review of policies and procedures and records reviewed (R.R), it was determined that the facility failed to ensure that sufficient nursing personnel are available all the time to provide nursing care according to patient needs for 7 out of 7 R.R #3, #4, #5, #6, #7 and 2 out of 2 patients interview (IV) patients IV #1 and #2 interview.

Findings include:

1. During the review of the daily nursing staffing program and interview with the DON employee #10 on 7/12/12 at 8:30 am related to the staffing pattern, she stated "in 2012 I evaluated the staffing pattern and it needed 3 registered nurses (RN), the pediatric emergency room needed 2 RNs, the surgery ward needed 2 RNs, the medicine ward needed 1 RN, the pediatric ward needed 3 RNs, The intermediate ward needed 3 RNs and the operating room needed 2 RNs to cover the three shift (7-3, 3-11,11-7) with sufficient RNs to cover patient care needs.

2. A mechanism to ensure that the facility provides sufficient registered nurse that are immediately available for the care of patients, was not found or followed, nor performed as evidenced by the following:

a. The patient IV# 1 was interview on 7/10/12 at 10:05 am said "I called the nurses and it takes them a long time to arrive, around 20 to 30 minutes". She stated that the venous puncture area of the intra venus fluid hurts a lot and when the nurse arrived she removed the IV and it had an edematous area.

b. R.R #3 is a 46 years old female who was admitted on 7/8/12 with a diagnosis of Cellulites Abscess Lumbar Area and Asthma. The patient stated during an interview on 7/10/12 at 10:27 am that last night she activated the nursing call system and told them that she had a lot of pain and they never came, and it is not until the 7-3 shift that she was given Demerol. During the record review it was found that it did not have nursing progress notes shifts 7-3 and 3-11. The nursing progress note of the 11-7 shift was found with no evidence of the pain estimate. The skin care nursing note documents that the patient has cellulites on 7/9/12 of the lower lumbar area with radiation into the left buttock. Cellulite with bloody drainage exudates is less, erythema, hardened to the touch and pain.

c. R.R #4 is a 78 years old male who was admitted on 7/7/12 with a diagnosis of Chronic Liver Disease and Diabetes Mellitus Type II. During the record review on 7/11/12 at 9:00 am, a medical order for dextrostix every 8 hours was found. On 7/8/12 a DXT was not performed during the 3-11 shift and on 7/9/12 a DXT was not performed for the 3-11 and 11-7 shifts.

d. R.R #5 is a 63 years old female who was admitted on 6/1/12 with a diagnosis of Diverticulitis. During interview on 7/11/12 at 10:47 am, the patient said she activated the nursing call system and nobody responded. She called because she has a colostomy and it is draining all the time and she can not move. When her husband is around he cleans her all the time. The nurses come into the room a few times a day. During the record review on 7/11/12 at 9:40 am it was found without nursing progress notes on 7/8/12 shift 7-3. On 7/9/12 no nursing progress notes for the 3-11 and 11-7 shifts. On 7/10/12 no nursing progress notes for the 3-11 and 11-7 shifts were found.

e. R.R #6 is a 67 years old female who was admitted on 7/1/12 with a diagnosis of Cellulites and Left Leg Ulcer. During the record review on 7/11/12 at 10:24 am it was found without nursing progress notes on 7/5/12 shift 7-3. On 7/6/12 no nursing progress notes for the 3-11 shift were found. On 7/8/12 no nursing progress notes for the 3-11 shift were found. On 7/9/12 no nursing progress notes for the 3-11 shift were found. On 7/10/12 no nursing progress notes for the 7-3 and 3-11 shifts were found.

f. R.R #7 is an 88 years old female who was admitted on 7/1/12 with a diagnosis of Congestive Heart Failure (CHF) and Pneumonia. During the record review on 7/11/12 at 10:50 am it was found that there were no nursing progress notes on 6/30/12 shift 3-11. On 7/1/12 it was found without nursing progress notes from the 3-11 shift. On 7/3/12 it was found without nursing progress notes for the 3-11 shifts.

g. Patient IV #2 a 71 years old female who was admitted on 7/6/12 with Right Lower Extremity Cellulites and Diabetes Mellitus. During interview on 7/10/12 at 10:05 am she said "I activated the nursing call system and someone told me they were coming to help me and they arrived two hours later. I called because they left my food on a table far away and I could not reach it and I couldn't stop looking at the food".

Based on the review of clinical records and policies/procedures with the director of nursing (DON) (employee #10), it was found that the facility failed to ensure that 5 out of 7 records reviewed (R.R #2, #3, #4, #13 and #14) have developed, updated and implemented nursing care plans.

Findings include:

1. Five out of seven records reviewed for care plans from 7/10/12 through 7/12/12 from 9:30 am till 3:30 pm with the DON employee #10, provided evidence that care plans do not have written evidence of revisions during the patients' hospital stay related to their needs:

a. R.R #2 is a 2 years old male who was admitted on 7/8/12 with Acute Gastroenteritis, no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay. The facility used a standardized plan of care, however no evidence was found that the facility's nurses individualized the plan of care according to the patient's needs. No evidence was found of goals and objectives established to coordinate patients' nursing care.

b. R.R #3 is a 46 years old female who was admitted on 7/8/12 with Cellulites Abscess Lumbar Area and Asthma, no evidence was found of the standardized plan of care.

c. R.R #4 is a 78 years old male who was admitted on 7/7/12 with Intoxication with Coumadin, Rectal Bleeding and Alzheimer, no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay. The facility used a standardized plan of care, however no evidence was found that the facility's nurses individualized the plan of care according to the patient's needs. No evidence was found of goals and objectives established to coordinate patients' nursing care.

d. R.R #13 is an 89 years old female who was admitted on 7/9/12 with Cerebrovascular Accident, no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay. The facility used a standardized plan of care, however no evidence was found that the facility's nurses individualized the plan of care according to the patient's needs. No evidence was found of goals and objectives established to coordinate patients' nursing care.

e. R.R #14 is a 72 years old male who was admitted on 6/26/12 with an Ulcer and Cellulites of the left Leg and Diabetes Mellitus Type II, no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay. The facility used a standardized plan of care, however no evidence was found that the facility's nurses individualized the plan of care according to the patient's needs.

Based on the documents reviewed with the director of nursing (employee #10), it was determined that the facility failed to assign nursing care for patients related to patient's needs and care.

Findings include:

1. Patient's categories at pediatric ward were reviewed on 7/10/12 at 10:10 am and provided evidence that they were not performed during the followings dates: June 2 shift 7-3, 3-11 and 11-7, June 3 shift 7-3, 3-11 and 11-7, June 8 shift 7-3, 3-11 and 11-7, June 9 shift 7-3, 3-11 and 11-7, June 10 shift 7-3, 3-11 and 11-7, June 11 shift 7-3, 3-11 and 11-7, June 16 shift 7-3, 3-11 and 11-7, June 17 shift 7-3, 3-11 and 11-7, June 21 shift 7-3, 3-11 and 11-7, June 23 shift 7-3, 3-11 and 11-7 and June 24 shift 7-3, 3-11 and 11-7.

2. Patient's categories at the intermediate ward were reviewed on 7/11/12 at 9:30 am and provided evidence that they were not performed during the followings dates: June 3 shift 7-3, 3-11 and 11-7, June 4 shift 7-3, 3-11 and 11-7, June 5 shift 7-3, 3-11 and 11-7, June 6 shift 7-3, 3-11 and 11-7, June 9 shift 7-3, 3-11 and 11-7, June 10 shift 7-3, 3-11 and 11-7, June 11 shift 7-3, 3-11 and 11-7, June 15 shift 7-3, 3-11 and 11-7, June 16 shift 7-3, 3-11 and 11-7, June 17 shift 7-3, 3-11 and 11-7, June 18 shift 7-3, 3-11 and 11-7, June 19 shift 7-3, 3-11 and 11-7, June 20 shift 7-3, 3-11 and 11-7, June 21 shift 7-3, 3-11 and 11-7, June 22 shift 7-3, 3-11 and 11-7, June 23 shift 11-7 7-3, 3-11 and 11-7, June 24 shift 7-3, 3-11 and 11-7, June 26 shift 7-3, 3-11 and 11-7, June 29 shift 7-3, 3-11 and 11-7, June 30 shift 7-3, 3-11 and 11-7 and July 1 shift 7-3, 3-11 and 11-7.

Based on the observations of the medication drug cart with the director of nursing (DON) (employee #10), it was determined that the facility failed to ensure that drugs and biological are stored and protected in a proper manner related to medications not secured in the medication cart and drug administration procedure.

Findings include:

1. During the observational tour of pediatric ward on 7/10/12 at 9:20 am with the DON employee #10, the medication cart was observed unattended while the nurse was in a patient's rooms.

2. The following was observed during the medication administration on 7/10/12 from 9:25 am through 9:50 am related to medication administration:

a. During observation of the medication administration (oral medication) performed on 7/10/12 at 9:25 am accompanied by a Registered Nurse (RN) (employee #20), it was identified that she entered room #136-A, the nurse gave a capsules in a cup of Intestinex to the mother of the child and told her how to give it and left the room. The drug administration by the RN failed to ensure that the drug administration procedure protects patients related to safety. The drug administration performed by the RN does not follow nursing standards of practice for drug administration.

b. During the observational tour and medication administration in the room #136-b it was observed on 7/10/12 at 9:30 am accompanied by the DON employee #10 that the patient's night table had a cup of powder with Intestinex.

c. During an interview with the patient's mother on 7/10/12 at 9:35 am she said that the nurse left the medication and told her that when the patient wakes up that she could give the medication. The drug administration by the RN failed to ensure that the drug administration procedure protects the patients related to safety. The drug administration performed by the RN does not follow nursing standards of practice for drug administration..

3. During the observational tour of surgery ward on 7/10/12 at 10:47 am with the DON employee #10, the medication cart was observed unattended while the nurse was in patient's rooms.

a. The following drugs were found in the surgery ward on 7/10/12 at 10:50 am on the top of the medication cart: Lovenox, Novolin 70/30 and Dilantin 125/5ml. The Medication Administration Record (MAR) was also observed open.

b. During the medication administration (subcutaneous anticoagulant) on 7/10/12 at 11:15 am it was observed that in room #121 the RN employee #19 put the patient in supine position, cleaned the abdomen 5 times in a circular motion with the same alcohol swab and applied the Lovenox. The nurse fails to use aseptic measures in the administration of the medication.

c. During the medication administration on 7/10/12 at 11:18 am it was observed in room #122-A with the RN employee #19 that the patient was to receive Cozar 10 mg tablet and Invanz 1 Gm injection.

d. During interview with the nurse on 7/10/12 at 11:20 am she said that these drugs are not currently available. She also stated that sometimes drugs that the pharmacy supplies are not complete and during the shift they supply the missing ones. Not having complete medications slows the process. She stated that she began administering medications at 9:00 am and it is 11:18 am now and she was still missing drugs and patients to complete the drug pass. The facility failed to ensure that drugs are administered within 30 minutes of the scheduled time for administration.

e. During the intravenous (IV) medication administration to the patient in room #107-B on 7/10/12 at 10:20 am with a RN employee #21, the nurse was observed administering medications by IV line. The nurse cleans the port of IV line 4 times with the same alcohol. The nurse failed to follow aseptic measures of infection control.

4. During the observational tour of medicine ward on 7/10/12 at 10:17 am with the DON employee #10, the medication cart was observed unattended while the nurse was in patient's rooms.

5. During the medication administration (inhalation medication) to the patient in room #216-A on 7/12/12 at 1:26 pm with the DON employee #10, the RN employee #22, it was observed administering medications by inhalation (Advair). The nurse tells the patient about the medication and its side effects. She tells him to place the Advair in his mouth and inhale. The patient does it twice and the nurse asks if he felt the powder and he said no and the nurse left. The nurse failed to ensure that the patient received the dose as ordered. Advair literature says that the patient opens the diskus, hold the diskus to level, flat position with the mouthpiece toward the user. Before inhaling the dose from the diskus, breathe out (exhale) fully while holding the diskus level and away from the mouth. Remove the diskus from the mouth. Hold breath for about 10 seconds, or for as long as is comfortable. Close the diskus then patient is finished taking a dose so that the diskus will be ready for the next dose.

Based on the observations of the medication drug cart with the director of nursing (DON)(employee #10), it was determined that the facility failed to ensure that drugs and biologicals administered within 30 minutes of the scheduled time for administration.

Findings include:

During the medication administration on 7/10/12 at 11:18 am it was observed in room #122- with the RN employee #19 that the patient was to receives Cozar 10 mg tablet and Invanz 1 Gm injection. During interview with the nurse on 7/10/12 at 11:20 am she said that these drugs are not currently available. She also stated that some times drugs that the pharmacy supplies are not complete and during the shift they supply the missing ones. Not having complete medications slows the process. She stated that she began administering medications at 9:00 am and it is 11:18 am now and she was still missing drugs and patients to complete the drug pass. The facility failed to ensure that drugs are administered within 30 minutes of the scheduled time for administration.

Based on the review of the policies and procedure's manual, a manual of abbreviations and personnel signature registry provided by the medical record administrator (employee
#28), it was determined that the facility failed to maintain an updated and approved by the Governing Body abbreviations and signature registry and are reviewed and revised as needed.

Findings include:

1. No evidence was found on 7/12/12 at 3:00 pm of an abbreviation manual that was updated and approved by the Governing Body and includes the pharmacy supervisor's signature of participation.

2. The signature registry of physicians and other disciplines (nursing, dietitian, respiratory therapist) were reviewed with the Medical Record Administrator (employee #28) on 7/12/12 at 3:00 pm. The signature registry was not updated nor was it approved by the Governing Body.

Based on the observational tour of the medical records department through the central file area with the medical record administrator (employee #28) and interviews, it was determined that the facility failed to properly secure the central file of the medical records department, it is completely full to capacity.

Findings include:

1. The central file of active records was visited on 7/12/11 at 2:30 pm and was found completely full to capacity (second floor). The physical area does not have extra space available for new records to be filed. Approximately 5,000 emergency room clinical records were observed in the first floor over different counter tops and tables without being filed because there is not enough space for storage. Approximately 500 emergency room clinical records were observed over the shelves near the entrance of the medical record room without being filed.

2. The second floor of the medical record department was visited on 7/12/12 at 2:30 pm and found with approximately 30 boxes with clinical records directly on the floor in a hallway near metal storage cabinets waiting to be moved to a contracted storage area. A medical record employee (employee #29) stated that it will take at least another month to move all the boxes from the floor and record the record numbers and then to send them to the storage area.

Based on the observational tour of the medical records department, it was determined that the facility failed to ensure that medical records are protected from unlawful entry and are protected from the environment outside.

Findings include

1. The medical record department was visited on 7/12/12 at 8:40 am with the facility's Engineer (employee #34) and the following was determined:
a. This department is located in a residential building next to the hospital (off campus). Personnel pass through a ramp and a controlled access gate to get to this building. This area has glass doors and large windows, but they do not have security bars or gates on them or a central alarm to ensure that the medical records are safe guarded.
b. Two windows on the second floor with large glass panels were observed cracked and had open spaces that rain and debris could enter and two other glass panels had hair line cracks.

Based on the review of fifty-six closed and active clinical records with nursing personnel and medical record Administrator (employee #28), it was determined that the facility failed to ensure that medical staff, nursing personnel and other disciplines maintain legible entries for fifty-six out of fifty-six records reviewed (R.R #1 through #56).

Findings include:

Fifty-six clinical records reviewed from 7/10/12 through 7/13/12 from 9:30 am till 4:00 pm contained portions that are not legible. Most notable were the physician's progress notes, nurse's notes, signatures (physicians and nurses), consults, diagnosis, operative reports, informed consent forms, anesthesia reports and physician's orders.

Based on the review of eight records reviewed (R.R) for operating room, it was determined that the facility failed to ensure that 4 out of 8 records contain appropriate documents related to consult evaluations and appropriate findings by clinical and others staff involved in the care of the patient (R.R #52, #54, #55 and #56).

Findings include:

1. R.R #52 was reviewed on 7/13/12 at 11:40 am and failed to provide evidence on a consult of the patient room number, the hour when was requested and the handwriting is not legible. The consult was request on 5/1/12 and was performed by the physician on 5/4/12 at 10:30 am. (one day later).

2. R.R #54 was reviewed on 7/13/12 at 10:00 am and failed to provide evidence on the requested consult of the physician signature.

3. R.R #55 was reviewed on 7/13/12 at 10:34 am and failed to provide evidence on one consult of the patient room number, the date and hour when the consult was notified and who notified the consult and to whom the consult was notify too.

4. R.R #56 was reviewed on 7/13/12 at 7:35 am and failed to provide evidence on one consult related to the patient room number, date and hour when it was requested, who notified the consult, the date and hour when was notified and to whom it was notified.

Based on the review of documents, observational tour with the X-Ray Director (employee #17) and Pharmacist (employee #18), it was determined that the facility failed to ensure that the drug storage areas are administered in accordance with accepted professional principles related with the lack of an updated list of medications with the date of expiration for the nuclear medicine crash cart and emergency container.

Findings include:

During the observational tour of the nuclear medicine area on 7/11/12 at 1:30 pm, it was found that a plastic container with medications and equipment for cardiorespiratory emergencies was over the medication crash cart. This container does not have available an updated list of medications with the date of expiration included. A list was not available with the medications with the date of expiration of the crash cart either.

Based on the review of medication adverse drug reactions reports with the Pharmacist
(employee #18), it was determined that the facility failed to promote that drug reactions and drug incompatibilities are immediately reported to the attending physician and if appropriate to the hospital-wide quality assurance program and investigate circumstances where medication irregularities occurred.

Findings include:

1. This facility dispatches approximately 45,000-50,000 medications monthly. However from the period of January through June of 2012 only two adverse drug reactions were reported and documented. The facility failed to promote the immediate reporting of drug reactions and incompatibilities to the pharmacy department as determined on 7/11/12 at 10:00 am.

2. According with information provided by the Pharmacist (employee #18) on 7/11/12 at 9:50 am, the medication error monthly report (from January/2012 through June/2012) omissions are the highest percent of incidents found. However investigation of the circumstances where the omissions occurs were not performed on an ongoing basis, in order to determine reasons for the omissions and implement corrective actions to improve the medication administration process. The facility failed to identify and take actions in response to medication administration irregularities.

1. Based on observation and interview with the laboratory testing personnel on 7/10/2012 at 11:30 AM, it was determined that the laboratory did not have enough testing space for all the services offered in the coagulation, chemistry, immunohematology and general immunology areas.
The findings include:
a. The coagulation, immunohematology and general immunology counter area measured 12 " x 3 " . Over the counter the following instruments and materials were observed: Clay Adams centrifuge, syphilis serology rotator, computer monitor and keyboard, tube racks, tube dispenser, six reagent kits and disposable pipettes box.
b. The routine and special chemistry area measured 15 " x 17 " . In the area the following instruments were observed: ELECSYS 2010, Fusion 5.1 , Vitros 250 and ECI. Over the instruments were also observed several quality control and maintenance records. Also the surveyor observed an alcohol swab box, cotton tip applicator box and test tube racks (7).
c. The testing personnel did not have space for specimen preparation nor paper work.
2. Based on review of records and interview with the testing personnel, it was determined that the laboratory failed to include a non reactive and a tittered reactive control material when they processed and reported syphilis serology patient test with tittered results.
The finding includes:
a. The laboratory processed and reported the following reactive patient samples with tittered results and no non reactive nor a tittered control material were included with the patient ' s sample
Date Patient Result
3/27/2012 45485 Reactive 1: 16 dils
6/20/2012 72981 Reactive 1:16 dils
7/6/2012 75038 Reactive 1:4 dils
3. Based on lack of records and interview with the laboratory testing personnel, it was determined that the laboratory failed to evaluate the new control materials prior to use it with patient samples.
The findings include:
a. The laboratory began to use on 2/21/2012 the new control material (lot numbers 160406 and 160409) for follicular stimulating hormone, quantitative pregnancy, luteinizing hormone, prolactin and estradiol tests. However, no evaluation of the stated manufacturer ' s values was performed prior to use it with patient samples.
b. The laboratory began to use on 4/1/2012 the new control material (lot numbers 164664 and 164665) for troponin test. However, no evaluation of the stated manufacturer ' s values was performed prior to use it with patient samples.
c. The laboratory began to use on 6/1/2012 the new control material (lot numbers 165086 and 165087) for CKMB test. However, no evaluation of the stated manufacturer ' s values was performed prior to use it with patient samples.

Based on the kitchen observational tour with the administrative dietitian (employee #14), review of policies/procedures and food code guidelines, it was determined that the facility failed to operationalize procedures to ensure that relative humidity and temperature in the enteral storage room are recorded and registered, that walk-in freezer and refrigerators are not free of rust, personnel do not follow wiping cloth policies and procedures, cold food is not maintained at proper temperature and food is not labeled with the date when received.

Findings include:

1. The kitchen was visited with the administrative dietitian (employee #14) on 7/10/12 from 9:25 am through 12:18 pm and the following was determined:

a. No evidence was found of the temperature and humidity registration for the room used to prepare formula and enteral nutrition.

b. A lot of rust was observed on the floor of refrigerators #1, #2 and the walk-in freezer #4. Metal racks inside the walk-in freezer and refrigerators use to place food were observed with a lot of rust.

c. During the tray line service, two wiping cloths (towel type) were observed, one located at the right side of the steam table and one located in the area where trays are assembly by personnel. The administrative dietitian (employee #14) stated on 7/10/10 at 11:55 am that in the kitchen it is not allowed to use this type of wiping cloth.

d. Cups of milk located on a metal tray ready to be used for the tray line service, were observed covered with pieces of ice in order to maintain appropriate temperature. The dietitian (employee #14) took the temperature of the milk and it was found to be 45 ºF and the appropriate temperature should be no more than 41 ºF.

e. Cups with pineapple located on a metal tray ready to be used for the tray line service, were observed covered by pieces of ice in order to maintain appropriate temperature. The dietitian (employee #14) took the temperature of the item and it was found to be 46 ºF and the appropriate temperature should be at least 41 ºF.

f. The dietitian (employee #14) is not able to provide written procedures for the use of a chemical cleanser and test strip used in the three compartment sink.

g. In the kitchen's dry food storage area, it was identified that seventeen cans of 8.5 ounces mandarin oranges slices and nineteen cans of 42 ounces guava juice does not have the date when these items were delivered. The facility failed to store new products behind older ones in order to promote "first in first out" rotation based on date received.

Based on five medical records reviewed (R.R) and policies/procedures, and interview with the clinical dietitian (employee #15) and administrative diettitian ( employee # 14 ) it was determined that the facility failed to ensure that patient's nutritional requirements are addressed according with professional standards of practice.

Findings include:

A. A mechanism to ensure that patients who are feed by nasogastric or gastrostomy tubes receive appropriate treatment and services to prevent complications was not performed, nor followed for two out of five records reviewed (R.R #24 and #25). The following findings were found during the review of cases who had orderd enteral feeding with the clinical dietitian (employee #15) on 7/10/12 at 11:40 am:

1. R.R #24 is a 78 years old female admitted to the facility on 6/26/12 with a diagnosis of Pneumonia. The patient was admitted with a nasogastric tube and the physician was ordered to remain NPO until 6/27/12. On 6/27/12 at 11:46 am the dietitian evaluated the patient and recommended to begin with Diabetic source enteral formula at 30 ml/hour for 16 hours; to reach a goal of 67ml/hour. Instead of being continuously administered it has to be administered in a bolus, due to the lack of enteral feeding machines in the hospital. Enteral feeding for this patient started to be administered by bolus, but on 6/30/12 the patient develop diarrhea and the dietitian re-assessed the patient, and recommended as a priority to get an enteral feeding machine for this patient in order to prevent complications and enhance adequate tolerance and absorption. The patient continued presenting diarrhea episodes intermittently. However, the enteral feeding machine was not available until 7/6/12 when the patient was started on continuous enteral feeding.

2. R.R #25 is a 74 years old male admitted to the facility on 7/7/12 with a diagnosis of Sacral Ulcer, R/O Sepsis, Hx of Alzheimer and Dehydration. The patient was admitted with a PEG tube and gastrostomy. On 7/8/12 at 8:30 am the dietitian evaluates the patient and recommends to begin with Peptamen 1.0 enteral formula at 30 ml/hour for 16 hours; to reach a goal of 80ml/hour. Instead of being continuously administered it was started as a bolus, due to the lack of enteral feeding machines in the hospital. However, during the initial evaluation the dietitian made a written recommendation to proceed to administer the enteral feeding by machine if the machine was available in order to prevent complications and enhance adequate tolerance and absorption.

3. The Clinical dietitian (employee #15) was interviewed on 7/10/12 at 1:00 pm and she stated that due to the lack of availability of enteral feeding machines in the facility, when she assesses patients for nutritional risk for those patients who need nutritional support with enteral feedings, she make recommendations for the feeding by bolus and for the feeding continuously in the event that the machine was available. Enteral feedings can be delivered as a bolus or continuously, depending on the patient ' s clinical situation. But patients who are critically ill must receive appropriate treatment to prevent aspiration, vomiting, diarrhea, dehydration and metabolic abnormalities.

4. The administrative dietitian (employee #14) was interviewed on 7/10/12 at 1:15 pm and she stated that the facility only has 5 enteral feeding machines and they were in the process of having a contract with a company to deliver six more machines to be used with patients. However, she does not know approximately when the machines are going to be available.

5. The dietitian (employee # 14) was not able to provide written procedures for the administration of enteral feeding by bolus on 7/10/12 at 1:20 pm.

Based on tests performed on equipment, interviews and observations made during the survey for the physical environment with the facility's Engineers (employee #33) and (employee #34), it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well being of patients receiving services related to
the 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 long fluorescent light bulbs that did not have protective plastic covers, the roof of the emergency room leaks, the air conditioner leaks in the pharmacy department, the minor surgery room is not properly maintained, the pediatric emergency room is not properly maintained and the Intensive Care Unit failed to record temperature and humidity for the sterile material storage room, the facility failed to follow established procedures for the storage of biohazardous and regular trash related to the outside metal biohazardous and regular trash storage containers that were found opened and unlocked, the facility failed to ensure that it is in compliance with Federal and State laws related to an expired Fire Department Endorsement, the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to the respiratory therapy department not properly maintained, crash carts without oxygen cylinders, the back door of the laboratory department has a space at the bottom where vermin can pass, the X-ray department is not properly maintained, the main material supply area and medical record department are not maintained to safeguard its contents and defibrillators at the X-ray and Nuclear medicine departments did not receive regular preventive maintenance, the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to the respiratory therapy department not properly maintained, crash carts without oxygen cylinders, the back door of the laboratory department has a space at the bottom where vermin can pass, the X-ray department is not properly maintained, the main material supply area and medical record department are not maintained to safeguard its contents and defibrillators at the X-ray and Nuclear medicine departments did not receive regular preventive maintenance, the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas which are not equipped with an air disinfection system; also it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101, cited tags are K0018, K0022, K0033, K0046, K0048, K0050, K0051, K0052, K0064, K0075, K0130, K0134, K0144, K0147 and K0211. All of the above findings makes this condition "Not Met".

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Engineers (employee #33) and (employee #34) and interview, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well being of patients receiving services related to long fluorescent light bulbs that did not have protective plastic covers, the roof of the emergency room leaks, the air conditioner leaks in the pharmacy department, the minor surgery room is not properly maintained, the pediatric emergency room is not properly maintained and the Intensive Care Unit failed to record temperature and humidity for the sterile material storage room.

Findings include:

1. Exposed light fixtures were observed on 7/12/12 from 8:40 am through 9:10 am with the facility's Engineer (employee #34) in medical record department and in the general material supply department. These departments have long fluorescent light bulbs that did not have protective plastic covers over the fixtures or on the light bulbs; as personnel work in these area, these fluorescent light bulbs can break and the small pieces of glass can fall on personnel or into their eyes.

2. Water stained ceiling acoustic tiles were observed on 7/10/12 at 9:25 am with the facility's Engineer (employee #33) at the emergency room department. The Engineer stated during an interview on 7/10/12 at 9:30 am that the roof has been leaking since the recent rain storms. The facility must ensure that the roof is properly fixed to maintain emergency room integrity and safety.

3. The minor surgery room of the emergency room was visited on 7/10/12 at 9:50 am with the facility's Engineer (employee #33) and provided evidence that the facility failed to record temperature and humidity for this room to ensure that it complies with appropriate perimeters.

4. The minor surgery room of the emergency room was visited on 7/10/12 at 9:52 am with the facility's Engineer (employee #33) and provided evidence that the light fixture above the treatment bed in this room was detaching from the ceiling, which does not allow for proper cleaning and causes a risk for pieces of gypsum board to fall over patients being treated.

5. The minor surgery room of the emergency room was visited on 7/10/12 at 9:55 am with the facility's Engineer (employee #33) and provided evidence that there is a small room within this area for orthopedic procedures that was found with the following:
a. It is used as a storage area for broken and used equipment (I.V stands, wheel chairs and I.V pumps),
b. This room has a strong malodorous smell near and around the sink with the cast trap. No evidence was provided when the trap was last cleaned.

6. The air conditioner in the pharmacy department was observed on 7/10/12 at 2:10 pm with the Facility's Engineer (employee #33) and provided evidence that two large garbage containers were collecting water leaking from the air conditioner unit at two different sites.

7. The curtain around bed #216B was observed broken on 7/10/12 at 3:10 pm with the facility's Engineer (employee #34).

8. The following was observed at the pediatric emergency on 7/11/12 at 8:30 am with the facility's Engineer (employee #34):
a. The door of the medication preparation room was observed broken.
b. The waiting room does not have a water fountain or cooler.
c. Observation cubicles #4 and #5 is only 100 square feet combined and does not have a curtain to divide the two cubicles.
d. All treatment stretchers/beds were found with rust.

9. The Intensive Care Unit was visited on 7/11/12 at 1:50 pm with the facility's Engineer (employee #34) and provided evidence that the facility failed to record temperature and humidity for the sterile material storage room to ensure that it complies with appropriate perimeters.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Engineers (employee #33) and (employee #34), it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0018, K0022, K0033, K0046, K0048, K0050, K0051, K0052, K0064, K0075, K0130, K0134, K0144, K0147 and K0211).

Based on observations made during the survey for the physical environment with the facility's Engineer (employee #34) and interview, it was determined that the facility failed to follow established procedures for the storage of biohazardous and regular trash related to the outside metal biohazardous and regular trash storage containers that were found opened and unlocked.

Findings include:

1. The outside metal biohazardous storage container located at the back of the facility was visited on 7/11/12 at 10:10 am with the facility's Engineer (employee #34) and provided evidence that one of the doors was wide open and unlocked which does not prevent unauthorized access. The facility's Engineer (employee #34) stated during an interview on 7/11/12 at 10:15 am that these doors where biohazardous materials are placed are to be kept in a locked and secure area, away from unauthorized persons.

2. An outside metal trash container/compactor located at the back of the hospital was visited on 7/11/11 at 10:20 am and provided evidence that the main hatch where small trash containers are emptied was found wide open with an accumulation of trash. The facility's Engineer (employee #34) stated on 7/11/12 at 10:25 am that regular trash is to be compacted to ensure that trash does not remain in the hatch. The trash container/compactor does not have a metal or plastic door that can be swung over the hatch after the trash is compacted to ensure that trash is not accessible to pigeons, pests and rodents; the trash container/compactor is approximately 100 feet from the hospital.

Based on the review of hospital licenses/certifications, it was determined that the facility failed to ensure that it is in compliance with Federal and State laws related to an expired Fire Department Endorsement.

Findings include:

During the review of the facility's licenses/certifications on 7/13/12 at 11:30 am, it was identified that the facility's Fire Department Endorsement expired on May 5, 2012. The facility provided evidence that they submitted and paid for the fire department inspection, but they have not arrived to perform the inspection and give them the endorsement.

Based on observations made during the survey for the physical environment with the facility's Engineers (employee #33) and (employee #34), it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to the respiratory therapy department not properly maintained, crash carts without oxygen cylinders, the back door of the laboratory department has a space at the bottom where vermin can pass, the X-ray department is not properly maintained, the main material supply area and medical record department are not maintained to safeguard its contents and defibrillators at the X-ray and Nuclear medicine departments did not receive regular preventive maintenance.

Findings include:

1. During the observational tour of the respiratory therapy department with the facility's Engineer (employee #33) on 7/10/12 from 10:10 am through 11:00 am, the following was found:
a. The area where ventilators are placed after they are cleaned was found with serious roof filtration which caused the ceiling paint to detach and the ceiling was observed with visible stains from the leaking roof.
b. Clean ventilators were also observed in the hallway of the respiratory therapy department, this hallway is used by maintenance personnel to bring dirty laundry into a back room located at this department. The dirty laundry room also has an outside entrance but when it rains they pass through the respiratory therapy department. Cleaned ventilators shall be kept separated, covered and out of the path of travel of dirty material. Dirty laundry should enter and leave the dirty laundry room from the same outside entrance to reduce possible cross contamination in the hospital.
c. The outside entrance door to the dirty laundry room was found broken on the bottom which can allow pests and vermin to enter this room.
d. The dirty laundry room does not have an air extractor (to ensure negative pressure) or a hand sink for personnel to wash their hands after sorting the dirty linen.
e. The respiratory therapy department also has a back door to access the clean linen room. Facility personnel also access the respiratory therapy department to retrieve clean linen and surgical scrubs when it is raining, even though the clean laundry room has an outside entrance.
f. The clean laundry room was also found with wall filtration under the wall mounted air conditioner. Against this wall were hanging surgical scrubs (many without plastic covers) on a metal pole and against this wall was also the sorting table.

2. The crash cart located at the surgery ward was found without a type E oxygen cylinder attached to the cart on 7/11/12 at 9:30 am with the facility's Engineer (employee #34). To ensure that patients receive immediate care in the event of an emergency the oxygen cylinder shall be attached to the crash cart to ensure that it goes where the cart goes.

3. The laboratory department was visited on 7/11/12 at 1:20 pm and provided evidence that the back exit door has a space at the bottom of the door where pests and vermin can pass into the laboratory department. A weather strip at the bottom of the door is needed to protect this area from pests from the outside.

4. The X-ray department was visited on 7/11/12 at 1:20 pm with the facility's Engineer (employee #34) and the following was found:
a. Ceiling acoustic tiles were missing.
b. The fire extinguisher was hanging from its safety pin.
c. The waiting room does not have a water fountain.

5. The medical record department was visited on 7/12/12 at 8:40 am with the facility's Engineer (employee #34) and the following was determined:
a. This department is located in a residential building next to the hospital (off campus). Personnel pass through a ramp and a controlled access gate to get to this building. This area has glass doors and large windows, but they do not have security bars or gates on them or a central alarm to ensure that the medical records are safe guarded.
b. Two windows on the second floor with large glass panels were observed cracked and had open spaces that rain and debris could enter and two other glass panels had hair line cracks.
c. The air conditioner return room located on the first floor was found with approximately 200 medical medicals (these records were removed 7/12/12 at 1:00 pm).

6. The main material supply area located in a building next to the hospital was visited on 7/12/12 at 9:10 am and provided evidence that this area is located in a residential building next to the hospital (off campus). Personnel pass through a ramp and a controlled access gate to get to this building. This area has glass doors and large windows, but they do not have security bars or gates on them or a central alarm to ensure that this area and material are safe guarded.

7. The main material supply area located in a building next to the hospital was visited on 7/12/12 at 9:10 am and provided evidence that this area is located in a residential building next to the hospital (off campus). Personnel pass through a ramp and a controlled access gate to get to this building. A personnel (employee #35) was observed removing supplies on an open cart with wheels on 7/12/12 at 9:15 am. The cart was stacked high and as he moved the cart material began to fall off the cart and then it started to rain slightly and the material got wet. The facility failed to ensure the integrity of supplies from the supply building to the hospital.

8. During the review of preventive maintenance documentation of the defibrillators of the Nuclear medicine department and X-ray department on 7/12/12 at 2:45 pm, it was determined that the defibrillator located in the Nuclear medicine department was last verified by biomedical services in May of 2011 and the defibrillator in the X-ray department was last verified by biomedical services in March of 2009.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Engineers (employee #33) and (employee #34) and interview, it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to the respiratory therapy department not properly maintained, crash carts without oxygen cylinders, the back door of the laboratory department has a space at the bottom where vermin can pass, the X-ray department is not properly maintained, the main material supply area and medical record department are not maintained to safeguard its contents and defibrillators at the X-ray and Nuclear medicine departments did not receive regular preventive maintenance.

Findings include:

1. The two handicapped toilets (male and female) located within the emergency room (E.R) waiting area were visited on 7/10/12 at 9:15 am with the facility's Engineer (employee #33) and it was found that grab bars are needed behind both toilets (these toilets have only one grab bar, but at least two are required. They can either be placed on both sides of the toilet or on one side and behind the toilet).

2. The two handicapped toilets (male and female) located within the emergency room (E.R) waiting area were visited on 7/10/12 at 9:15 am with the facility's Engineer (employee #33) and provided evidence that they did not have emergency call systems (ECS) to notify personnel if help is needed (the facility installed the ECS before the end of the day).

3. The handicapped parking spaces in front of the emergency room were visited on 7/10/12 from 9:00 am till 9:15 am with the facility's Engineer (employee #33) and the following was found:
a. The handicapped parking spaces in front of the emergency room do not have handicapped signs and one of these signs must indicate "Van Accessible" and have the appropriate space requirements.
b. The handicapped spaces are not divided with the appropriate painted divisions.
c. The path of travel from the handicapped parking spaces to the ramp of the building (crosses a road) is not painted with the appropriate lines to advise persons in cars to be aware of persons crossing.

4. The ramp located outside of the emergency room (E.R) near the ambulance entrance to the E.R was visited on 7/10/12 at 9:10 am with the facility's Engineer (employee #33) and was found with only one hand rail on one side of the ramp. To ensure that persons with impediments on either side of their bodies can safely access this ramp, hand rails are needed on both sides of the ramp according with the "Americans with Disabilities Act" (Ley ADA) requirements.
a. Also, the ramp located within the hospital near the laboratory department was observed on 7/11/12 at 1:10 pm with only one hand rail on one side.

5. The emergency room was visited on 7/10/12 at 9:30 am with the facility's Engineer (employee #34) and it provided evidence that there are seven observation cubicles. Observation cubicles #1 and #7 all contained two patients each. Within these cubicles there were only one nursing call system each and no ceiling mounted curtains to separate the patients in these cubicles.

6. The isolation room of the emergency room was visited with the facility's Engineer (employee #33) on 7/10/12 at 9:45 am and provided evidence that there is a space between the negative pressure machine and the wall it's mounted on. The light of day could be seen through this space and the facility must verify this space and seal it to ensure the integrity of the isolation room and the proper function of the negative pressure machine.

7. All janitors' closets, biohazardous closets and dirty linen closets throughout the facility were visited from 7/10/12 through 7/13/12 from 8:00 am till 4:00 pm with the facility's Engineer (employee #33). These closets did not have functional air extractors, door closers or fire rated doors.

8. The janitor's closet located at the surgery ward was visited on 7/11/12 at 9:25 am with the facility's Engineer (employee #34) and provided evidence that it does not have a floor receptor (floor sink). A service sink was found at approximately three feet high (from the floor), which increases the risk of staff hurting themselves when lifting pails filled with dirty water and splashing.

9. The operating room department was visited on 7/11/12 from 1:15 pm till 3:15 pm with the facility's Engineer (employee #34) and provided evidence of the following:
a. The patient's dressing room handicapped toilet (male and female) seat is 15 inches high from the ground, but to comply with "Americans with Disabilities Act" (Ley ADA) it needs to be at least 17-19 inches in height from the floor to ensure that patients can get up and sit down with ease and grab bars are needed for the toilet (at least two grab bars are required, they can either be placed on both sides of the toilet or on one side and behind the toilet). Also the soap and paper dispensers were measured at 58 inches in height, but the handle or push button must not exceed 48 inches in height.
b. Observations made during the initial tour provided evidence that the biohazardous closet had four full bags of waste placed directly on the floor on blue pads.
c. The facility operates on ambulatory patients but they do not have a designated phase II area. The lounge chairs for this area must be separated by curtains and there needs to be at least four feet between each chair and the seats should be placed to avoid visual contact from patient to patient, area for patient's family members and area for nursing personnel too write and have visual contact with patients.
d. Operating suite #2 is currently not in use waiting to be remodeled, however it was found with two trays of Cidex OPA. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media and no evidence was found that the facility has a spill kit to use if Cidex OPA accidentally fall on the floor.
e. The sterile material room does not have temperature and humidity daily registrations.
f. The front door of operating suite #4 does not close flush to its frame and was found partially open during a surgical procedure.
g. The handicapped toilet seats at the recovery room and waiting room (male and female) are at 15 inches high from the ground, but to comply with "Americans with Disabilities Act" (Ley ADA) it needs to be at least 17-19 inches in height from the floor to ensure that patients can get up and sit down with ease and the toilet at the waiting room does not have at least two grab bars.
h. The waiting room does not have a water fountain or water cooler.

10. The facility has two outside staircases located at the sides of the building used in the event of an emergency to egress from the second and first floors as observed on 7/11/12 at 12:00 noon with the facility's Engineer (employee #34). Both staircases only have one handrail on one side of the stairs instead of both sides to ensure that persons with limitations on either side of their bodies can access these stairs if needed.
a. The steps from the parking building which provides access to the hospital was found without handrails on both sides of the steps (three to four steps).

11. The emergency room was visited on 7/10/12 at 9:00 am and provided evidence that the triage room is looking out into the waiting room and main entrance. The triage room has three windows where persons can look into the triage room while patients are being accessed. The inside of the triage room has a curtain, however it was found that when the curtain is pulled down over the windows and doors, it prevents the triage nurse from seeing clearly out into the waiting room (to see patient's facial expression) and incoming patients from the main entrance. According with "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) section 5.1.3.4 and appendix A5.1.3.4, triage shall be located to permit staff observations and control of access to treatment areas, pedestrian and ambulance entrances and public waiting area.

12. The respiratory therapy department was moved to a new area as observed on 7/11/12 at 4:00 pm with the facility's Engineer (employee #34), however this area needs enough electrical receptacles to keep all of the ventilators (they have battery packs) plugged into and these receptacles must be connected to the generator, so that the ventilators can continue to be charged when the facility is on generator power.

Based on observations made during the survey for the physical environment with the facility's Engineer (employee #34), it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas which are not equipped with an air disinfection system (such as ultraviolet lights).

Findings include:

The emergency room (adult and pediatric) was visited on 7/10/12 from 9:00 am through 10:00 am and provided evidence that the waiting area, triage area and the observation area of the adult and pediatric emergency room are not equipped with an air disinfection system (for example: Ultraviolet lights). According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) the triage area is the point of entry of undiagnosed and untreated airborne infections and should be designed and ventilated to reduce exposure of staff, patients and families to airborne infectious diseases. Through the facility's infection control program, determinations must be made related to general ventilation and air disinfection similar to inpatient requirements for airborne infection isolation rooms according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". The waiting area and observation area are other areas to provide protection with an air disinfection system.

Based observational tour of the entire facility for infection control standards of practice and interview on 7/10/12 from 10:40 am till 12:30 pm through 7/12/12 from 9:00 am till 4:00 pm with Infection Control Officer (employee #16) , it was determined that the facility failed to maintain an active program for the prevention to comply of standards of infection control are followed related to materials exposed to the environment, housekeeping equipment and supplies were found unattended, sharp containers and linen were not protected properly, failure to ensure appropriate temperatures in the central storage area, venipuncture kit found on the floor, facility equipment not properly maintained, ventilator filters not changed according with manufacturer's recommendations and respiratory equipment a labeled, I.V venipuncture without labeled, failure to ensure that the outside laundry company and facility personnel handle clean and dirty linen appropriately, all of which makes this condition of participation "Not Met".

Based on the observational tour with Infection Control Officer (ICO) (employee #16), interviews and review of policies/procedures (P&P), it was determined that the facility failed to promote sanitary and safe care through its infection control program in the emergency room, laundry room, central supply department, operating room department, medicine intensive care unit and X-ray department related to improper infection control procedures and failed to follow infection control standards of practice.

Findings include:

1. The following was observed in the emergency room on 7/10/12 from 9:30 am till 3:00 pm related to infection control procedures:
a. The minor surgery room of the emergency room was visited on 7/10/12 at 9:55 am with the nursing supervisor (employee #30) and provided evidence that there is a small room used for orthopedic cases within this area that was found with broken and used equipment (I.V stands, wheel chairs and I.V pumps) and this room also has a strong odor near and around the sink with the cast trap, however no evidence was provided when the trap was last cleaned.
b. Small packages of gauze were observed on 7/10/12 from 9:30 till 12:00 noon in the treatment area, triage area, pediatric area, critical/surgery care area and on the I.V access cart without protective covers, exposing them to the environment.
c. A plastic container with tongue depressors was observed in the examination area, treatment area, pediatric area and critical/trauma room without protective covers exposing them when personnel take them out of the container.
d. One I.V bag of .45 normal saline was observed in the medication room with an expiration date of April 2012.
e. Sharp containers (3 gallon size) were observed without security bases during the observational tour of the emergency room on 7/10/12 from 9:30 am till 12:30 pm in the following areas: one in the triage room, one in the medication room, one in the blood sample collection area, one in the minor surgery room and one in the pediatric cardio area. Security bases and label are needed to protect the sharp containers from unauthorized removal.
f. Two multiple use vials of Xylocaine 2% (20 ml) used for local anesthesia were observed in the minor surgery room without labels indicating the date when they were opened as reviewed on 7/10/12 at 11:15 am which is not in accordance with CDC guidelines to label and discard after 28 days from opened.
g. Two single use vials of Furosemide 100mg/10ml were observed in the medication room without labels indicating the date when they were opened as reviewed on 7/10/12 at 11:20 am which is not in accordance with CDC guidelines to be discard after opened or use.
h. Heparin locks were found in cubicles #1 and #2 (cardio), #1 and #12 (observation) without labels with the date and time that the heparin lock was placed. The facility's policies and procedures were reviewed on 7/11/12 at 9:30 am and provided evidence that the heparin locks were to be changed every 72 hours.
i. Sharp containers (1 gallon size) were observed full with biohazardous waste and placed in the biohazardous trash containers in patient cubicles during the observational tour of the emergency room on 7/10/12 from 10:00 am till 12:30 pm (cubicles #1, #2, #4 and #5). The Nursing Supervisor (employee #30) stated on 7/12//12 at 10:10 am that maintenance employees remove the full sharp containers and placed them into the biohazardous trash container and then later they take them out of the area to the dumpster behind the facility.
j. Respiratory therapy equipment were observed in the pediatric area on 7/10/12 at 11:15 am in a plastic container (4 drawers) that was placed upon a wood base and the bottom two drawers were found filled with material and covered in dust.
k. In the closet used to place dirty linen, a large container was found used to deposit the linen, however it did not contain a plastic bag, which forces personnel to handle the dirty linen more than once.

2. No evidence was found of the daily registration of the cleaning and disinfecting of the digital thermometer in the triage room as reviewed on 7/10/12 at 10:45 am.

3. On 7/10/12 at 9:50 am the respiratory therapist (employee #32) was observed removing a ventury mask from the patient (from cubicle #5) and took it to the sink and rinse the mask with water, then dried it and put it back into a plastic bag (the respiratory therapist performed this task without gloves). Then he went into cubicle #1 (with a different patients) and connected the oxygen cannula to the patient, however he did not washing his hands first or use hand sanitizer.

4. On 7/11/12 at 9:00 am, housekeeping personnel (employee #26) was found cleaning the floor in the observation area and in the hallway in front of the treatment area. She stated that "the emergency room does not have a janitor ' s closet, so I use the janitor ' s closet at the pediatric ward " . She also stated that with this same pail and mop, she cleans the emergency room first, then the X-ray department. After she collects the garbage from the areas, she takes the mop out to the main garbage dumpster and there is where she cleans the mops with a hose and leaves it there to dry. Also, a material safety data sheet (MSDS) in the pediatric housekeeping room was not found.

5. The following was observed in the laundry room department (LRD) on 7/10/12 from 10:30 am till 11:30 am related to infection control procedures:
a. During the observational tour of the clean and dirty laundry rooms located on the ground floor with the laundry supervisor (employee #23) on 7/10/12 at 10:30 am till 11:30 am, it was determined that the facility's dirty laundry room has an outside entrance but when it rains they pass through the respiratory therapy department. Cleaned ventilators shall be kept separated, covered and out of the path of travel of dirty material. Dirty laundry should enter and leave the dirty laundry room from the same outside entrance to reduce possible cross contamination in the hospital.
b. The clean laundry room was also found with wall filtration under the wall mounted air conditioner. Against this wall were hanging approximately 30 surgical scrubs (many without plastic covers) on a metal pole and against this wall was also the sorting table.
c. The outside hallway in front of the dirty laundry room was found with four large bins that are filled with dirty linen after collected from the hospital. Personnel placed the dirty linen in this container until the next day in the outside hallway.
d. On 7/11/12 at 8:45 am the dirty linen room was visited again with the ICO (employee #16) and one laundry employee (employee #38) and the process of separating and counting the dirty linen and the protective equipment used by this employee was observed, she had a disposable gown, gloves and masks. The employee stated on 7/11/12 at 8:50 am that when the dirty linen arrives from the hospital areas she does not have to count the contaminated linen because it is written on the bags, only on occasions she counts them, but the dirty linen comes loose (without a blue bag) in the large transport bin. No evidence was found that the facility is evaluating possible cross contamination between clean and dirty linen.
e. On 7/11/12 at 10:45 am four mops were observed at an outside area of the hospital air drying with the pole against the floor and the mop against the wall. The maintenance supervisor (employee #27) stated on 7/11/12 at 11:00 am that every maintenance employee brings their mops to the same area and then wash them in this area (this area does not have a drain to collect the dirty water after rinsing the mops) and then leans them against the wall to air dry. She also stated that the mop are brought here because of the limited space in the janitor's closets.
f. On 7/11/12 at 11:45 am a pediatric maintenance employee (employee #37) was observed carrying the mop in her hand suspended in the air from the pediatric ward to the back area of the hospital where the hose is to clean the mops.

6. The following was observed in the X-Ray department on 7/11/12 from 11:00 am till 11:30 am related to infection control procedures:
a. One sharp container (3 gallon size) was observed without a security base during the observational tour of the X-Ray department on 7/11/12 at 11:00 am near the entrance and near of the blood sample collection area. A security base and label are needed to protect the sharp containers from unauthorized removal.
b. Two clean sheets used to cover patients were observed over the biohazardous waste container in the CT room on 7/11/12 at 11:10 am.

7. The following was observed in the central supply department (CSD) on 7/11/12 at 1:10 pm related to infection control procedures:
a. No evidence was found of the registration log to record temperature and humidity for the room used to maintain the sterile materials and the room did not have a thermometer to measure the temperature or another device to measure the humidity.
b. The area was found without ceiling acoustic tiles, the ICO stated during an interview on 7/11/12 at 1:15 pm that the acoustic tiles were removed when the air conditioner was repaired last week and they failed to put them back. This area was found with six boxes of adult briefs, three boxes of endotracheal tubes and one box of 1x1 gauze pads. Also, three trays with chest tubes were found on a shelf on the bottom rack within 12 inches from the floor.

8. The following was observed in the pediatric venepuncture area on 7/11/12 at 1:25 pm related to infection control procedures:
a. The tray used to perform venepuncture was found with an open package of gauze exposing it to the environment.

9. Record review (R.R) #33 was reviewed on 7/12/12 from 2:00 pm till 3:30 pm to verify documentation of Organ Procurement Responsibilities of patients who died while receiving treatment in the Emergency Room and provided evidence of the following:

a. R.R #33 is a 42 years old male who visited the emergency room (ER) on 1/28/12 at 3:58 pm with Fever and Viral Syndrome. The triage was performed at 3:58 pm and the patient was categorized as "non urgent" with the following vital signs (V/S): temperature-38.5ºC, pulse-91, respiration-17 and blood pressure-131/70 and complaint with generalize pain, fever, nauseas and vomits. The record was reviewed on 7/12/12 at 2:30 pm and provided evidence that the E.R physician evaluated the patient for fever as of four days ago with vomits and the patient's mother died about 2 to 3 weeks ago. The physician ordered treatment at 4:30 pm of .9% Normal Saline to run full drip, Pepcid 20 mg IV, Tigan 2 ml IM, Tylenol 500 mg stat, laboratory samples and chest X ray. The results of the laboratory taken on 1/28/12 at 5:30 pm provided evidence that the white blood cell (WBC) count was 11.72 ul, platelets on 293.0 ul and low sodium 134 mmol/l. On 1/29/12 at 12:05 pm the physician's discharge progress notes refers that the patient denies systemic disease, cough with sputum, diarrhea, melena, dysuria, cephalea and dyspepsia. The chest X-Ray provided evidence of no infiltrates seen, laboratory evidence of bacteria infection and grief reaction over mother's death. On 1/29/12 at 12:05 pm, the patient was discharged home (20 hours later) with the following recommendations: Regular diet, look for reactions and friends support to avoid depression, psychologist or psychiatric ambulatory evaluations, repeat (CBC) on 24-48 hours, observed for bleeding, hematomas, high fever, no aspirin or derivatives and only to take acetaminophen.

b. On 1/31/12 at 9:04 am the patient (R.R #33) returned to the ER (45 hours later) and the triage was performed at 8:52 am and was categorized as "urgent" with the following vital signs (V/S): temperature-39.1ºC, pulse-117, respiration-25 and blood pressure-95/60, oxygen saturation 99% and complaint with generalize malaise and fever. The ER physician evaluated the patient for fever, nauseas and cough with blood and a provisional diagnosis of Viral Syndrome, Fever and possible BKP. The physician ordered treatment at 9:30 am of .9% of Normal Saline to run 250 ml, Tylenol 500 mg stat, laboratory samples and chest X ray. The results of the laboratory taken on 1/31/12 at 10:00 am provided evidence that the (WBC) count was 6.91 ul, platelets on 183.0 ul, low sodium 132 mmol/l and low chloride 96 mmol/l. On 1/31/12 at 3:00 pm nursing progress notes were found that the patient was "observed in isolation and a vomited blood on the floor and the physician was notified". On 1/31/12 at 4:00 pm the CBC was repeated and type/cross was taken, PT-PTT sample and the WBC of CBC was taken and was notified by the laboratory as a "panic result" of .80 ul and platelets of 147.0 ul and prothrombin time of 16.4 sec. At 7:00 pm the respiratory therapist placed a ventury mask at 50% for respiratory difficulty with blood gas ph of 7.365, low pCO2 of 20.7, low pO2 of 57.1, low BE of 11.2, low HCO3 of 11.6 (mmol/L) and low O2 saturation of 87.1%. The X-rays' findings on 1/31/12 was "right lung lobe ill defined patchy consolidation with suggestions of air bronchogram's in favor of pneumonia". The physician tries to transfer the patient 1/31/12 a 7:00 pm due to a Bronchopneumonia and to rule out T.B. On 1/31/12 at 8:20 pm the nurse notified "code green" and began cardiorespiratory resuscitation and the patient was pronounced dead at 9:00 pm. No evidence was found that the case was notified or evaluated by the Infection control officer related to personnel handling of this case during the first and second visits related to possible TB infection.


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10. During the observational tour of the respiratory therapy department with the facility's Engineer (employee #33) on 7/10/12 from 10:10 am through 11:00 am, the following was found:
a. The area where ventilators are placed after they are cleaned was found with serious roof filtration which caused the ceiling paint to detach and the ceiling was observed with visible stains from the leaking roof.
b. Clean ventilators were also observed in the hallway of the respiratory therapy department, this hallway is used by maintenance personnel to bring dirty laundry into a back room located at this department. The dirty laundry room also has an outside entrance but when it rains they pass through the respiratory therapy department. Cleaned ventilators shall be kept separated, covered and out of the path of travel of dirty material. Dirty laundry should enter and leave the dirty laundry room from the same outside entrance to reduce possible cross contamination in the hospital.
c. The outside entrance door to the dirty laundry room was found broken on the bottom which can allow pests and vermin to enter this room.
d. The dirty laundry room does not have an air extractor (to ensure negative pressure) or a hand sink for personnel to wash their hands after sorting the dirty linen.
e. The respiratory therapy department also has a back door to access the clean linen room. Facility personnel also access the respiratory therapy department to retrieve clean linen and surgical scrubs when it is raining, even though the clean laundry room has an outside entrance.
f. The clean laundry room was also found with wall filtration under the wall mounted air conditioner. Against this wall were hanging surgical scrubs (many without plastic covers) on a metal pole and against this wall was also the sorting table.

11. The outside metal biohazardous storage container located at the back of the facility was visited on 7/11/12 at 10:10 am with the facility's Engineer (employee #34) and provided evidence that one of the doors was wide open and unlocked which does not prevent unauthorized access. The facility's Engineer (employee #34) stated during an interview on 7/11/12 at 10:15 am that these doors where biohazardous materials are placed are to be kept in a locked and secure area, away from unauthorized persons.

12. An outside metal trash container/compactor located at the back of the hospital was visited on 7/11/11 at 10:20 am and provided evidence that the main hatch where small trash containers are emptied was found wide open with an accumulation of trash. The facility's Engineer (employee #34) stated on 7/11/12 at 10:25 am that regular trash is to be compacted to ensure that trash does not remain in the hatch. The trash container/compactor does not have a metal or plastic door that can be swung over the hatch after the trash is compacted to ensure that trash is not accessible to pigeons, pests and rodents; the trash container/compactor is approximately 100 feet from the hospital.

13. The operating room department was visited on 7/11/12 from 1:15 pm till 3:15 pm with the facility's Engineer (employee #34) and provided evidence of the following:
a. Observations made during the initial tour provided evidence that the biohazardous closet had four full bags of waste placed directly on the floor on blue pads.
b. Operating suite #2 is currently not in use waiting to be remodeled, however it was found with two trays of Cidex OPA. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media and no evidence was found that the facility has a spill kit to use if Cidex OPA accidentally fall on the floor.
c. The sterile material room does not have temperature and humidity daily registrations.
d. The front door of operating suite #4 does not close flush to its frame and was found partially open during a surgical procedure.


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14. The following was observed during the initial tour on 7/10/12 from 11:50 am through 2:00 pm related to infection control issues:
a. Three irrigation syringes were observed in patient's rooms #227A, #235 B (telemetry) and #243A which did not have a label with the date when started. Standards of practice requirements and recognized guidelines (National Standards for Prevention and Control of Hospital Acquired Infection 2008) establishes that enteral feeding irrigation syringes must be changed between 48-72 hours.


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15. The following was observed during the initial tour on 7/10/12 from 10:00 am through 3:30 pm related to infection control issues:

a. A blanket was found on the floor next to the trash can near a refrigerator that was observed with a lot of rust in patient's room #119 (surgery).

b. A bed with rust was observed in patient's rooms #117 (surgery).

c. A canalization tray was observed with a soda and nineteen pens at the nursing counter. During interview with the nursing supervisor (employees #44) on 7/10/12 at 10:45 am she stated that every employee has their own canalization trays which they keep in their lockers. The facility failed in follows accepted standards of practice in order to prevent cross contamination.

Based on the observational tour with the Infection Control Officer (employee #16), interviews and review of policies/procedures (P&P), it was determined that the facility failed to maintain a log of all incidents related to infections to promote sanitary and safe care through its infection control program in the emergency room, laundry room, central supply department, operating room department, medicine intensive care unit and pediatric care unit related to improper infection control procedures and failed to follow infection control standards of practice.

Findings include:

The Infection Control Officer (ICO) (employee #16) has statical information reviewed on 7/12/12 at 3:00 pm related to events in the hospital, however she does not have the capability with her documents to identify specific events that have occurred at the hospital, if further information is required by other departments. No evidence was found that the ICO has an infection control log to document all incidents and take the appropriate measures.

Based on eights medical record review (R.R) for discharge planning, policies and procedure and interviews with the social worker (employee #43), it was found that the facility failed to ensure that discharge planning evaluations are performed during the first 48 hours for 4 out of 8 record review (R.R #4, #6, #10 and #14).

Findings include:

1. On 7/13/10 at 2:30 pm the facility failed to establish a list of criteria and place a mechanism to screen all cases admitted to the facility to identify them during with the admission process and which cases have psycho-social problems and require discharge planning interventions according with the patients' needs.

2. The facility's policies and procedures related with the initial evaluation and reassessment for discharge planning reviewed on 7/13/12 at 1:00 pm, states that the social worker performed an evaluation on the first 48 hours of the admission and the patient is to be re-evaluated during the hospitalization every seven day and when necessary. Every patient referred to the social worker, received the services of evaluation in the first 24 hours of the admission.

3. Four out eight records reviewed (R.R #4, #6, #10 and #14) provided evidence that the discharge planning personnel-social worker performed the initial evaluations and discharge planning evaluations after 48 hour of admission as reviewed on 7/13/12 from 1:00 pm till 3:00 pm with the social worker (employee #43):

a. R.R #4 is a 78 years old male who was admitted on 7/7/12 with Intoxication with Coumadin, Rectal Bleeding and Alzheimer as reviewed on 7/11/12 at 9:00 am with the social workers (employee #43). Evidence was found that the patient was admitted to the emergency room admission area then was brought to the ward on 7/7/12 at 8:30 am. No evidence was found that the social worker performed the discharge planning initial assessment to identify the patients' social needs. However, the social worker performed the discharge planning initial assessment to identify the patients' social needs on 7/12/10 and identify the need of services for physical therapy in the home.

b. R.R #6 is a 67 years old female who was admitted on 7/1/12 with Cellulites and Left
Leg Ulcer as reviewed on 7/10/12 at 2:50 pm with the social worker (employee #43). No evidence was found that the social worker performed the discharge planning initial assessment to identify the patients' social needs. During interview on 7/10/12 at 2:50 pm with the social worker (employee #43) she stated that during discharge planning visits the patient is notified that a company will offer him services in the home for antibiotics and home care.

c. R.R #10 is a 78 years old female who was admitted on 6/27/12 with Congestive Heart Failure (CHF), Pneumonia, High Blood Pressure (HBP) and Diabetes Mellitus (DM) as reviewed on 7/13/10 at 3:10 pm with the social workers (employee #43). The social worker performed the discharge planning initial assessment to identify the patients' social needs on 7/7/12, eight days later. However, the social worker performed the discharge planning initial assessment to identify the patients' social needs on 7/7/10 and identify the need of a glucometer and pressure machine, but no evidence was found of coordinated services.

d. R.R #14 is a 72 years old male who was admitted on 6/26/12 with Ulcer, Cellulites of the left Leg and Diabetes Mellitus (DM) as reviewed on 7/13/10 at 2:20 pm with the social workers (employee #43). The social worker performed the discharge planning initial assessment to identify the patients' social needs on 7/5/12, seven days later. However, when the social worker performed the discharge planning initial assessment to identify the patients' social needs on 7/5/10, she identified the need for home care services for ulcer care.

Based on observations, records reviewed (R.R) and review of documents, policies/procedures and interviews from 7/10/12 through 7/13/12 from 9:30 am till 4:30 pm, it was determined that the facility failed to ensure that the hospital's surgical department provides services in accordance with acceptable standards of practice and complexity of services provided, failed to ensure that surgical services maintains a high standard of medical practice and patients' care, failed to execute complete surgery informed consents, failed to ensure that the operating room log registry is complete and up dated, which makes this
Surgical Condition of Participation "Not Met".

Based on observations made of the surgical department, interview and review of policies/procedures with the Nursing Supervisor (employee #4) it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice and patients' care.

Findings include:

1. The operating room department was visited on 7/11/12 from 9:00 am till 12:00 noon and 1:00 pm. till 3:00 pm and 7/12/12 from 10:30 am till 11:30 am with the nurse supervisor ( employee #4 ) and provided evidence of the following evidence:

2. It is required by local law to comply with the guidelines for Design and Construction of Hospital and Health Care Facilities. These guidelines on table 7.2 (ventilation requirements for areas affecting patient care in hospitals and outpatient facilities) requires that the relative humidity must be kept between 30-60 % and temperature of 68-73ºF in the operating suites, the following relative humidity were measured on January, February, March, April, May, June and July / 2012. The facility provides evidence on 7/11/12 at 9:00 am that has five operating rooms suites but the suite #2 is out of services at this moment. The operating rooms suites #1, #3, #4 and #5 are use for inpatients and outpatients. Accordance with the registry provided by the employee #4 the operating rooms has problems of temperature and humidity. The last two months of June and July of 2012 was evaluated and the following was provided:

a. On 6/1/12 suite #1 the temperature registered 60.0ºF at 7:00 am and the relative humidity registered 61%, suite #2 the temperature registered 60.0ºF, suite #3 the temperature registered 61.0ºF, no evidence was found of temperature and relative humidity was taken on the suite #4, and suite #5 the temperature registered 60.0ºF at 7:00 am and the relative humidity registered 62%. On 6/2/12 in suite #2 the temperature registered 61.0ºF at 7:00 am and the relative humidity registered 64%, on suite #2 the temperature registered 60.0ºF, no evidence was found of temperature and relative humidity was taken on the suite #3 and no evidence was found of temperature was taken on suite #4 because it did not have a thermometer, and on suite #5 the temperature registered 64.0ºF and the relative humidity registered 68%.

b.On 6/3/12 in suite #1 the temperatures registered 61.0ºF at 6:00 am the relative humidity registered 63%, on suite #2 the temperature registered 60.0ºF, on suite #3 the temperature registered 64.0ºF, no evidence was provided of temperature and relative humidity on suite #4 because it did not have thermometre on the suite and on suite #5 the temperature registered 60.0ºF and the relative humidity registered 62%. On 6/4/12 in suite #1 the temperature registered 60.0ºF at 6:00 am and the relative humidity registered 61%., in suite #2 the temperature registered 45ºF, in suite #3 the temperature registered 50.0ºF., no evidence was provided of temperature and relative humidity on suite #4 because it did not have thermometer and on suite #5 the temperature registered 60.0ºF.

c. On 6/5/12 in suite #1 the temperature registered 61.0ºF, in suite #2 the temperature registered 45.0ºF, in suite #3 the temperature registered 55.0ºF at 6:00 am., no evidence was provided of temperature and relative humidity on suite #4 because it did not have thermometer and on suite #5 the temperature registered 60.0ºF. On 6/6/12 in suite #1 and suite #5 the temperature registered 60.0ºF, in suite #2 and #3 the temperature registered 55.0ºF and no evidence was provided of temperature and relative humidity on suite #4 because it did not have thermometer and on suite #5 the temperature registered 60.0ºF.

d. On 6/7/12 in suite #1 the temperature registered 61.0ºF, in suite #2 the temperature registered 55.0ºF, in suite #3 the temperature registered 45.0ºF, no evidence was provided of temperature and relative humidity on suite #4 because it did not have thermometer and on suite #5 the temperature registered 60.0ºF. On 6/8/12 in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 55.0ºF, in suite #3 the temperature registered 50.0ºF, no evidence was provided of temperature and relative humidity on suite #4 because it did not have thermometer and on suite #5 the temperature registered 60.0ºF.

e.On 6/9/12 at 7:00 am. in suite #1 the temperature registered 65.0ºF, in suite #2 the temperature registered 63.0ºF, in suite #3 the temperature registered 61.0ºF, no evidence was provided of temperature and relative humidity on suite #4, on suite #5 the temperature registered 60.0ºF. On 6/10/12 at 7:23 am. in suite #1 the temperature registered 61.0ºF, in suite #2 the temperature registered 64.0ºF, in suite #3 the temperature registered 60.0ºF, no evidence was provided of temperature and relative humidity on suite #4, on suite #5 the temperature registered 59.0ºF.

f. On 6/11/12 at 5:50 am. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 50.0ºF, in suite #3 the temperature registered 60.0ºF, no evidence was provided of temperature and relative humidity on suite #4, on suite #5 the temperature registered 60.0ºF. On 6/12/12 at 5:55 am. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 50.0ºF, in suite #3 the temperature registered 60.0ºF, no evidence was provided of temperature and relative humidity on suite #4, on suite #5 the temperature registered 60.0ºF.

g. On 6/13/12 at 6:00 am. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 55.0ºF, in suite #3 the temperature registered 60.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 60.0ºF. On 6/14/12 at 5:50 am. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 61.0ºF, in suite #3 the temperature registered 55.0ºF, no evidence was provided of temperature and relative humidity on suite #4, on suite #5 the temperature registered 60.0ºF. On 6/15/12 at 6:00 am. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 57.0ºF, in suite #3 the temperature registered 55.0ºF, no evidence was provided of temperature and relative humidity on suite #4 did not have thermometer and in suite #5 the temperature registered 59.0ºF.

h. On 6/16/12 at 7:00 am. in suite #1 the temperature registered 60.0ºF and the relative humidity 61%, in suite #2 the temperature registered 57.0ºF, in suite #3 the temperature registered 55.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 59.0ºF.

i.On 6/17/12 at 7:00 am. in suite #1 the temperature registered 60.0ºF and the relative humidity 62%, in suite #2 the temperature registered 51.0ºF, in suite #3 the temperature registered 55.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 60.0ºF. On 6/18/12 at 5:50 am. in suite #1 and #2 the temperature registered 60.0ºF, in suite #3 the temperature registered 55.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 59.0ºF.

j. On 6/19/12 at 2:00 pm. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 59.0ºF, in suite #3 the temperature registered 55.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 59.0ºF. On 6/20/12 at 2:00 pm. in suite #1 the temperature registered 60.0ºF and the relative humidity 61%, in suite #2 the temperature registered 61.0ºF, in suite #3 the temperature registered 55.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 60.0ºF.

k. On 6/21/12 at 2:00 pm. in suite #1 the temperature registered 61.0ºF, in suite #2 the temperature registered 57.0ºF, in suite #3 the temperature registered 55.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 59.0ºF. On 6/22/12 at 3:00 pm. in suite #1 the temperature registered 61.0ºF, in suite #2 the temperature registered 57.0ºF, in suite #3 the temperature registered 55.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 59.0ºF.

l. On 6/23/12 at 11:00 am. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 55.0ºF, in suite #3 the temperature registered 61.0ºF and the relative humidity 62%, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 59.0ºF. On 6/24/12 at 6:00 am. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 57.0ºF, in suite #3 the temperature registered 60.0ºF, no evidence was provided of temperature and relative humidity on suite #4 it did not have thermometer and in suite #5 the temperature registered 60.0ºF.

m. On 6/25/12 at 6:00 am. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 55.0ºF, in suite #3 the temperature registered 60.0ºF and the relative humidity 62%, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 60.0ºF.

n. On 6/26/12 at 6:00 am. in suite #1 the temperature registered 61.0ºF, in suite #2 the temperature registered 50.0ºF, in suite #3 the temperature registered 60.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 59.0ºF. On 6/27/12 at 6:00 am. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 55.0ºF, in suite #3 the temperature registered 59.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 60.0ºF.

o. On 6/28/12 (the hour taken was not documented ) in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 50.0ºF, in suite #3 the temperature registered 59.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 60.0ºF. On 6/29/12 the hour taken was not documented in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 60.0ºF, in suite #3 the temperature registered 59.0ºF, no evidence was provided of temperature and relative humidity on suite #4 and in suite #5 the temperature registered 60.0ºF. No evidence was provided of temperature and relative humidity registered on 6/30/12 for operating suites #1, #2, #3, #4 and #5.

p. On 7/1/12 at 7:01 am. evidence was provided of temperature and humidity registered for operating suites #1 of 62ºF and relative humidity 63.0%, in suite #2 the temperature registered 41.0ºF, in suite #3 the temperature registered 60.0ºF, in suite #4 no evidence was provided of the temperature and relative humidity registered, in suite #5 the temperature registered is 63ºF and relative humidity registered is 64%. On 7/2/12 at 6:00 am no evidence was provided of temperature and relative humidity registered for operating suites #1 and #4. The temperature registered for suite #2 is 55.0ºF at 6:00, however did not specify if am or pm. In suite #5 the temperature registered 60.0ºF. On 7/4/12 in suite #1 and #5 the temperature registered 60.0ºF at 6:00 am, in suite #2 the temperature registered 50.0ºF at 6:00 am., no evidence was found of temperature and humidity registered of suite #4.

q. On 7/5/12 in suite #1 the temperature registered 61.0ºF and the relative humidity registered 62%, in suite #2 the temperature registered 60.0ºF at 6:00 am., no evidence was provided of temperatures and humidity of suites #4. On 7/6/12 in suite #1 the temperature registered 62.0ºF, in suite #2 the temperature registered 55.0ºF, and in suite #3 the temperature registered 60.0 º F at 5:00 am. and the relative humidity registered 61.0%. In suite #4, no evidence was found of temperature and humidity registered. In suite #5 the temperature registered 60.0ºF.

r. On 7/7/12 at 7:30 am. in suite #1 the temperature registered 60.0ºF, in suite #2 the temperature registered 42.0ºF, in suite #3 the temperature registered 64.0ºF and the relative humidity registered 61%, in suite #4 no evidence was provided of temperature and humidity registered. On 7/8/12 in suite #1 the temperature registered 60.0ºF at 6:05 am. and relative humidity registered 61.0%, in suite #2 the temperature registered 60.0ºF, in suite #3 the temperature registered 50.0ºF, in suite #4 no evidence was provided of temperature and humidity registered it did not have thermometer and in suite #5 the temperature registered 61.0ºF.

s. On 7/9/12 at 7:00 am. in suite #1 the temperature registered 60.0ºF and relative humidity registered 61.0%, in suite #2 the temperature registered 55.0ºF, in suite #3 the temperature registered 60.0ºF, in suite #4 no evidence was provided of temperature and humidity registered it did not have thermometer and in suite #5 the temperature registered 69.0ºF. On 7/10/12 at 7:00 am. in suite #1 the temperature registered 62.0ºF, in suite #2 the temperature registered 57.0ºF, in suite #3 the temperature registered 60.0ºF, in suite #4 no evidence was provided of temperature and humidity registered it did not have thermometer and in suite #5 the temperature registered 69.0ºF.

3. During the operating room department observational tour on 7/11/12 from 9:00 am till 12:00 noon and 1:00 pm. till 3:00 pm and 7/12/12 from 10:30 am till 11:30 am it was observed personnel of the operating room department and personnel of other hospital areas entered to the different areas, restrictive and semi-restrictive areas of the operating room without traffic control.

a.On interview with the O.R Supervisor (employee #4) related to personnel without shoe covers in the restrictive area, without scrub and face mask, hand washing inadequate hands techniques she stated: " That personnel do not use shoe cover because they use their shoes inside the operation suites area, all of the operating room personnel have knowledge of the policies and procedures related to the scrub and others policies and procedures of the operating room department " .

4. No evidence was found related to policies and procedure related to personnel shoe cleaning when not using shoe covers. The operating room secretary was observed entered at the semi-restricted area on 7/12/12 at 1:30 pm. The OR supervisor was interview and she stated: '' She's new in the department. ''

5. Evidence was provide related to the clothe used in the different areas of the operation room (non restrictive area, semi- restrictive area and restrictive area) and refers that in the restrictive area, all personnel need to use scrub, hair cap, shoe covers and faces masks. However the operating room department did not have the non restrictive area, semi- restrictive area and restrictive area delineate accordance of operating room policies and procedures.

6. In the main entrance use by the personnel at the Operating Room (OR) right side is a room that was use by the physician for changing clothes. Now is use for housekeeping. There are various ceiling tiles missing. A ladder, biohazard wasted disposal without plastic bag, a regular trash container, housekeeping cart, pail with water and a mop inside, broom, dust pan and three sharps container with waste (syringe and needles) directly on the floor. A bath-tub with a grey pail and a mop inside. The housekeeping employee #46 stated that they are use for contaminated cases. This is not label as such; also it was observed an extra mop, two squeegees, and a gallon of wax, a duster, two chairs and three sharps container. Two surgical tables are observed in the hallway, one employee said is to discard. This area is observed with a lot of dust, dirty and has no hand washing station, paper towel or soap. The facility failed to ensure that surgical services maintain a high standard of medical practice, patients' care and infection control practice.

7. No evidence was provided of infected and non-infected cases on 7/12/12 at 2:00 pm.

8. The annual training plan for 2012 is not revised or approved by the administrative personnel.

9. No evidence was provide on 7/12/12 at 2:15 pm. of pathology register, employee #4 provided the surveyor a lose sheet of paper in a binder but did not have a complete registry and organized as establish by the policies and procedures.

10. The policies and procedures administrative manual was reviewed on January of 2012 however lack of nurse executive director signature.

11. The guideline for Infection Control was reviewed on January of 2012 however, lack of the Infection Control Epidemiology signature, the anesthesiologist and the infectologist ' s signature.

12. The main door of the operating room does not close and was maintain partially open during the surgical procedurer and personnel of the operating room and other personnel was observed enter at this area without control and expose the patients during the surgical procedures.
13. The sterile material room '' Central Supply '' located near the autoclave room at the operating suite department was visited on 7/11/12 at 10:30 am and it was found that the room was warm due to its location near the autoclave room; the temperature was measured to be 77 ºF. The sterile material room does not have thermometer and the personnel does not take a temperature and humidity daily registrations. The air conditioning was full of dust.
14. Biohazard container was observed without lid on the emergency door of the '' autoclave room''
15. A large sharp container was observed in the main corridor near the emergency crash cart on the floor without a security rack.
16. The sterile storage room located near the autoclave room at the operating suite department was visited on 7/11/12 at 2:00 pm and it was found that the room was warm due to its location near the autoclave room; the temperature was measured to be 75 ºF. The area lack of thermometer to registered the daily temperatures. The air conditioning was full of dust.
17.On the emergency exit side of the sterile material storage as observed a metal warmer and a stainless steel table with tools.
18. The operating room supervisor employee #4 was interview on 7/11/12 at 2:05 pm and she stated: '' This warmer is use to heat the patient's linens and the table with tools is use by the handyman. She open the metal warmer and as observed linens in the interior, much rust observed on the interior of the warmer and do not protect the linens from cross contamination from patient to patient.
19. The patient's dressing room lack of identification label male and female.
20. The hospital operates ambulatory patients but the facility does not have a designated phase II area. The patients is located on the lounge area on the main entrance of the recovery room, this lounge area has two recliner chairs separated by curtains.
21. A biohazard closet located on the main entrance of the operating room department was observed with four full bags of waste placed directly on the floor on blue pads.
22. Rust was found on I.V stands and other metal tables in operating suites #1, #3, #4 and #5.
23. The housekeeping maintenance room was observed on 7/12/12 at 2:00 pm. and one green pail used by the housekeeping (employee #46) he stated '' this pail is use to clean the three operating suites.''
24.One pail with dirty water and mop on the interior of the pail was observed, no evidence of the Material Safety Data Sheet Manual (MSDS ), one gallon of Marzan 256, two large stick with sponges was observed, the housekeeping (employee #47) stated " one sponge is used to cleaning the operating rooms suites including the contaminated room and the other one is use to clean the regular suites " .
25.One broom and one dust pan was observed and the housekeeping employee # 47 refers " it is used on the corridors " . The equipment used to cleaning and disinfecting the operating room department lacks of identification labels for contaminated and non contaminated cases.
26. During interview with the housekeeping personnel (employee #46 and #47) they stated that they do not have separate mops or pails to clean all areas of the operating room including recovery and hallway, we use a mop and pail from any suite " .
27. The housekeeping room was observed on 7/11/11 at 2:00 pm with three mops and two pails without identification labels. This procedure does not protect the facility's patients from possible cross contamination from one suite to another.
28. Sharp containers were found in operating room suites #1, #3, #4 and #5 placed directly on the floor.
29. The room used to process equipment with Cidex OPA was visited and it did not have an exhaust hood: Manufacturers' recommendations suggests that the solution is used in a well-ventilated area and stored in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media and no evidence was found that the facility has a spill kit to use if Cidex OPA accidentlly falls on the floor.

30. The glass door of the storage cabinet in operating suites #1, #3, #4 and #5 did not close which does not protect the material from cross contamination from patient to patient.

31. Operating suites #4 lack of identification label.

32. The surgeon was observed on 7/11/12 at 10:15 am using cellular phone in the operating suite area during the operating room personnel prepared the patient to initiate a Thyroid surgery. Policies and procedures states that personal calls must be done during periods of rest.

33. The surgeon and the anesthetist employee were observed on 7/11/12 at 10:15 am in the operating suite restrictive area using crocs shoes without shoe covers.

34. The operating department did not have a daily, between cases, weekly and terminal cleaning monthly log book and failed to maintain a list of which chemical products are used to clean the operating rooms suites and others areas of the department.

35. The operating room supervisor employee #4 was interview and she stated: '' We never perform a daily and weekly terminal cleaning log book for operating suites. The housekeeping employees perform a daily cleaning on the operating suites, they clean when surgery procedure end and one weekly terminal cleaning.''

36. On 7/12/12 at 10:50 am the anesthesia room was visit and the following was observed:

a. No evidence was provided of the medication refrigerator cleaning. No evidence was provided of temperatures registry during March of 2012. The form used for the anesthesia department provides evidence that the refrigerator is broken, however no evidence of documentation related to this event. No written documentation of what kind of action the facility was taken to ensure the medication was preserved. No evidence was found if the temperature was taken on May 30 and 31 and June 24 of 2012. The facility provide evidence that on June 20 and 26 the temperature was 35 grades, however the form used by the facility did not provide the person who takes the temperature, the hour, action was taken, who is the person to notify the event and corrective action.

b. Two bottles of alcohol al 70% over the counter and two bottles were observed in the medication stock. Interview on 7/11/12 at 10:30 am to employee #48 refer: '' One of the bottles of alcohol was open on 7/4/12 and was use to disinfect the counter and surface. The alcohol is supply by the pharmacy department, I make the requisition to the pharmacy except for control medications.''

c. One gallon of Emzol open on 7/4/12 is observed placed over the counter were the medication or daily use are located.

d. A Un vial Sodium Bicarbonate 50 ml. single dose vial 8.4 % in use is observe open without label when open.

e. Under the sink inside a hole was observe on the cement wall, humidity, dust and a gallon of Emzol.

f. A carton box with mask use by the anesthetist is observe on the floor beside the washing station (sink).

g. An open vial of Ketamine HCL 500 mgs. / 10 ml. multiple doses without identification label.

h. A vial of Dexametaxone 10 mgs./ml. Open without label in the narcotic storage. The anesthetiologist (employee #50 ) refers on 7/11/12 at 10:15 am that he saves it in the narcotic storage so no one takes it because there is not a lot available.

37. On 7/12/12 at 11:15 am the operating suites was visit and the following was observed:

a. Suite #4 without identification label.

b. A metal table with rust.

c.Surgeon and anesthetist with cross shoes without shoe cover.

d. A circulating nurse is observed during the preparation of the patient, change his gloves touch the warmer and move the wooden stool use by the staff during procedures, did not wash his/her hands during procedures and glove change.

e. Suite #1- as observed the anesthetist medication cart with lots of dust and rust.

f.- A stand for the microscope with rust.

g. A 6 gallon sharp container and 1 big one directly on the floor without security lock.

h. A cart for sterile materials with rust.

i. A intravenous line (IV) tied to the cart with 8 rolls of surgical tape.

38. On 7/12/12 at 11:30 am the operating Endoscopy and Colonoscopy area was visit and the following was observed:

a. Structure is observed deteriorated.

b. Over bioharzard trash disposal a tray use by nurses to perform IV cannulation of patients that have endoscopy and colonoscopy. (needles, vacutainers, electrodes, tweezers for biopsy and other materials).

c.- Plastic trash disposal full with regular wasted without lid.

d. A gallon of Emzol directly on the floor beside the trash disposal full of waste without lid, the nurse refers it is use to clean the endoscopy tubes.

e. Hand paper dispenser detach from the wall.

f. There is only on hand washing station (sink) wich is use by the nursing personnel and physicains before and afther the procedures.

g. A plastic basin with turbid water was observed inside the sink, the endoscopy nurse employee #3 stated " this is the only hand washing station there is and that the plastic basin is use to submerge the endoscopy and colonoscopy tubes after the procedure " .

h.-As observed at the endoscopy machine there was still gastric content of the last case performed in the morning. The area was still not clean by the housekeeping personnel; paper was observed on the floor and floor was dirty.

i.- Medication Cetacaine (topical anesthetic ) label indicate date when open 5/23/12 discard on 6/20/12 ( 28 days of use) this was found over the endoscopy machine. RN (employee # 3) was interview and she stated, " the medication was use on the previous procedure " . The medication with 21 days of expiration.

j. Adult crash cart was observed deteriorated with rust and dust in the interior and exterior. A label was observed on the door of the crash cart that read "this cart was reviewed on the year 2000".

k. A pediatric valise with a lot of dust inside and dirty.

l. Two vials of Epinephrine expired on June 1, 2012. The RN employee #3 stated that last month it was reviewed by the pharmacy personnel " , however no evidence was provided of the monthly review or a registry log.

m. In the disinfecting and cleaning room of the endoscopy and colonoscopy equipment the wall was observed with brown spot.

n. A tray with Cidex OPA over the counter with a seal of when it was prepared on 7/9/12 to 7/22/12. The tray was observed deteriorated with a lot of dark spots. This was observed over a blue pad with dark spots and humidity.

o. During interview with the RN employee #3 stated " after flushing the colonoscopy and the endoscopy it is clean with Emzol (enzymatic detergent) it is rinse in the sink and placed in the Cidex tray. I use a regular mask " . No evidence provided of a policy and procedures manual or protocols of procedures perform in this area.

p. Under the counter it was observed with dust and humidity, yellow precaution gowns that are use by the physicians and nurses during the procedures, humidifiers for respiratory treatment, machine to perform '' leak test '' that is done after each procedure.

q. In the housekeeping equipment room and procedure room as observed there was dust, humidity odor and was visibly dirty.
r. Two hose that are place to the endoscopy machine to avoid penetration of Cidex so it would no damage the optic fiber of the endoscopy was observed on the back door knobs of the housekeeping room, it was not label of when they were clean and disinfected. Another hose for the same use was hanging on the front door knob.

s. A plastic tray with a vase that contain formalin is observed over a box located on the counter were the equipment cleaning and disinfecting is performed.

t. On 7/11/12 at 2:00 pm it was observed that the gastroenterologist ( employee #49 ) enters the treatment room to perform a Colonoscopy, no hand washing is perform by the nurse or physician, physician puts on the gown, disposable gloves and mask without washing his hands.

u. The treatment bed was observed with rust and dust.

Based on the review of eight medical records and policies/procedures of the operating room with the Operating Room Supervisor (employee #4), it was determined that the facility failed to execute complete surgery informed consents that includes date, hour, name of the anesthesiologist, record number, benefits of the surgery, signature of the guardian and signature of the witness, patient signature and name of surgeon and license for 8 out of 8 records reviewed ( R.R #49, #50, #51, #52, #53, #54, #55 and #56 ).
Findings include:

1. During the review of eight records on 7/11/12 through 7/13/11 from 9:30 pm till 3:00 pm, the following was determined:

A. The facility consent form did not provided space to document the risks and benefits of the surgery procedures, date and hour when the patient signed the consent, date and hour when the physician took the patient signed of the consent form and patient and physician signature.

a. R.R #49 provided evidence that the anesthesiologist consent form did not include the patient record number and signature of witness.
b. R.R #50 provided evidence that the surgical procedure consent form did not included the record number, the anesthesiologist name, the benefits of the surgery, signature of the guardian and signature of the witness.
c. R.R #51 provided evidence that the surgical procedure consent form did not include the signature of witness. The anesthesiologist consent form lacks the patient record number and the signature of witness. The anesthesia pre-operative form lack of anesthesiologist signature and license number.
d. R.R #52 provided evidence that the surgical procedure consent form did not included the record number, the anesthesiologist name, the benefits of the surgery, signature of the guardian and signature of the witness.
e. R.R #53 provided evidence that the surgical procedure consent form did not include the record number, name of the anesthesiologist, benefits of the surgery procedure, patient/s signature, signature of guardian or person authorized or give the consent, signature of witness, name of surgeon and license. The form used is a copy and did not provide the information on the back of the paper.

f. R.R #54 provided evidence that the surgical procedure consent form did not include the record number, name of the anesthesiologist, benefits of the surgery procedure, patients signature, signature of guardian or person authorized or give the consent, signature of surgeon and license number. The form used is a copy and did not provide the information on the back of the paper.

g. R.R #55 provided evidence that the surgical procedure consent form did not include the record number, the alternative methods of treatment can be, anesthesiologist signature, witness, name of surgeon and lacks the signature of surgeon and license. The form used is a copy and did not provide the information on the back of the paper.

h. R.R #56 provided evidence that the surgical procedure consent form did not include the record number, the hour, the anesthesiologist name, the initials of the patient or guardian that authorize to dispose the tissues, benefits of the surgery procedure and signature of witness.

Based on documents reviewed with the Operating Room Supervisor (employee #4) and interview, it was determined that the facility failed to ensure that the operating room log registry is complete and up dated.

Findings include:

1. A surgery registration log book was observed on 7/12/12 at 3:00 pm and did not include the following: the total amount of the operation procedure, name of the surgeon assistant, name of nursing personnel (scrub and circulating nurses), type of anesthesia used, pre and post-op diagnosis and age of patient.
2. The recovery registry logbook was not updated.
During interview on 7/12/12 at 2:40 pm with the Operating Room Supervisor employee #4 she stated: "it is not update because the information is listed in a notebook and then we pass it to the registry on the computer".

Based on documents reviewed with the Operating Room Supervisor (employee #4) and interview, it was determined that the facility failed to maintain ongoing Quality Assessment and Performance Improvement Program (QAPI), policies and procedures related to responsibilities of anesthesia services in the operating room, 3 out of 6 credential files (C.Fs) reviewed for anesthetists functions and duties did not provide the date when signed the anesthetists functions and duties (C.Fs #4, #5 and #6) and failed to ensure that the anesthesia services are provided in a well organized manner and comply with all the requirements of this Condition of Participation.

Findings include:

1. On 7/12/12 at 1:15 pm. the anesthesia department did not provide evidence that the anesthesia service is integrated into the hospital wide quality program.

2. On 7/12/12 at 9:15 am. provide evidence that the Anesthesia Services is a contracted services for the hospital as Professional Services with the Metro Health Company Inc. A private corporation date December 27, 2004. During review of the contract on 7/12/2012 at 9:15 am. This contract does not say it will be renew automatically.

3.The facility could not provide evidence of an ongoing Quality Assessment and Performance Improvement Program (QAPI) which evaluates the appropriateness of services related to patient's care for the past year 2011 as reviewed on 7/12/12 at 2:00 pm.

4. No evidence was found related to ongoing quality monitoring to identify processes that need improvement, corrective actions implemented or the evaluation of the resolutions of the situations identified.
6. No evidence was found on 7/13/128 at 2:10 pm of policies and procedures related to responsibilities of anesthesia services in the operating room regarding inpatients, outpatients, the delivery room, invasive procedure room or with the radiology department.

Based on the observational tour, review of policies/procedures manual, six anesthetist credentials files (C.F) it was determined that the facility failed to maintain policies and procedures related to responsibilities of anesthesia services in the operating room, 3 out of 6 C.Fs reviewed for anesthetists functions and duties did not provide the date when signed the anesthetists functions and duties (C.Fs #1, #3, #4 and #6).

Findings include:

1. Credential file #1 did not have the anesthesist registry updated, the last anesthesist registry expired on 7/7/2010.

2. Credential file #3 did not have the nurse registry updated, the last anesthesist registry expired on 10/27/2011.

3.Credential file #4 did not have the nurse registry updated, no evidence was found of nurse annual association for 2012, no evidence was found of CPR, the job description lacks of the date when the anesthesist signed the functions and duties and no evidence of privileges.

4.Credential file #6 did not have the nurse registry updated, no evidence was found of nurse registry and the job description lack of the date when the anesthesist signed the functions and duties.

Based on the review of seven medical records to evaluate anesthesia services with the Operating Room Supervisor (employee #4 ), it was determined that the facility failed to ensure that anesthesia consent forms are properly executed for 4 out of 8 records reviewed (R.R #49, #50, #52 and #55) and 1 out of 8 records lack pre- anesthesia assessment RR #56.

Findings include:
1. During the review of eight medical records on 7/11/12 from 9:30 am till 1:30 pm and 7/13/12 from 9:00 am till 11:25 am the pre-anesthesia assessment form did not provide space to write the date and hour that the patient sign, did not provide space to write the date and hour that the physician sign, lack of anesthesiologist name, did not provide space to write the patient benefits.
2. During the review of eight medical records on 7/11/12 from 9:30 am till 1:30 pm. no evidence was found of the pre-anesthesia assessment on 4/20/12 for record review #56.
3. Record review #49, #50, #52 and #55 lack of the anesthetist consent form.

Based on the observational tour through the operating rooms (O.R) and review of policies and procedures of anesthesia services with the Operating Room Supervisor (employee #4), it was determined that the facility failed to ensure a proper post-anesthesia recovery follow up.

Findings include:

1. No evidence was provided of the facility's policies and procedures of post-operative calls on 7/13/12 at 1:15 pm, it states that patients are evaluated by telephone calls to their homes between 24 to 48 hours after surgery. If they do not make contact within this time they shall extend the time to 72 hours and the files remain in this area.

2. The facility failed to establish the number of phone call during the 24 to 48 hours to estimate the post anesthesia recovery and failed to attach this form to the medical record as reviewed on 7/13/11 at 1:25 pm.

Based on the review of nine closed and active records reviewed (R.R), policies/procedures manual, interview and the observational tour with the emergency room nursing supervisor (employee #30) on 7/10/12 from 9:00 am till 3:30 pm and 7/11/12 from 8:30 am till 10:30 am, it was determined that the facility failed to comply with revision dates for E.R manuals, policies and procedures related to the compliance with EMTALA requirements, no evidence was found that the emergency department evaluates quality assurance, sign posting in the ambulance entrance, a sign was not posted in the entrance/waiting area notifying patients that arrive to the emergency room (E.R) where the triage is located, emergency personnel do not have a plan or assignments for all specific tasks in the event of an emergency, the triage area is not properly designed, infection control issues and no evidence was found that R.R #33 was evaluated by the emergency room medical director related to the patient's death, transfer or return to the E.R within 48 hours and the facility failed to comply with procedures related to the integration or coordination between the emergency room and other departments. All of the above findings makes this condition "Not Met".

Based on the review of the policies/procedures manual with the emergency room medical director (employee #24) and nursing supervisor (employee #30), it was determined that the facility failed to comply with procedures related to the integration or coordination between the emergency room and other departments.

Findings include:

1. The following was determined related to the emergency department's policies/procedures reviewed on 7/11/12 from 8:30 am till 10:30 am:

a. No evidence was found of procedures related to the integration and coordination between the Emergency Department with the other departments of the hospital such as: the surgical services, laboratory, intensive care unit, admission department, pharmacy services, diet services and the radiology department. The hospital must be able to demonstrate how the hospital's other departments provide emergency patients the care and services needed within a safe environment, within a timely manner and with appropriate/available personnel.

Based on the review of nine closed and active records reviewed (R.R), policies/procedures manual, interview and the observational tour with the emergency room nursing supervisor (employee #30), it was determined that the facility failed to comply with revision dates for E.R manuals, policies and procedures related to the compliance with EMTALA requirements, no evidence was found that the emergency department evaluates quality assurance, sign posting in the ambulance entrance, a sign was not posted in the entrance/waiting area notifying patients that arrive to the emergency room (E.R) where the triage is located, emergency personnel do not have a plan or assignments for all specific tasks in the event of an emergency, the triage area is not properly designed, infection control issues and no evidence was found that R.R #33 was evaluated by the emergency room medical director related to the patient's death, transfer or return to the E.R within 48 hours.

Findings include:

1. The following was observed related to the review of the policies/procedures manual and observations of the emergency department with the E.R Nursing Supervisor (employee #30) on 7/10/12 from 9:00 am till 3:30 pm and 7/11/12 from 8:30 am till 10:30 am:

a. No evidence was found that the Emergency Department manual adopted and revised all of their policies/procedures according with the recent changes related to accepted standards of practice, infection control recognized guidelines and procedures to provide emergency services.
The last revision of the Emergency Administrative Manual of policies and procedures was in 2008. The last revision of the Nursing Administrative Manual was in 2009. The last revision of the Administrative Services (Governing Body) Manual was in 2000. The last revision of the Infection Control Manual was in 2009. The Pediatric Emergency Administrative Manual of policies and procedures did not have the last revision date.

b. Policies and procedures related to the compliance with EMTALA requirements did not include the following related to: anti-dumping provisions, report suspected incidences of individuals with an emergency medical condition transferred in violation, sign posting to notify of the rights of the individuals who enter the emergency room, maintain transfer records for five years, on call physicians, complete emergency room log, no delay in examination or treatment to inquire about payment status, whistleblower protection and recipient hospital responsibilities.

2. No evidence was found that the emergency department evaluates quality assurance and identifies issues that require potential intervention with staff that are responsible for direct patient care: mortality, transfer, appropriate medical screening/stabilizing treatment, elopement and return to the emergency room within 48 hours, no evidence was found of the discussion and information related to these issues from 2011 and 2012 as determined on 7/13/12 at 9:00 am.

3. No signs were posted at the entrance (ambulatory/ambulance) and treatment area for the notification of the rights of the individuals who enter the E.R as observed on 7/10/12 at 9:20 am. Also, the ambulance area entrance is located in the hallway near the observation area, however a sign was not posted in the ambulance entrance area notifying patients that arrive to the E.R where triage is located.

4. The triage room located near the waiting area was found on 7/10/12 at 9:30 am did not have visibility of the patients that arrive at the emergency room for nursing interviews and to categorize the patients. The triage room where patients are evaluated was observed with three walls with windows and patients could be seen during the triage process, the triage room and the computer can be seen by patients waiting in the observation area after the triage process. The triage nurse (employee #31) stated during an interview on 7/10/12 at 9:35 am that patients are called in the order of their arrival and once inside she lowers the curtains at the moment of the initial assessment, but with the curtain down she does not have visibility of the waiting room and ambulance entrance of the emergency room. This triage room does not comply with minimum construction requirements related to its location and failure to verify the patient's category status during the triage process and any changes in patient's status when in the waiting room (Please cross reference Tag A725 #11).

5. No evidence was found on 7/10/12 at 9:45 am that emergency personnel have a plan or assignments for all specific tasks in the event of an emergency. All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

6. The following was observed in the emergency room on 7/10/12 from 9:30 am till 3:00 pm related to infection control procedures:

a. The minor surgery room of the emergency room was visited on 7/10/12 at 9:55 am with the nursing supervisor (employee #30) and provided evidence that there is a small room used for orthopedic cases within this area that was found with broken and used equipment (I.V stands, wheel chairs and I.V pumps) and this room also has a strong odor near and around the sink with the cast trap, however no evidence was provided when the trap was last cleaned.
b. Small packages of gauze were observed on 7/10/12 from 9:30 till 12:00 noon in the treatment area, triage area, pediatric area, critical/surgery care area and on the I.V access cart without protective covers, exposing them to the environment.
c. A plastic container with tongue depressors was observed in the examination area, treatment area, pediatric area and critical/trauma room without protective covers exposing them when personnel take them out of the container.
d. One I.V bag of .45 normal saline was observed in the medication room with an expiration date of April 2012.
e. Sharp containers (3 gallon size) were observed without security bases during the observational tour of the emergency room on 7/10/12 from 9:30 am till 12:30 pm in the following areas: one in the triage room, one in the medication room, one in the blood sample collection area, one in the minor surgery room and one in the pediatric cardio area. Security bases and label are needed to protect the sharp containers from unauthorized removal.
f. Two multiple use vials of Xylocaine 2% (20 ml) used for local anesthesia were observed in the minor surgery room without labels indicating the date when they were opened as reviewed on 7/10/12 at 11:15 am which is not in accordance with CDC guidelines to label and discard after 28 days from opened.
g. Two single use vials of Furosemide 100mg/10ml were observed in the medication room without labels indicating the date when they were opened as reviewed on 7/10/12 at 11:20 am which is not in accordance with CDC guidelines to be discard after opened or use.
h. Heparin locks were found in cubicles #1 and #2 (cardio), #1 and #12 (observation) without labels with the date and time that the heparin lock was placed. The facility's policies and procedures were reviewed on 7/11/12 at 9:30 am and provided evidence that the heparin locks were to be changed every 72 hours.
i. Sharp containers (1 gallon size) were observed full with biohazardous waste and placed in the biohazardous trash containers in patient cubicles during the observational tour of the emergency room on 7/10/12 from 10:00 am till 12:30 pm (cubicles #1, #2, #4 and #5). The Nursing Supervisor (employee #30) stated on 7/12//12 at 10:10 am that maintenance employees remove the full sharp containers and placed them into the biohazardous trash container and then later they take them out of the area to the dumpster behind the facility.
j. Respiratory therapy equipment were observed in the pediatric area on 7/10/12 at 11:15 am in a plastic container (4 drawers) that was placed upon a wood base and the bottom two drawers were found filled with material and covered in dust.
k. In the closet used to place dirty linen, a large container was found used to deposit the linen, however it did not contain a plastic bag, which forces personnel to handle the dirty linen more than once.

7. No evidence was found of the daily registration of the cleaning and disinfecting of the digital thermometer in the triage room as reviewed on 7/10/12 at 10:45 am.

8. On 7/10/12 at 9:50 am the respiratory therapist (employee #32) was observed removing a ventury mask from the patient (from cubicle #5) and took it to the sink and rinse the mask with water, then dried it and put it back into a plastic bag (the respiratory therapist performed this task without gloves). Then he went into cubicle #1 (with a different patients) and connected the oxygen cannula to the patient, however he did not washing his hands first or use hand sanitizer.

9. On 7/11/12 at 9:00 am, housekeeping personnel (employee #26) was found cleaning the floor in the observation area and in the hallway in front of the treatment area. She stated that "the emergency room does not have a janitor ' s closet, so I use the janitor ' s closet at the pediatric ward " . She also stated that with this same pail and mop, she cleans the emergency room first, then the X-ray department. After she collects the garbage from the areas, she takes the mop out to the main garbage dumpster and there is where she cleans the mops with a hose and leaves it there to dry. Also, a material safety data sheet (MSDS) in the pediatric housekeeping room was not found.

10. Two closed clinical records were reviewed on 7/12/12 from 2:00 pm till 3:30 pm to verify documentation of Organ Procurement Responsibilities of patients who died while receiving treatment in the Emergency Room and provided evidence of the following:

a. R.R #33 is a 42 years old male who visited the emergency room (ER) on 1/28/12 at 3:58 pm with Fever and Viral Syndrome. The triage was performed at 3:58 pm and the patient was categorized as "non urgent" with the following vital signs (V/S): temperature-38.5ºC, pulse-91, respiration-17 and blood pressure-131/70 and complaint with generalize pain, fever, nauseas and vomits. The record was reviewed on 7/12/12 at 2:30 pm and provided evidence that the E.R physician evaluated the patient for fever as of four days ago with vomits and the patient's mother died about 2 to 3 weeks ago. The physician ordered treatment at 4:30 pm of .9% Normal Saline to run full drip, Pepcid 20 mg IV, Tigan 2 ml IM, Tylenol 500 mg stat, laboratory samples and chest X ray. The results of the laboratory taken on 1/28/12 at 5:30 pm provided evidence that the white blood cell (WBC) count was 11.72 ul, platelets on 293.0 ul and low sodium 134 mmol/l. On 1/29/12 at 12:05 pm the physician's discharge progress notes refers that the patient denies systemic disease, cough with sputum, diarrhea, melena, dysuria, cephalea and dyspepsia. The chest X-Ray provided evidence of no infiltrates seen, laboratory evidence of bacteria infection and grief reaction over mother's death. On 1/29/12 at 12:05 pm, the patient was discharged home (20 hours later) with the following recommendations: Regular diet, look for reactions and friends support to avoid depression, psychologist or psychiatric ambulatory evaluations, repeat (CBC) on 24-48 hours, observed for bleeding, hematomas, high fever, no aspirin or derivatives and only to take acetaminophen.

b. On 1/31/12 at 9:04 am the patient returned to the ER (45 hours later) and the triage was performed at 8:52 am and was categorized as "urgent" with the following vital signs (V/S): temperature-39.1ºC, pulse-117, respiration-25 and blood pressure-95/60, oxygen saturation 99% and complaint with generalize malaise and fever. The ER physician evaluated the patient for fever, nauseas and cough with blood and a provisional diagnosis of Viral Syndrome, Fever and possible BKP. The physician ordered treatment at 9:30 am of .9% of Normal Saline to run 250 ml, Tylenol 500 mg stat, laboratory samples and chest X ray. The results of the laboratory taken on 1/31/12 at 10:00 am provided evidence that the (WBC) count was 6.91 ul, platelets on 183.0 ul, low sodium 132 mmol/l and low chloride 96 mmol/l. On 1/31/12 at 3:00 pm nursing progress notes were found that the patient was "observed in isolation and a vomited blood on the floor and the physician was notified". On 1/31/12 at 4:00 pm the CBC was repeated and type/cross was taken, PT-PTT sample and the WBC of CBC was taken and was notified by the laboratory as a "panic result" of .80 ul and platelets of 147.0 ul and prothrombin time of 16.4 sec. At 7:00 pm the respiratory therapist placed a ventury mask at 50% for respiratory difficulty with blood gas ph of 7.365, low pCO2 of 20.7, low pO2 of 57.1, low BE of 11.2, low HCO3 of 11.6 (mmol/L) and low O2 saturation of 87.1%. The X-rays' findings on 1/31/12 was "right lung lobe ill defined patchy consolidation with suggestions of air bronchogram's in favor of pneumonia". The physician tries to transfer the patient 1/31/12 a 7:00 pm due to a Bronchopneumonia and to rule out T.B. On 1/31/12 at 8:20 pm the nurse notified "code green" and began cardiorespiratory resuscitation and the patient was pronounced dead at 9:00 pm. The facility failed to ensure that the patient's was given a psychological evaluation during his first admission, no evidence was found that this cases was evaluated by the emergency room medical director related to the patient's death, transfer or return to the E.R within 48 hours. No evidence was found that the case was notified or evaluated by the Infection control officer related to personnel handling of this case during the first and second visits related to possible TB infection.

Based on observations, interviews with Human Resource Director (employee #8), Executive Director (employee # 9), Medical Director (employee # 42) and records reviewed on 7/12/12 from 10:05 am till 2:00 pm, 7/13/12 from 9:30 am till 3:00 pm, it was determined that the facility failed to ensure that Rehabilitation services is organized and staffed to ensure the health and safety of patients, no evidence was found policies and procedures, credential files, the organizational chart to indicate lines of authority and delegation of responsibilities within the department, Physical therapy staffing and schedules, implemented and maintained on an ongoing Quality Assessment and Performance Improvement (QAPI) program, quality indicators related to patient's goals being met during their treatment and when discharge. The facility did not have a director of services and organizer rehabilitation department, the have written plan of treatment, individualized assessments, short-term and long-term goals of the patient's response reviewed related to the therapeutic intervention.

Based on the observational tour, interview and three records reviewed (R.R) with the respiratory therapy supervisor (employee #1) and executive director (employee # 9), it was determined that the facility failed to ensure that services are provided according to the scope of services offered for therapeutic intervention for three out of three records reviewed (R.R) #8, #9 and #12.

Findings include:

1. No evidence was found on 7/13/12 at 2:00 pm of the policies and procedures to verify that the scope of rehabilitation services offered is defined in writing.

2. No evidence was found on 7/13/12 at 2:10 pm of the personnel files to verify current licensure, certifications and ongoing training, consistent with applicable State laws.

3. No evidence was found on 7/13/12 at 2:20 pm of the organizational chart to indicate lines of authority and delegation of responsibilities within the department or services offered in the rehabilitation services.

4. No evidence was found on 7/13/12 at 2:30 pm of the PT staffing and schedules to determine adequacy of staff or of a registered nurse to provide supervision of the rehabilitation services.

5. No evidence was found that the physical therapy department implemented and maintained an ongoing Quality Assessment and Performance Improvement (QAPI) program as reviewed on 7/13/12 at 2:30 pm for all procedures and conditions for the complexity of cases they managed. No evidence was found of quality indicators related to patient's goals being met during their treatment and when discharged.

6. During interview with the Executive Director (employee #9) on 7/12/12 at 2:00 pm., he stated: '' There is a Physical Medicine & Rehabilitation (PM&R) Physician who performs consults. Facility physicians place consultations for the PM&R Physician and she evaluates the patients and provide the physical therapy during the patient hospitalization, however no evidence was found of the therapist and the physiatrist coordinates with the discharge planning to provide services at their home. Once we had a Physical Therapist from a private office and she provide services to the patients. At the present time there are no contracts with the Physical Medicine Physician and physical therapist. The executive director (employee #9 ) refers that the hospital had an office inside the hospital which was used by the physiatrist who provided his consult services, evaluation of hospitalized patients and physical therapy treatments provided by a private physical therapist of the physician in exchange of the monthly payment for the rent of the office. Now a day the office of the physiatrist is located outside the hospital at the Medical Tower and the physical therapy is provided to the patients with no charge.
7. The facility did not provided evidence of previous contracts or updated contract of the physiatrist or of the physical therapist does that provide the services to the hospitalized patients. During the evaluation of three clinical records (RR #8, #9and #12) of hospitalized patients on 7/12/12 de 1:30 pm. at 2:30 pm., Record Review #9 revealed that on 7/9/12 at 11:45 am., the initial evaluation was performed and on 7/10/12 at 11:40 am., the first physical therapy was provided by the therapist employee #39, personal employee of the physiatrist employee #41. On 7/12/12 at 8:30 am till 9:30 am. The patient received physical therapy services provided by the therapist employee #40 (private employee of the physiatrist doctor).
During the interview performed on 7/12/12 at 11:45 am with The Human Resource Director employee #8, she stated: " I did not know that this physical therapist employee #40 provided direct services to hospitalized patients.
8. During the investigation conducted it was found that this therapist did not have privilege nor contract with the hospital was referred by the Physiatrist because the other therapist had personal problems and was substitute with her to provide the physical therapy treatments to hospitalized patients.
The human resource director employee # 8 stated on 7/ 12/12 at 50 am: " I got in touch with the physiatrist by telephone who in the absence of one therapist for two weeks she provided another therapist but was not notified administratively. These two therapist are not employees of the hospital, they do not have contracts nor privilege at the hospital and the therapist # 40 does not have credentials available at the human resource department.''
During interview with the Hospital Medical Director (employee #42) at the administration conference room on 7/12/12 at 11:15 am she stated: " we offer physical therapy services but I have no inherence related to the services provided by the physiatrist to the hospitalized patients. The doctor has provided these services for year in exchange to minimize the monthly rent of her office located at the hospital. The physician does not have her office on lease since a year ago she provides free services to hospitalized patients. I do not know the agreements at a contract level or administratively that were actually done, the only thing I know is that she does not receive payments for the services provided. The physiatrist has one Physical Therapist (PT) that provided physical therapy as per patient ' s needs after been evaluated and base on the initial physiatrist initial assessment. The physician places an order for a consultation for the PM&R and staff calls the PM&R physician. The PM&R physician come to the hospital and reads the record first and then examines the patient, orders therapies and communicates with the physical therapist who works for the PM&R Physician " .
During interview with the nursing supervisor (employee #10) in the administration conference room on 7/12/12 at 11:25 am she stated: '' I ' m new in the hospital, I have being here for a month and I did not know this situation of the physical therapy services offered. I do not know how the protocol is to offer the therapy services.''

19. The facility failed to ensure that services are provided according to the scope of services offered and that the personnel that provide physical therapy complies with the requirements establish by the human resource department to maintain a credential file of all personal to assure that all personal employees of the hospital maintain an update contract and required credential. The facility did not assure that these employees or contracted personnel are evaluated at the human resource department placing at risk the safety of all patients.

Based on the observational tour, interview, three records reviewed (R.R) with the executive director (employee #9), human recourse director (employee # 8) and respiratory therapy supervisor employee (# 1) it was determined that the facility failed to have a director of the rehabilitation services.

Findings include:

1. No evidence was found on 7/12/12 at 11:30 am that the facility have a rehabilitation services director that must have the necessary knowledge, experience, and capabilities to properly supervise and administer the services.

During interview with the executive director (employee #9) on 7/12/12 at 2:00 pm, he stated: " there is a Physical Medicine & Rehabilitation (PM&R) Physician who performs consults. Facility physicians place consultations for the PM&R Physician and he evaluate the patients and offer the physical therapy during the patient hospitalization. Once we had a Physical Therapist from the physiatrist office that provided services to the hospitalized patients. At the present time there are no contracts with the physiatrist and physical therapist (PT) " .

Based on interview with the Executive Director (employee #9), it was determined that the facility failed to maintain credential files of the Physical Medicine & Rehabilitation (PM&R) Physician and Physical therapist (PT) personnel.
Findings include:
1. No evidence was provided on 7/13/12 at 1:05 pm that the facility maintains credential files for the Physical Medicine & Rehabilitation (PM&R) Physician and Physical Therapist as required in accordance with state and local laws.
a. During interview with the executive director (employee #9) on 7/13/12 at 2:00 pm, he stated: " There is a Physical Medicine & Rehabilitation (PM&R) Physician who performs consults. Facility physicians place consultations for the PM&R Physician and she evaluate the patients and provides therapy services to hospitalized patient. Once we had a Physical Therapist from a private physiatrist office and she provide services to hospitalized patients. At the present time there are no contracts or privileges with physiatrist and physical therapist.''

Based on the review of three clinical records of hospitalized patients and interviews with the Nursing Director (employee #10) and Executive Director (employee #9), it was determined that the facility failed to ensure that services are furnished in accordance with a written plan of treatment, individualized assessments, short-term and long-term goals and the patient's response is reviewed related to the therapeutic intervention for 3 out of 3 records reviewed (R.R) #8, #9 and #12.

Findings include:

1. Three out of three records reviewed on 7/12/12 from 10:05 am till 2:00 pm provided evidence that the physician did not write the date and the hour when solicited the consult for the patient, frequency of treatment, the hour of medical order, amount of treatment, duration of treatment, short and long term goals and name of patient and no evidence was found of the hour when the nurse notified the consult at the physiatrist (R.R) #8, #9 and #12.

2. Three out of three clinical records reviewed on 7/12/12 from 10:05 am till 2:00 pm lacks documentation of the physical therapist related to plans of treatment, frequency of treatment, short-term and long-term goals, type and duration of services, patient's initial individualized assessment, pain assessment, response and changes to therapeutic interventions and therapist notes. The incomplete treatment and goals did not reflect changes in the patient's status.

3. R.R #8 is a 93 years old male admitted to the facility on 7/8/12 with a diagnosis of Abdominal Pain. On 7/10/12 at 9:30 am the social worker evaluated the patient and described the patient alert, clean, no ambulated, in regular diet, needs assistant on alimentation, lived with his daughter, bedridden and needs assistant on daily living. Physician order was placed to PMR Service Consult on 712/12 at 9:30 am. The patient record is evaluated on 7/12/12 at 1:30 pm. and recommends beginning physical therapy to all extremities, mobility on his bed, sitting on bed, transference and sitting training out of bed and continuing with social worker at home program. No evidence was found if the consult was notified at the physiatrist to evaluate the patient and established the patient plan of care and accordance of patient needs.

4. R.R #9 is a 77 years old female admitted to the facility on 6/21/12 at 8:00 pm. with a diagnosis of Myeloma Multiple, Diabetes Mellitus, High Blood Pressure and Chronic Obstructive Pulmonary Disease (COPD). On 7/5/12 at 2:00 pm. a physician order was placed to PMR Service Consult. The patient record is evaluated on 7/12/12 at 1:45 pm. and provides evidence that the physiatrist initial assessment was performed on 7/6/12 at 10:35 am., and recommends to begin in physical therapy to left side, mobility on his bed, sitting on bed, training transference, sitting training out of bed and continue with social worker at home program. The therapist initial assessment was performed on 7/9/12 at 11:45 am., three days later than the physiatrist initial assessment was performed. The therapist note indicated that the patient needs physical therapy, occupational therapy and social worker service. However no evidence was found of occupational therapy service was provided and no evidence of social service evaluation. The physical therapy initial evaluation was performed on 7/9/12 at 11:45 am. and the therapist note provide evidence that the patient is alert, clean, no ambulated, in regular diet, needs assistant on alimentation, lived with his daughter, bedridden and needs assistant on daily living. No evidence was found if the consult was notified at the physiatrist to evaluate the patient and established the patient plan of care and accordance with patient needs.
5. R.R #12 is a 69 years old male admitted to the facility on 7/8/12 with a diagnosis of Cardio Vascular Accident (CVA) and Left Side Hemiplegic. On 7/10/12 a physician order was placed to PMR Service Consult. The physician order lacks of hour when the physician wrote the order and the consult lacks of date and hour when the physician requested the consult. The nurse takes the order on 7/10/12 at 5:28 pm. and the physiatrist is notify by the secretary on 7/ 11/12 at 11:35 am.
a. The patient record RR#12 evaluated on 7/12/12 at 2:00 pm and provide evidence that the physiatrist initial assessment was performed on 7/11/12 at 12:10 pm. and recommends to begin in physical therapy and the physician plan of care reveals right side weakness, right handed and articulation and consulted for physical therapist for transference, sitting and waking and home care program after discharge home. No evidence was found of the initial therapist assessment. No evidence was found of physical therapist plan of treatment for type of therapy, amount, frequency and duration of the therapies, no evidence of short and long term goals.
b. The physical therapy note on 7/12/12 at 9:40 am. till 10:05 am., provide evidence that the therapist write new treatment and orientation was given to patient caregiver related to treatment to follow however no evidence was found of what kind of treatment the patient will received. The therapist note provide evidence that the patient looks alert all the time, oriented per three and will benefit of physical therapy and recommended to continue on physical therapy service. However, the facility failed to evaluate the patient and established the patient plan of care accordance of patient needs.

Based on observations and the review of medical records, documents and the lack of policies and procedures on 7/10/12 from 9:15 am till 2:30 pm, it was determined that the facility failed to meet the needs of its patients in accordance with acceptable standards of practice, perform post-assessment, patient's assessment after respiratory therapy treatment, patient's estimated initial respiratory therapy treatments, in-services training for the department, sufficient personnel available, sign posting for those patients using oxygen, labeled with the date and hour when started on the equipment, and the respiratory therapy staff pattern. No evidence was provided that respiratory services are integrated into the Quality assessment and performance improvement program and no evidence was provided of in-services training for the department.

Based on six medical records reviewed (R.R), the lack of documents provided, the lack of policies/procedures and interview with the supervisor of the Respiratory Therapy Department employee #1, it was determined that the facility failed to ensure that the organization of the respiratory care services is appropriate to the scope and complexity of the services for 5 out of 6 clinical records reviewed (R.R #7, #36, #44, #45 and #47).

Findings include:

1. During the survey of the respiratory therapy services on 7/10/12 at 9:15 am, the supervisor of the Respiratory Therapy Department (employee #1) stated during an interview on 7/10/12 at 11:30 am, "The facility has a contract with a private company; I'm the only hospital employee and have seven years as a supervisor. The Respiratory Therapy Department has fourteen respiratory therapists all under contract with rotating shifts from 6:00 am to 2:00 pm, 2:00 pm to 10:00 pm and 10:00 pm to 6:00 am. The respiratory company provides all the employees and performs the schedule every fifteen days. If someone is absence with notification or without notification or any changes on the program it is notified to the supervisor. To cover the different areas assigned by the shift there are three therapists from 6:00 am to 2:00 pm, three therapists from 2:00 pm to 10:00 pm and two therapists to cover from 10:00 pm to 6:00 am. If there is someone absent that did not notified it previously, I call the company and the pertinent arrangements are made. The company is available 24 hours a day, 7 days a week. Everything related to materials is supplied by the hospital. We have three ventilators owned by the hospital and from 8 to 10 ventilators supplied by the private company. Any situation with the rent ventilators, the company resolves it including the preventive maintenance. The 3 ventilators owned by the hospital, the preventive maintenance is provided annually by Puerto Rico Sales. All supplies used by the ventilators are disposable including the filters''.

2. No evidence was found on 7/10/12 at 1:20 pm of in-service training for the year of 2011 and from January through June of 2012.

3. Respiratory therapy services has not submitted a quality assurance plan or activities for improvement from January through December 2011 as reviewed on 7/10/12 at 1:30 pm. Only provided evidence of four indicators during the months from January to May of 2012 related to " Evaluation of the Services for Respiratory Care to the patient, Procedure for Arterial Assess, Care for the Client on Mechanical Ventilator and Clinical Documentation of the Record " .

4. Six medical records were reviewed on 7/10/12 from 2:40 pm till 4:00 pm and 7/11/12 from 9:00 am till 11:30 am of patients who received respiratory therapy and provided evidence that respiratory therapists did not administer respiratory therapy treatment in accordance with physician orders for R.R #7, #36, #44, #45 and #47. Records reviewed provided evidence that patients did not receive respiratory treatment in a timely manner:

a.R.R #7 is an 88 years old female admitted on 6/18/12 at 4:36 pm with a diagnosis of Bronchitis/R/O Bronchopneumonia. The record review was performed on 7/10/12 at 3:00 pm and provided evidence that the physician ordered Xopenex 0.63 mgs and Atrovent 0.02 % every 4 hours on 6/18/12 at 8:40 pm. The patient received the first respiratory therapy on 6/18/12 at 8:45 pm, the next respiratory therapy was given at 11:30 pm (one hour and 15 minutes before), and no evidence of the date, the hour and the patient vital signs before and after the respiratory therapy technician gives the treatment, they only write that the patient tolerated the treatment. The next therapy was given on 6/19/12 at 4:30 pm (seventeen hours late), the next therapy was given at 8:00 pm and 12 midnight, the next therapy was given on 6/20/12 at 4:00 am, 8:00 am, 12:00 md, 4:00 pm and 8:00 pm. On 6/21/12 respiratory therapy was given at 12:00 am, 4:00 am, 8:00 am, 12:00 md, 4:30 pm and 8:00 pm. On 6/22/12 respiratory therapy was given at 12:00 mn, 4:00 am, 8:10 am, 12:00 md, 4:20 pm and 8:10 pm. On 6/23/12 respiratory therapy was given at 12:30 am, 4:30 am and 7:00 am the respiratory therapy was given one hour before. The record revealed that the physician re-evaluated the patient on 6/23/12 at 9:30 am the respiratory therapy was given at 1:00 pm and 7:00 pm. On 6/24/12 respiratory therapy was given at 12:30 am, 6:30 am, 12:00 md and 6:00 pm. On 6/25/12 respiratory therapy was given at 12:00 mn, 6:30 am, 12:30 pm and 6:30 pm. On 6/26/12 respiratory therapy was given at 12:00 mn, 6:30 am, 12:30 pm and 6:00 pm. No evidence of the respiratory therapy was re-evaluated by the physician in accordance of the respiratory therapy policies and procedures. The patient record has a respiratory label that indicate the expiration date on 6/26/12 for re-evaluation by the physician; however the physician re-evaluated the respiratory therapy treatment on 6/27/12 at 7:45 pm, thirteen hours and forty-five minutes late. The physician ordered Atrovent 0.02 % every 6 hours at 7:45 pm and the respiratory therapy was given at 7:50 pm, the patient did not receive respiratory therapy on 6/28/12 at 1:50 am and 7:50 am, the next respiratory therapy was given at 6:30 am (10 hours and 40 minutes later), the respiratory therapy was given at 12:30 pm and 6:30 pm, 12:30 pm. On 6/29/12 the respiratory therapy was given at 12:00 mn, 7:00 am (30 minutes late), at 12:40 pm and 6:30 pm. On 6/30/12 the respiratory therapy was given at 12:30 am, 6:30 am, at 12:30 pm and 6:00 pm. On 6/30/12 and 7/1/12 a respiratory label was placed on the patient record to re-evaluated the patient respiratory therapies and the physician re-evaluated the respiratory treatment on 7/1/12 at 6:00 pm. to Albuterol 0.083 % every 6 hours and signed by therapist on 7/1/12 at 6:00 pm. and the patient received the treatment on 7/2/12 and 7/3/12 every 6 hours in accordance with the physicians' orders and her respiratory needs. On 7/3/12 at 5:00 pm. the physician re-evaluated the respiratory therapy and continues on Albuterol 0.083 % every 6 hours signed by therapist but lacks the hour when the therapist signed the physician order. On 7/4/12 the respiratory therapy was given at 12:00 mn, 7:00 am (30 minutes late), at 1:00 pm and 7:00 pm. On 7/5/12 the respiratory therapy was given at 12:00 mn. On 7/3/12 at 5:00 pm. the physician re-evaluated the respiratory therapy and continues on Albuterol 0.083 % every 6 hours signed by therapist but lacks the hour when the therapist signed the physician order. 6:30 am., 12:30 pm and 6:00 pm. (30 minutes before). On 7/5/12 at 11:00 pm. the physician re-evaluated the respiratory therapy and change the treatment to Proventyl 0.083 % every 4 hours and Pulmicort 0.5 mgs., every 12 hours signed by therapist at 11:00 pm. and was given at patient at 1:50 am.( 2 hours and 50 minutes later ) and at 7:15 am. (1 hour later ). The first Pulmicort therapy was given on 7/6/12 at 9:00 am.( 10 hours later than the physician ordered ) then continue with treatments accordance of physician order and patient needs. On 7/7/12 at 6:00 pm. the physician re-evaluated the respiratory therapy and continue with Proventyl 0.83 % every 4 hours and Pulmicort every 4 hours signed by therapist but lacks the hour when the therapist signed the physician order and the physician order lacks of Pulmicort dose. The Pulmicort therapy was given on 7/7/12 at 8:00 pm, the respiratory treatment form on 7/8/12 did not provide evidence of documentation if the Pulmicort was given during the night at 12:00 mn. and 4:00 am. ,the next therapy was given at 8:30 am. and continue with the Pulmicort therapy not accordance with physician order. On 7/10/12 at 6:45 am. The physician re-evaluated the respiratory therapy and ordered Albuterol 0.83 % every 6 hours and the patient received the therapies however, the patient continue on Pulmicort therapy and no evidence of new order to continue on this treatment.

b. R.R #36 is a 82 years old female admitted on 7/9/12 at 8:30 pm with a diagnosis of Congestive Heart Failure (CHF) NOVO, White Lung and R/O Suspected Pneumonia. The record review was performed on 7/11/12 at 10:00 am and provided evidence that the patient physician ordered at 3:30 pm. ABG'S and placed on Ventury mask at 50 % FiO2. On 7/9/12 at 8:30 pm. the physician ordered Atrovent 0.02 per one treatment and administered at 9:20 pm. The patient was admitted at Intensive Unit Care at 10:40 pm. with Pneumonia Protocol. A new order of Albuterol 0.083 % per 15 minutes every 4 hours and ventury mask at 50 % was placed by the physician. The patient received respiratory therapy on 7/9/12 at 8:30 pm., 12:00 mn., 4:00 am., 7:30 am.,12:45 pm. ( 45 minutes later ) and 5:30 pm.( 15 minutes later ). On 7/10/12 at 9:25 am. the patient developed on respiratory arrest and endotraqueal tube was placed and placed on ventilator. On 7/10/12 at 5:45 pm. the physician ordered discontinues Albuterol. On 7/10/12 at 8:20 pm. Xopenex 0.63 mgs. and Atrovent 0.02 % every 6 hours was ordered by telephone call and the treatment administered at 12:30 am..(4 hours and 10 minutes later), 7:00 am., 12:35 pm. and 7:00 pm. On 7/12/12 was administered at 12:30 am. and 6:50 am ( the order lacks of date and hour of the pneumologist ). On 7/12/12 the respiratory therapy was re-evaluated and increases the dose of Xopenex to 1.25 mgs. and Atrovent 0.02 % every 6 hours the next therapy was given at 12:55 pm. The therapies were administered not according to the physician's orders and patient needs.

c. R.R #44 is a 78 years old male admitted on 7/9/12 at 9:46 am. The record review was performed on 7/10/12 at 2:40 pm and provided evidence that the patient physician ordered on 7/9/12 at 1:00 pm. Albuterol 0.083 by power nebulizer every 6 hours and Intensive spirometry therapy and was taken by the nurse on 7/9/12 at 4:00 pm. (3 hours later when the physician writes the order). The order was signed by the respiratory therapist but no evidence was found of date and hour when the therapist signed the order. The patient received respiratory therapy on 7/9/12 at 4:30 pm. (3 hours later) and spirometry at 4:55 pm. The initial assessment was performed on 7/9/12 at 8:30 pm. (4 hours after the respiratory treatment was initiated), the respiratory therapy not given at 10:30 pm. however was given on 7/10/12 at 1:00 am. (9 hours later), at 6:30 am. and 12:30 pm. On 7/10/12 at 3:00 pm the patient was visit at he's room #103 B accompanied with the respiratory therapy supervisor and the spirometry equipment was observed on the patient washbasin, the patient was interview related to the spirometry exercises and he stated: '' I not to know the use of this equipment the respiratory therapist did not explain related to the use and the benefits of this equipment.'' The therapies were administer not according to the physician's orders and patient needs and the respiratory therapy department failed to educate the patient on the management and the benefits of the spirometry therapy based on patient needs.

d. R.R # 45 is a 62 years old female admitted at medicine north two on 7/4/12 with diagnosis of Right Pleural Effusion. The record review was performed on 7/10/12 at 3:10 pm and provided evidence that the patient physician ordered on 7/4/12 at 8:40 pm. oxygen by nasal cannula at 3 liters per minute and respiratory therapy by nasal cannula of Xopenex 0.63 % and Atrovent 0.02 % by power nebulizer every 6 hours. The first respiratory therapy was given on 7/4/12 at 9:00 pm. On 7/6/12 at 6:40 pm. a label was placed on the patient record for the physician to renew the respiratory therapy, however no evidence was found of re-evaluation. On 7/6/12 at 7:15 pm. a label was placed by the respiratory therapy department related to the power nebulizer order expiration and a new order was placed on 7/7/12 at 6:15 pm for Intensive Spirometry every 2 hours per 8 minutes, chest tapping, Xopenex 0.03 % by power nebulizer every 8 hours and ABG's ( arterial blood gases). The order was taken by the nurse on 7/7/12 at 6:20 pm. On 7/8/12 at 9:00 am. the patient continue with nasal cannula with oxygen at 3 liters per minutes. No evidence was found when the order was signed by the respiratory therapist. The respiratory therapy of Xopenex 0.63 % by power nebulizer was given on 7/8/12 at 4:30 pm. (16 hours later) and continue at 12:30 am. and 6:00 am. No evidence was found when the therapist oriented the patient related to the spirometry exercise. On 7/9/12 at 6:00 pm. and 7/10/12 the respiratory therapist placed a seal to notified at physician the respiratory therapy expired and needs re-evaluation. On 7/10/12 at 9:00 am. the physician re-evaluated the patient and ordered Xopenex 0.63 % by power nebulizer every 6 hours. No evidence was found at what time the patient received the respiratory therapy. The initial respiratory therapy assessment was performed on 7/4/12 at 9:00 pm. but did not provided information related to the patient breathings and referred that the patient have symmetric chest and wheezing at auscultation. The therapies offered but did not administer according to the physician's orders and patient needs and the respiratory therapy department failed to educate at patient the management and the benefits of the spirometry therapy based on patient needs.

e. R.R # 47 is a 50 years old female admitted on 7/9/12 with diagnosis of Bronchitis Asthmatic and R/O Bronchopneumonia. The record review was performed on 7/11/12 at 11:15 am and provided evidence that the patient physician ordered on 7/9/12 at 12:30 pm. on Emergency Room Albutherol 0.083 % by power nebulizer every 30 minutes per three times and Atrovent every 30 minutes per 3 times, arterial blood gases (ABG's ) at room air and Ventury mask at 50 %. The ABG's was performed on 7/9/12 at 12:48 pm. and the patient is placed on oxygen at 50 % by ventury mask. The first respiratory therapy was given on 7/9/12 at 12:50 pm., 1:15 pm. and 1:45 pm. (15 minutes later). Albutherol with Atrovent 0.2 by power nebulizer every 6 hours and Oxygen at 3 liters by nasal cannula was ordered by physician and was taken to Emergency room at 9:00 pm. (3 hours later than the physician ordered) and no evidence of therapist sign. The respiratory therapies of Albuterol and Atrovent 0.2 by power nebulizer every 6 hours was initiated at the emergency room on 7/9/12 at 12:00 mn. On 7/10/12 at 1:25 am. the patient was admitted at telemetry area at the medicine ward. The next respiratory therapies were given on 7/10/12 at 6:30 am., 12:30 pm. and 7 pm. On 7/10/12 at 5:45 pm. the patient was evaluated by pneumologist and a new order was placed to increase Albuterol 0.83 % and Atrovent 0.2 % every 4 hours per 15 minutes. The order was signed by the therapist at 6:45 pm. (1 hour later) and taken by the nurse at 7:03 pm. (1 hour and 18 minutes later). The patient received the last respiratory therapy of Albutherol with Atrovent 0.2 by power nebulizer not the actually respiratory therapy treatment ordered by pneumologist on 7/10/12 at 5:45 pm. The respiratory therapy was given on 7/11/12 at 12:30 am. (6 hours and 45 minutes later than the physician as ordered), then at 4:00 am., 8:00 am. and 12:00 md. The initial respiratory therapy assessment was performed on 7/10/12 at 12:00 md. and provide evidence on the therapist notes that the patient have rhonchus, force breathing and respiratory difficulty. (2 days after the respiratory treatment was initiated). The therapies given but were not administer according to the physician's orders and patient needs.

Based on the review of medical records (R.R.), documents, policies/procedures and interview with the Director of the Respiratory Therapy Department (employee #1), it was determined that the facility failed to ensure that there an adequate number of respiratory therapists and other personnel to meet qualifications specified by the medical staff and consistent with State law to meet the respiratory needs of patients for 6 of 6 records reviewed R.R #7, #36, #44, #45 and #47.

Findings include:

1.During the survey of the respiratory therapy services on 7/10/12 at 9:15 am till 2:30 pm, the supervisor of the Respiratory Therapy Department (employee #1) stated during an interview on 7/10/12 at 11:30 am, "The facility has a contract with a private company, I'm the only hospital employee and have seven years as a supervisor. The Respiratory Therapy Department has fourteen respiratory therapists all under contract with rotating shifts from 6:00 am to 2:00 pm, 2:00 pm to 10:00 pm and 10:00 pm to 6:00 am. The respiratory company provides all the employees and performs the schedule every fifteen days. If someone is absence with notification or without notification or any changes on the program it is notified to the supervisor. To cover the different areas assigned by the shift there are three therapists from 6:00 am to 2:00 pm, three therapists from 2:00 pm to 10:00 pm and two therapists to cover from 10:00 pm to 6:00 am. If there is someone absent that did not notified it previously, I call the company and the pertinent arrangements are made. The company is available 24 hours a day, 7 days a week.

2. The facility does not have sufficient personnel available to respond to respiratory care needs of its patient's population as reviewed on 7/10/12 at 3:20 pm. Review of the July monthly treatment of respiratory therapy services. The treatments offered by the respiratory therapy staff during July of 2012 are suction, place patients ' oxygen, arterial blood gas (ABG), respiratory therapy treatments, incentive spirometry ( IS), chest tapping, measurement of peak flow, cardio pulmonary resuscitation (CPR) and patient in ventilator.
3. Review of the May monthly program of respiratory therapy services personnel with the director of the Respiratory Therapy Department (employee #1) on 7/11/12 at 9:00 she stated " I prepared the program for fourteen therapies and three respiratory therapists for each shift working during 6:00 am. till 2:00 pm and 2:00 pm till 10:00 pm and two respiratory therapist during shift 10:00 pm till 6:00 am.
4. During review of the May program of the respiratory therapy employees on 5/3/12 they have only two therapist to covered the shift 6:00 am till 2:00 pm. On 5/6/12 only have two therapists to cover the 6:00 am till 2:00 pm shift and one therapist to cover 10:00 pm till 6:00 am. On 5/9/12, 5/11/12, 5/13/12, 5/14/12, 5/22/12, 5/24/12, 5/28/12 and 5/31/12 there were two therapists to cover the 2:00 pm till 10:00 pm shift.
5. During review of the June program of the respiratory therapy employees on 6/2/12 there were only 2 therapists to cover the shift 2:00 pm till 10:00 pm. and 2 therapist to cover 2:00 pm till 10:00 pm shift. On 6/3/12 there were only 2 therapist to cover the shift 2:00 pm till 10:00 pm. On 6/7/12 there were only 2 therapists to cover 2:00 pm till 10:00 pm. shift. On 6/11/12 only 2 therapist to cover 2:00 pm till 10:00 pm. shift. On 6/16/12 only 2 therapist to cover 2:00 pm till 10:00 pm. shift. On 6/17/12 only 2 therapists to cover 6:00 am till 2:00 pm. and 2 therapist to covered 2:00 pm till 10:00 pm. shift. On 6/19/12 only 2 therapists to covered 6:00 am till 10:00 pm. shift. On 6/22/12 only 2 therapists covered 2:00 pm till 10:00 pm. shift. On 6/23/12 only 2 therapists covered 6:00 pm till 2:00 pm. and on 6/30/12 only one therapist to covered 6:00 am till 2:00 pm. shift.
6. The facility does not have sufficient personnel available to respond to the respiratory care needs of its patient population as evidenced on 7/11/12 at 9:00 am. Six medical records of hospitalized patients were reviewed on 7/10/12 from 2:40 pm till 4:00 pm and 7/11/12 from 9:00 am till 11:30 am. and provided evidence that patients are receiving respiratory therapy services but they did not receive respiratory therapies in accordance with the physicians' orders and their respiratory needs for five out of six (#7, #36, #44, #45 and #47).

5. Six medical records were reviewed on 7/10/12 from 9:30 am till 3:40 pm of patients who received respiratory therapy and provided evidence that respiratory therapist did not administer respiratory therapy treatment in accordance with physician orders for R.R #7, #36, #44, 45 and #47. Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis.

a. R.R #7 is an 88 years old female admitted on 6/18/12 at 4:36 pm with a diagnosis of Bronchitis/R/O Bronchopneumonia. The record review was performed on 7/10/12 at 3:00 pm and provided evidence that the physician ordered Xopenex 0.63 mgs and Atrovent 0.02 % every 4 hours on 6/18/12 at 8:40 pm. The patient received the first respiratory therapy on 6/18/12 at 8:45 pm, the next respiratory therapy was given at 11:30 pm (one hour and 15 minutes before), and no evidence of the date, the hour and the patient vital signs before and after the respiratory therapy technician gives the treatment, they only write that the patient tolerated the treatment. The next therapy was given on 6/19/12 at 4:30 pm (seventeen hours late), the next therapy was given at 8:00 pm and 12 midnight, the next therapy was given on 6/20/12 at 4:00 am, 8:00 am, 12:00 md, 4:00 pm and 8:00 pm. On 6/21/12 respiratory therapy was given at 12:00 am, 4:00 am, 8:00 am, 12:00 md, 4:30 pm and 8:00 pm. On 6/22/12 respiratory therapy was given at 12:00 mn, 4:00 am, 8:10 am, 12:00 md, 4:20 pm and 8:10 pm. On 6/23/12 respiratory therapy was given at 12:30 am, 4:30 am and 7:00 am the respiratory therapy was given one hour before. The record revealed that the physician re-evaluated the patient on 6/23/12 at 9:30 am the respiratory therapy was given at 1:00 pm and 7:00 pm. On 6/24/12 respiratory therapy was given at 12:30 am, 6:30 am, 12:00 md and 6:00 pm. On 6/25/12 respiratory therapy was given at 12:00 mn, 6:30 am, 12:30 pm and 6:30 pm. On 6/26/12 respiratory therapy was given at 12:00 mn, 6:30 am, 12:30 pm and 6:00 pm. No evidence of the respiratory therapy was re-evaluated by the physician in accordance of the respiratory therapy policies and procedures. The patient record has a respiratory labell that indicated the expiration date on 6/26/12 for re-evaluation by the physician; however the physician re-evaluated the respiratory therapy treatment on 6/27/12 at 7:45 pm, thirteen hours and forty-five minutes late. The physician ordered Atrovent 0.02 % every 6 hours at 7:45 pm and the respiratory therapy was given at 7:50 pm, the patient did not receive respiratory therapy on 6/28/12 at 1:50 am and 7:50 am, the next respiratory therapy was given at 6:30 am (10 hours and 40 minutes later), the respiratory therapy was given at 12:30 pm and 6:30 pm, 12:30 pm. On 6/29/12 the respiratory therapy was given at 12:00 mn, 7:00 am (30 minutes late), at 12:40 pm and 6:30 pm. On 6/30/12 the respiratory therapy was given at 12:30 am, 6:30 am, at 12:30 pm and 6:00 pm. On 6/30/12 and 7/1/12 a respiratory label was placed on the patient record to re-evaluated the patient respiratory therapies and the physician re-evaluated the respiratory treatment on 7/1/12 at 6:00 pm. to Albuterol 0.083 % every 6 hours and signed by therapist on 7/1/12 at 6:00 pm. and the patient received the treatment on 7/2/12 and 7/3/12 every 6 hours in accordance with the physicians' orders and her respiratory needs. On 7/3/12 at 5:00 pm. the physician re-evaluated the respiratory therapy and continues on Albuterol 0.083 % every 6 hours signed by therapist but lacks the hour when the therapist signed the physician order. On 7/4/12 the respiratory therapy was given at 12:00 mn, 7:00 am (30 minutes late), at 1:00 pm and 7:00 pm. On 7/5/12 the respiratory therapy was given at 12:00 mn. On 7/3/12 at 5:00 pm. the physician re-evaluated the respiratory therapy and continues on Albuterol 0.083 % every 6 hours signed by therapist but lacks the hour when the therapist signed the physician order. 6:30 am., 12:30 pm and 6:00 pm. (30 minutes before). On 7/5/12 at 11:00 pm. the physician re-evaluated the respiratory therapy and change the treatment to Proventyl 0.083 % every 4 hours and Pulmicort 0.5 mgs. every 12 hours signed by therapist at 11:00 pm. and was given at patient at 1:50 am.( 2 hours and 50 minutes later ) and at 7:15 am. (1 hour later). The first Pulmicort therapy was given on 7/6/12 at 9:00 am, (10 hours later than the physician ordered) not in accordance with physician order and patient needs. On 7/7/12 at 6:00 pm. the physician re-evaluated the respiratory therapy and continues with Proventyl 0.83 % every 4 hours and Pulmicort every 4 hours signed by therapist but lacks the hour when the therapist signed the physician order and the physician order lacks of Pulmicort dose. The Pulmicort therapy was given on 7/7/12 at 8:00 pm. The respiratory treatment form on 7/8/12 did not provide evidence of documentation if the Pulmicort was given during the night at 12:00 mn. and 4:00 am. The next therapy was given at 8:30 am. and continue with the Pulmicort therapy not accordance of physician order. On 7/10/12 at 6:45 am. the physician re-evaluated the respiratory therapy and ordered Albuterol 0.83 % every 6 hours and the patient received the therapies however, the patient continue on Pulmicort therapy and no evidence of new order to continue on this treatment.

b. R.R #36 is a 82 years old female admitted on 7/9/12 at 8:30 pm with a diagnosis of Congestive Heart Failure (CHF) NOVO, White Lung and R/O Suspected Pneumonia. The record review was performed on 7/11/12 at 10:00 am and provided evidence that the patient physician ordered at 3:30 pm. ABG'S and placed on Ventury mask at 50 % FiO2. On 7/9/12 at 8:30 pm. the physician ordered Atrovent 0.02 per one treatment and administered at 9:20 pm. The patient was admitted to Intensive Unit Care at 10:40 pm. with Pneumonia Protocol. A new order of Albuterol 0.083 % per 15 minutes every 4 hours and Ventury mask at 50 % was placed by the physician. The patient received respiratory therapy on 7/9/12 at 8:30 pm., 12:00 mn., 4:00 am., 7:30 am.,12:45 pm. ( 45 minutes later ) and 5:30 pm.( 15 minutes later ). On 7/10/12 at 9:25 am. the patient developed a respiratory arrest and a endotraqueal tube was placed and patient put on ventilator. On 7/10/12 at 5:45 pm. the physician ordered discontinue Albuterol. On 7/10/12 at 8:20 pm. Xopenex 0.63 mgs. and Atrovent 0.02 % every 6 hours was ordered by telephone call and the treatment administered at 12:30 am..(4 hours and 10 minutes later), 7:00 Am., 12:35 pm. and 7:00 pm. On 7/12/12 was administered at 12:30 am. and 6:50 am , the order lacks of date and hour of the pneumologist. On 7/12/12 the respiratory therapy was re-evaluated and increases the dose of Xopenex to 1.25 mgs. and Atrovent 0.02 % every 6 hours the next therapy was given at 12:55 pm. The therapies were administer but not according to the physician's orders and patient needs.

c. R.R #44 is a 78 years old male admitted on 7/9/12 at 9:46 am. The record review was performed on 7/10/12 at 2:40 pm and provided evidence that the patient physician ordered on 7/9/12 at 1:00 pm. Albuterol 0.083 by power nebulizer every 6 hours and Intensive spirometry therapy and was taken by the nurse on 7/9/12 at 4:00 pm. (3 hours later than the physician write the order). The order was signed by the respiratory therapist but no evidence was found of date and hour when the therapist signed the order. The patient received respiratory therapy on 7/9/12 at 4:30 pm. (3 hours later) and spirometry at 4:55 pm. The initial assessment was performed on 7/9/12 at 8:30 pm. (4 hours after the respiratory treatment was initiated), the respiratory therapy not given at 10:30 pm. however was given on 7/10/12 at 1:00 am. (9 hours later), at 6:30 am. and 12:30 pm. On 7/10/12 at 3:00 pm the patient was visit at he's room accompanied with the respiratory therapy supervisor and the spirometry equipment was observed on the patient washbasin, the patient was interview related to the spirometry exercises and he stated: '' I not to know the use of this equipment the respiratory therapist did not explain related to the use and the benefits of this equipment.'' The therapies are privided but did not administer according to the physician's orders and patient needs and the respiratory therapy department failed to educated at patient the management and the benefits of the spirometry therapy based on patient needs.

d. R.R # 45 is a 62 years old female admitted at medicine nort two on 7/4/12 with diagnosis of Right Pleural Effusion. The record review was performed on 7/10/12 at 3:10 pm and provided evidence that the patient physician ordered on 7/4/12 at 8:40 pm. oxygen by nasal cannula at 3 liters per minute and respiratory therapy by nasal cannula of Xopenex 0.63 % and Atrovent 0.02 % by power nebulizer every 6 hours. The first respiratory therapy was given on 7/4/12 at 9:00 pm. On 7/6/12 at 6:40 pm. a label was placed on the patient record for the physician to re-evaluate the respiratory therapy, however no evidence was found of re-evaluation. On 7/6/12 at 7:15 pm. a label was placed by the respiratory therapy department related to the power nebulizer order expiration and a new order was placed on 7/7/12 at 6:15 pm for Intensive Spirometry every 2 hours per 8 minutes, chest tapping, Xopenex 0.03 % by power nebulizer every 8 hours and ABG's ( arterial blood gases ). The order was taken by the nurse on 7/7/12 at 6:20 pm. On 7/8/12 at 9:00 am. the patient continue with nasal cannula at 3 liters per minutes. No evidence was found when the order was signed by the respiratory therapist. The respiratory therapy of Xopenex 0.63 % by power nebulizer was given on 7/8/12 at 4:30 pm. (16 hours later) and continues at 12:30 am. and 6:00 am. No evidence was found when the therapist oriented the patient related to the spirometry exercise. On 7/9/12 at 6:00 pm. and 7/10/12 the respiratory therapist placed a label to notify the physician that the respiratory therapy expired and needs re-evaluation. On 7/10/12 at 9:00 am. the physician re-evaluated the patient and ordered Xopenex 0.63 % by power nebulizer every 6 hours. No evidence was found at what time the patient received the respiratory therapy. The initial respiratory therapy assessment was performed on 7/4/12 at 9:00 pm. but did not provided information related to the patient breathings and refer that the patient have symmetric chest and wheezing at auscultation. The therapies are offered but not administer according to the physician's orders and patient needs and the respiratory therapy department failed to educated at patient the management and the benefits of the spirometry therapy based on patient needs.

e. R.R # 47 is a 50 years old female admitted on 7/9/12 with diagnosis of Bronchitis Asmathic and R/O Bronchopneumonia. The record review was performed on 7/11/12 at 11:15 am and provided evidence that the patient physician ordered on 7/9/12 at 12:30 pm. on Emergency Room Albutherol 0.083 % by power nebulizer every 30 minutes per three times and Atrovent every 30 minutes per 3 times, arterial blood gases (ABG's) at room air and Ventury mask at 50 %. The ABG's was performed on 7/9/12 at 12:48 pm. and the patient placed on oxygen at 50 % by Ventury mask. The first respiratory therapy was given on 7/9/12 at 12:50 pm., 1:15 pm. and 1:45 pm. (15 minutes later). Albutherol with Atrovent 0.2 by power nebulizer every 6 hours and Oxygen at 3 liters by nasal cannula was ordered by physician and was taken to the Emergency room at 9:00 pm. (3 hours later than the physician ordered) and no evidence of therapist sign. The respiratory therapies of Albuterol and Atrovent 0.2 by Power nebulizer every 6 hours was initiated at the emergency room on 7/9/12 at 12:00 mn. On 7/10/12 at 1:25 am. the patient was admitted at telemetry area on the medicine ward. The next respiratory therapies was given on 7/10/12 at 6:30 am., 12:30 pm. and 7 pm. On 7/10/12 at 5:45 pm. the patient was evaluated by pneumologist and a new order was performed to increase Albuterol 0.83 % and Atrovent 0.2 % every 4 hours per 15 minutes. The order was signed by the therapist at 6:45 pm. (1 hour later) and taken by the nurse at 7:03 pm. (1 hour and 18 minutes later). The patient received the last respiratory therapy of Albutherol with Atrovent 0.2 by power nebulizer not the actual respiratory therapy treatment ordered by pneumologist on 7/10/12 at 5:45 pm. The respiratory therapy was given on 7/11/12 at 12:30 am. (6 hours and 45 minutes later than the physician as ordered), then at 4:00 am., 8:00 am. and 12:00 md. The initial respiratory therapy assessment was performed on 7/10/12 at 12:00 md. and provide evidence on the therapist note that the patient have rhonchus, force respiration and respiratory difficulty, (2 days after the respiratory treatment was indicated). The therapies offered were not administer according to the physician's orders and patient needs.

Based on the observational tour, six medical records reviewed (R.R), interview and review of policies and procedures with the Respiratory Therapist Clinic Supervisor ( employee #1 ), it was determined that the facility failed to ensure that services are provided in accordance with acceptable standards of practice related to appropriate measures of disinfecting, the appropriate solutions used to perform equipments disinfecting, the respiratory medication exposed and without security lock, respiratory equipment not labeled with the date and hour when started on the equipment, no evidence of sign posting for all patients using oxygen in the hospital. Failed to ensure that services are delivered in accordance with medical staff directives related to performing and completing patient's assessments and patient's are oriented about receiving respiratory care according to facility policies and procedures for 5 out of 6 medical records reviewed (R.R #7, #36, #44, #45 and #47 ).

Findings include:

1. During the observational tour, six medical records reviewed (R.R), interview and review of policies and procedures with the Respiratory Therapist Clinic Supervisor (employee #1 ) on 7/10/12 from 9:30 am till 2:30 pm and 7/11/12 from 9:0 am till 3:00 pm the following was found:

a. The Respiratory Therapy Department only has one door to enter which is use as an exit. From this door enter and exits all clean and sterile materials use for hospitalized patients including the intensive care unit which receives reparatory therapy. This door is use to transport biohazard waste, dirty materials and for entrance and exit of ventilators when disinfected and when they are brought from different areas of the hospital after disconnected from the patient to be disinfected at the reparatory department.

b.This respiratory department does not have a hand washing sinks and as observed personnel entering the supply area without washing their hands. Also as observed personnel enter the bathroom wash their hand and then enter the supply storage .

c. On 7/10/12 at 9:30 am the supply area was visited and as observed two ventilators and three boxes of the power adult blood gases directly on the floor. The light does not work and door is maintained open at all time.

d. The floor area was observed on 7/10/12 at 9:30 am. with black spots, a lot of dust and dirty.

e. The air condition ducts was observed at the right side near the supervisor office, under the duct two ten gallons Sharp container were observed without lid they were full of turbid water that fell from the air-condition duct. Also a wood table was observed near this air condition duct with 18 boxes, six boxes directly on the floor under this table and one box for biohazard trash deposal with used gloves. The supervisor (employee #1) stated that this boxes has copies of treatment forms of 2010 y 2011. It was verify and as observed inside the boxes the forms were as stated by the supervisor.

f. At 9:35 am. it was observed a trash disposal fill to the top with waste with no lid.

g. A bathroom for employees use next to the air-condition duct, it was observed deteriorated, dirty, with dust, dirty walls and deteriorated. A respiratory therapist was observe entering the bathroom to wash his hands.

h.The supervisor stated this bath room is used by the employees and also is use to clean the equipment use for patients by the therapist. The sink was used to perform materials disinfecting and mechanical ventilators disinfecting. The porcelain sink was observed dirty with dark spots on the corner and under the sink.

i.The Respiratory Department do not have washing or disinfection station to be use by the therapist to wash their hands and to clean and disinfect the equipment used wth hospitalized patients at the different areas of the hospital.

j. At 10:40 am it was observed a wood shelf with approximately 18 a 20 books which are respiratory treatment patient log books, these were for the corresponding years 2007, 2008, 2009, 2010 y 2011. Also, as observed paper and forms use by the therapist, manuals, a packet of gauze 4 x 4 open and expose to the environment, a telephone to be discarded, a pack of filters for ventilators, a circuit for ventilators and 2 used tubes of lubricant, this shelf including is content was observed with a lot of dust expose to the environment.

k. At 10:43 am it was observed a back door with access to the laundry department, the door was closed but not lock, this door has access to the Respiratory Therapy Department and is used as an emergency door by the laundry personnel when it rains.

l.In an interview with the respiratory therapy supervisor (employee #1) on 7/10/12 at 10:44 am. she stated: '' This door is used by the laundry personnel to be able to access the hospital, the laundry department does not have a canopy at their exit door area and when it rains they cannot take out the linens to distribute to the hospital and then they have to use this door from the center of the respiratory department , the only door that the respiratory department has as exit. ''

m. The area where respiratory therapy personnel clean and disinfect respiratory therapy equipment and used mechanical ventilator the following was observed: a plastic cabinet which has inside two big batteries, a flex arm used for ventilator, two boxes of cultures swaps for the ventilators, two open boxes of particular mask Type N-95 (Tecnol with Filter Respiratory and Surgical mask ), two boxes of yellow mask for procedure closed and one open, two boxes of gauze 4x4 open, six boxes of gloves (closed), fourteen boxes of glove open, one open box of Albuterol Sulfate Inhalation Solution 0.042 % 3 ml. unit dose vial, Oxygen lines open, five Breathing circuit 1.8, and a gallon of MedaCide-1, a plastic bottle of Foul Odor Eliminator, a packet of biohazardous plastic bags, one plastic bag and in the interior it was observed with twenty cultures tubes, a test lung for ventilators, on the third shelve that is directly on the floor it was observed a flex arm, culture tubes, bags with mask and ventilator lines. Over the cabinet it was observed a bottle of Meda-Cide in use, a plastic spray bottle with a liquid clear solution not label with content, 14 boxes of glove opened and two air compressors use for therapies of patients with on COPD hospitalized.

n. The area where respiratory therapy personnel clean and disinfect respiratory therapy equipment and used mechanical ventilator lacks of wash stand, hand soap with dispenser and hand paper with dispenser.

o. The respiratory therapy personnel pass from the dirty area to used the hand washing sink at the personnel bathroom to perform hand washing when they are going to performed the disinfection of the ventilators and when ended the procedures prior to passing the clean equipment to the clean area.

q. The respiratory therapy department did not have a plastic tray with a solution to disinfect the equipment.

r. The area where respiratory therapy personnel clean and disinfect respiratory therapy equipment and used mechanical ventilator lacks of a table to maintain the materials used during the disinfection of the ventilators and to place them when ended the procedures.

s. The hallway located near the disinfection area has a back door at the end of the hallway with access to dirty linens, this is the area designed to maintain ventilators when completely disinfected. On 7/10/12 at 11:00 am. it was observed with five ventilators without cover, non were identified as clean ventilator, in the corridor. Clean ventilator should be coverd and maintain separate and out of the path of travel of dirty materials. The back door is not lock as evidence on the survey date.

t.The supervisor (employee #1) stated on 7/10/2012 at 11:05 " the area for the dirty linens have a entrance door at the outside area of the hospital that is used by the laundry personnel but it does not have a canopy and when it rains they cannot go in and out so they use this door that get access to the hospital and is near the respiratory therapy department.''

u. As was observed on 7/10/2012 at 11: 15 am a room at the left side of the hallway which the employee #1 sated: "is use as an equipment storage", it is observed critically deteriorated with a strong odor of humidity, paint and ceiling detach, water bubbles at the ceiling cause by filtration, dark and white spots on the floor, wall with dark spots, lot of humidity, wood door open and pieces of door detach. Three ventilator stands were observed inside this room own by the private company that provide services to the hospital, a waste basket with regular trash without lid and a Christmas tree inside a deteriorated box.

2. No evidence was provided by the Supervisor of the Respiratory Therapy Department
(Employee #1) on 7/11/12 at 2:00 pm of written policies and procedures for the delivery of respiratory care services for the posting of signs when oxygen in use.

3. During the observational tour with the Supervisor of the Respiratory Therapy Department (employee #1) on 7/10/12 at 3:15 pm it was observed that all of the patient's rooms did not have evidence of sign posting for those patients using oxygen.

On interview with the Supervisor of the Respiratory Therapy Department (employee #1) on 7/10/12 at 3:15 pm she stated: '' The facility never use signs posting when oxygen is in use.''

4. During the observational tour on 7/10/12 from 3:15 pm till 3:45 pm with a Supervisor of the Respiratory Therapy Department ( employee #1) of patient's sleeping rooms #103B, #209A, #236B and #243A visited and provided evidence that the patient's respiratory equipment were found in plastic bags on the patient's night tables and on back of the patient bed. However, evidence was found of the respiratory equipment in plastic bags do not have the labeled with the date and hour when the equipment was started to use. Also, the facility must verify current guidelines related to respiratory equipment and the frequency of changes to ensure that they adhere to infection control standards.

5. On 7/10/12 at 1:15 pm. a used mask was observed in the personnel table used to eating.

6. On 7/10/12 at 2:30 pm. the respiratory therapist (RT) (employee # 45) was observed with gloves on, open the door to enter at the respiratory therapy department with a used ventilator without covered and exposed to the environment.

a. On interview at 2:33 pm. related to the procedure when the used ventilators are transfer to the respiratory therapy department the employee #45 stated: '' This ventilator was discontinued from a patient that was transfer to the Nuclear Medicine area and I brought it for disinfection " .

b. The employee took of his gloves and discarder them, he did no wash his hands, or use hand sanitizer because the reparatory department does not have hand sanitizer.

7. On 7/10/12 at 9:30 am it was observed that the respiratory department does not have a housekeeping room, no designated employee for housekeeping at this area. No evidence was provided related to the Material Safety Data Sheets (MSDS) orientation directed toward housekeeping and other personnel.

8. No evidence was provided from the supervisor of the Respiratory Therapy Department
(employee #1) on 7/11/12 at 1:15 pm of written policies for the delivery of respiratory care services which are developed and approved by the medical staff related to the time frame for updating the respiratory therapy plan of care.

9. The area was observed with a bathroom with a sink that was out of service, the respiratory personnel have to pass from the dirty area and cross to the clean area to another room to perform the hand washing process prior to passing the clean equipment to the clean area. Not following proper infection control practice.

Based on the review of fifteen respiratory therapists credential files (C.F) with the Director of the Respiratory Therapy Department (employee #1), it was determined that the facility failed to ensure that 2 out of 7 respiratory therapists meet the qualifications specified and are consistent with State laws related to the Professional Registry (C.F #2 and #5).

Findings include:

Two out of seven respiratory therapists credential files reviewed on 7/12/12 at 2:20 pm did not provide evidence of a Professional Registry (C.F #2 and #5).

Based on six medical records reviewed (R.R) for respiratory therapy services, policies/procedures and interviews, it was determined that the facility failed to ensure that the organization of respiratory therapy services is appropriate to the scope and complexity of the services provided for 5 out of 6 clinical records reviewed (R.R #7, #36, #44, #45 and #47).

Findings include:

1. Five medical records were reviewed on 7/10/12 from 2:40 pm till 4:00 pm and 7/11/12 from 9:00 am. till 11:30 am of patients who received respiratory therapy and provided evidence that respiratory therapists did not provide respiratory therapy treatment in accordance with physician orders for R.R #7, #36, #44, #45 and #47. Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis (some received treatment one hour before the scheduled time and other received treatment from one hour up to eleven hours after the scheduled establish treatment hours).

2. There is no written evidence of the respiratory therapy staff pattern to assure that the respiratory therapy staff meets the necessary needs of patients according with the type and amount of respiratory care.

3. The facility does not have a mechanism to assure when the respiratory orders are notify to the respiratory services.

4. Six medical records were reviewed with Respiratory Therapy Supervisor (employee #1) from 7/10/12 at 2:40 pm till 4:00 pm and 7/11/12 at 9:00 am till 11:30 am of patients who received respiratory therapy and provided evidence that respiratory therapists did not administer the respiratory therapy treatment in accordance with the physician ' s order for five out six records reviewed (RR#7, #36, #44, #45 and #47). Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis.

5. R.R #7 is an 88 years old female admitted on 6/18/12 at 4:36 pm with a diagnosis of Bronchitis/R/O Bronchopneumonia. The record review was performed on 7/10/12 at 3:00 pm and provided evidence that the physician ordered Xopenex 0.63 mgs and Atrovent 0.02 % every 4 hours on 6/18/12 at 8:40 pm.

a. The patient received the first respiratory therapy on 6/18/12 at 8:45 pm, the next respiratory therapy was given at 11:30 pm (one hour and 15 minutes before), and no evidence of the date, the hour and the patient vital signs before and after the respiratory therapy technician gives the treatment, they only write that the patient tolerated the treatment. The next therapy was given on 6/19/12 at 4:30 pm (seventeen hours late), the next therapy was given at 8:00 pm and 12 midnight, the next therapy was given on 6/20/12 at 4:00 am, 8:00 am, 12:00 md, 4:00 pm and 8:00 pm. On 6/21/12 respiratory therapy was given at 12:00 am, 4:00 am, 8:00 am, 12:00 md, 4:30 pm and 8:00 pm. On 6/22/12 respiratory therapy was given at 12:00 mn, 4:00 am, 8:10 am, 12:00 md, 4:20 pm and 8:10 pm. On 6/23/12 respiratory therapy was given at 12:30 am, 4:30 am and 7:00 am the respiratory therapy was given one hour before. The record revealed that the physician re-evaluated the patient on 6/23/12 at 9:30 am the respiratory therapy was given at 1:00 pm and 7:00 pm. On 6/24/12 respiratory therapy was given at 12:30 am, 6:30 am, 12:00 md and 6:00 pm. On 6/25/12 respiratory therapy was given at 12:00 mn, 6:30 am, 12:30 pm and 6:30 pm. On 6/26/12 respiratory therapy was given at 12:00 mn, 6:30 am, 12:30 pm and 6:00 pm. No evidence of the respiratory therapy was re-evaluated by the physician in accordance of the respiratory therapy policies and procedures.

b. The patient record has a respiratory label that indicated the expiration date on 6/26/12 for re-evaluation by the physician; however the physician re-evaluated the respiratory therapy treatment on 6/27/12 at 7:45 pm, thirteen hours and forty-five minutes late. The physician ordered Atrovent 0.02 % every 6 hours at 7:45 pm and the respiratory therapy was given at 7:50 pm, the patient did not receive respiratory therapy on 6/28/12 at 1:50 am and 7:50 am, the next respiratory therapy was given at 6:30 am (10 hours and 40 minutes later), the respiratory therapy was given at 12:30 pm and 6:30 pm, 12:30 pm. On 6/29/12 the respiratory therapy was given at 12:00 mn, 7:00 am (30 minutes late), at 12:40 pm and 6:30 pm. On 6/30/12 the respiratory therapy was given at 12:30 am, 6:30 am, at 12:30 pm and 6:00 pm.

c. On 6/30/12 and 7/1/12 a respiratory label was placed on the patient record to re-evaluated the patient respiratory therapies and the physician re-evaluated the respiratory treatment on 7/1/12 at 6:00 pm. to Albuterol 0.083 % every 6 hours and signed by therapist on 7/1/12 at 6:00 pm. and the patient received the treatment on 7/2/12 and 7/3/12 every 6 hours in accordance with the physicians' orders and her respiratory needs. On 7/3/12 at 5:00 pm. the physician re-evaluated the respiratory therapy and continues on Albuterol 0.083 % every 6 hours signed by therapist but lacks the hour when the therapist signed the physician order.

d. On 7/4/12 the respiratory therapy was given at 12:00 mn, 7:00 am (30 minutes late), at 1:00 pm and 7:00 pm. On 7/5/12 the respiratory therapy was given at 12:00 mn. On 7/3/12 at 5:00 pm. the physician re-evaluated the respiratory therapy and continues on Albuterol 0.083 % every 6 hours signed by therapist but lacks the hour when the therapist signed the physician order. Therapy was administered at 6:30 am., 12:30 pm and 6:00 pm. (30 minutes before). On 7/5/12 at 11:00 pm. the physician re-evaluated the respiratory therapy and change the treatment to Proventyl 0.083 % every 4 hours and Pulmicort 0.5 mgs every 12 hours signed by therapist at 11:00 pm. and was given to the patient at 1:50 am.(2 hours and 50 minutes later ) and at 7:15 am. (1 hour later). The first Pulmicort therapy was administer on 7/6/12 at 9:00 am (10 hours later than the physician ordered) then continue with treatments accordance of physician order and patient needs.

e.On 7/7/12 at 6:00 pm the physician re-evaluated the respiratory therapy and continues with Proventyl 0.83 % every 4 hours and Pulmicort every 4 hours signed by therapist but lacks the hour when the therapist signed the physician order and the physician order lacks of Pulmicort dose. The Pulmicort therapy was given on 7/7/12 at 8:00 pm, the respiratory treatment form on 7/8/12 did not provide evidence of documentation if the Pulmicort was administer during the night at 12:00 mn and 4:00 am. the next therapy was given at 8:30 am. and continue with the Pulmicort therapy not accordance of physician order.

f. On 7/10/12 at 6:45 am. the physician re-evaluated the respiratory therapy and ordered Albuterol 0.83 % every 6 hours and the patient received the therapies however, the patient continue on Pulmicort therapy and no evidence of new order to continue on this treatment.

6. R.R #36 is a 82 years old female admitted on 7/9/12 at 8:30 pm with a diagnosis of Congestive Heart Failure (CHF) NOVO, White Lung and R/O Suspected Pneumonia. The record review was performed on 7/11/12 at 10:00 am and provided evidence that the patient physician ordered at 3:30 pm. ABG'S and placed on Ventury mask at 50 % FiO2.

a.On 7/9/12 at 8:30 pm. the physician ordered Atrovent 0.02 per one treatment and is administered at 9:20 pm. The patient was admitted at the Intensive Care Unit at 10:40 pm. with Pneumonia Protocol. A new order of Albuterol 0.083 % per 15 minutes every 4 hours and Ventury mask at 50 % was placed by the physician. The patient received respiratory therapy on 7/9/12 at 8:30 pm., 12:00 mn., 4:00 am., 7:30 am.,12:45 pm. ( 45 minutes later ) and 5:30 pm.( 15 minutes later ). On 7/10/12 at 9:25 am. the patient developed on respiratory arrest and endotraqueal tube was placed and placed on ventilator.

b. On 7/10/12 at 5:45 pm. the physician ordered to discontinue Albuterol. On 7/10/12 at 8:20 pm. Xopenex 0.63 mgs. and Atrovent 0.02 % every 6 hours was ordered by telephone call and the treatment administered at 12:30 am.(4 hours and 10 minutes later ), 7:00 am., 12:35 pm. and 7:00 pm.

c. On 7/12/12 was administered at 12:30 am. and 6:50 am ( the order lacks of date and hour of the pneumologist ). On 7/12/12 the respiratory therapy was re-evaluated and increases the dose of Xopenex to 1.25 mgs. and Atrovent 0.02 % every 6 hours the next therapy was given at 12:55 pm. The therapies were provided but did not administer according to the physician's orders and patient needs.

7. R.R #44 is a 78 years old male admitted on 7/9/12 at 9:46 am. The record review was performed on 7/10/12 at 2:40 pm and provided evidence that the patient physician ordered on 7/9/12 at 1:00 pm. Albuterol 0.083 by power nebulizer every 6 hours and Intensive spirometry therapy and was taken by the nurse on 7/9/12 at 4:00 pm. (3 hours later than the physician writes the order). The order was signed by the respiratory therapist but no evidence was found of date and hour when the therapist administers the order. The patient received respiratory therapy on 7/9/12 at 4:30 pm. (3 hours later) and spirometry at 4:55 pm.

a.The initial assessment was performed on 7/9/12 at 8:30 pm. (4 hours after the respiratory treatment was initiated), the respiratory therapy is not given at 10:30 pm. However, was given on 7/10/12 at 1:00 am. (9 hours later), at 6:30 am. and 12:30 pm. On 7/10/12 at 3:00 pm the patient was visit at he's room accompanied with the respiratory therapy supervisor (employee #1) and the spirometry equipment was observed on the patient washbasin.

b. The patient was interview on 7/ 10 /12 at 3:00 pm related to the spirometry exercises and he stated: '' I not to know the use of this equipment the respiratory therapist did not explain related to the use and the benefits of this equipment.'' The therapies were offered but not administer according to the physician's orders and patient needs and the respiratory therapy department failed to educate at patient on the management and the benefits of the spirometry therapy based on patient needs.

8. R.R # 45 is a 62 years old female admitted at medicine north two on 7/4/12 with diagnosis of Right Pleural Effusion. The record review was performed on 7/10/12 at 3:10 pm and provided evidence that the patient physician ordered on 7/4/12 at 8:40 pm. oxygen by nasal cannula at 3 liters per minute and respiratory therapy by nasal cannula of Xopenex 0.63 % and Atrovent 0.02 % by power nebulizer every 6 hours. The first respiratory therapy was given on 7/4/12 at 9:00 pm. On 7/6/12 at 6:40 pm. a seal was placed on the patient record to the physician renew the respiratory therapy, however no evidence was found of re-evaluation.

a.On 7/6/12 at 7:15 pm. a seal was placed by the respiratory therapy department related to the power nebulizer order expiration and a new order was placed on 7/7/12 at 6:15 pm for Intensive Spirometry every 2 hours per 8 minutes, chest tapping, Xopenex 0.03 % by power nebulizer every 8 hours and ABG's ( arterial blood gases ). The order was taken by the nurse on 7/7/12 at 6:20 pm. On 7/8/12 at 9:00 am. the patient continue with nasal cannula at 3 liters per minutes. No evidence was found when the order was signed by the respiratory therapist. The respiratory therapy of Xopenex 0.63 % by power nebulizer was given on 7/8/12 at 4:30 pm. (16 hours later) and continues at 12:30 am. and 6:00 am. No evidence was found when the therapist oriented the patient related to the spirometry exercise.

b.On 7/9/12 at 6:00 pm. and 7/10/12 the respiratory therapist placed a seal to notified at physician the respiratory therapy expired and needs re-evaluation. On 7/10/12 at 9:00 am. the physician re-evaluated the patient and ordered Xopenex 0.63 % by power nebulizer every 6 hours. No evidence was found at what time the patient received the respiratory therapy. The initial respiratory therapy assessment was performed on 7/4/12 at 9:00 pm. but did not provided information related to the patient breathings and referred that the patient have symmetric chest and wheezing at auscultation. The therapies were offered but not administer according to the physician's orders and patient needs and the respiratory therapy department failed to educate at patient the management and the benefits of the spirometry therapy based on patient needs.

9. R.R # 47 is a 50 years old female admitted on 7/9/12 with diagnosis of Asthmatic Bronchitis and R/O Bronchopneumonia. The record review was performed on 7/11/12 at 11:15 am and provided evidence that the patient physician ordered on 7/9/12 at 12:30 pm. on Emergency Room Albutherol 0.083 % by power nebulizer every 30 minutes per three times and Atrovent every 30 minutes per 3 times ( the physician lacks of Atrovent dose ), ABG's ( arterial blood gases ) at room air and Ventury mask at 50 %. The ABG's was performed on 7/9/12 at 12:48 pm. and the patient placed on oxygen at 50 % by ventury mask. The first respiratory therapy was given on 7/9/12 at 12:50 pm., 1:15 pm. and 1:45 pm. (15 minutes later). Albutherol with Atrovent 0.2 by power nebulizer every 6 hours and Oxygen at 3 liters by nasal cannula was ordered by physician and was taken to the Emergency room at 9:00 pm. (3 hours later than the physician ordered) and no evidence of therapist countersign.
a. The respiratory therapies of Albuterol and Atrovent 0.2 by PN every 6 hours was initiated on emergency room on 7/9/12 at 12:00 mn. On 7/10/12 at 1:25 am. the patient was admitted at telemetry area on the medicine ward. The next respiratory therapies were given on 7/10/12 at 6:30 am., 12:30 pm. and 7:00 pm. On 7/10/12 at 5:45 pm. the patient was evaluated by pneumologist and a new order was performed to increase Albuterol 0.83 % and Atrovent 0.2 % every 4 hours per 15 minutes. The order was signed by the therapist at 6:45 pm. (1 hour later) and taken by the nurse at 7:03 pm. (1 hour and 18 minutes later). The patient received the last respiratory therapy of Albutherol with Atrovent 0.2 by power nebulizer not the actually the respiratory therapy treatment ordered by pneumologist on 7/10/12 at 5:45 pm. The respiratory therapy was given on 7/11/12 at 12:30 am. (6 hours and 45 minutes later than the physician as ordered), then at 4:00 am., 8:00 am. and 12:00 md.
b. The initial respiratory therapy assessment was performed on 7/10/12 at 12:00 md. and provide evidence on the therapist note that the patient have rhonchus, force respiration and respiratory difficulty. (2 days after the respiratory treatment was initiated). The therapies were offered but not administer according to the physician's orders and patient needs.