HospitalInspections.org

Based on a Complaint investigation ACTS Intake PR00000673 & PR 00000674, review of documents, observations, and interviews on 11/15/2022 through 11/17/2022 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. It did not provide the necessary oversight and leadership as evidenced by the lack of compliance with: 42 CFR §482.13 COP: Patient's Rights Condition, 42 CFR §482.41 COP: Physical Environment and 42 CFR §482.42 COP: Infection Control, which makes this condition 42 CFR §482.12 COP: Governing Body not met.

Based on an unannounced Complaint investigation ACTS Intake PR00000673 & PR 00000674, survey conducted on 11/15/2022 through 11/17/2022, review of twenty-nine medical records and policies, procedures, and interview with Quality Assessment Performance Improvement -QAPI Officer (employee #10), it was determined that facility failed to provide correct phone number to file a complaint and facility fail to promote patient rights of physical privacy. Which makes this Condition of Participation: §482.13 Patient Rights Not Met. (Cross Reference Tags A118, A142, A 143, and A154 and A164).

Based on a Complaint investigation ACTS Intake PR00000673 & PR 00000674, observational tour, patient's rights documents review, observation of delivery of care, review of policies and procedures, with Quality Assessment Performance Improvement-QAPI officer (employee #10) and patient's rights representative officer (employee #16) review of 29 medical records, documents and interview on 11/16/2022 with Institutional Program Director (employee #1) , it was determined that the facility fail to provide the correct phone number to file a complaint to ensure that patients were provided with an update phone number to contact state agency if they want to contact or file a grievance.

Findings include:

1.Hospital admission documents provided to patient's and/or the patient's representative when admitted to the facility to receive care, who include procedures to file a grievance (complaint) and phone numbers lodging a grievance with the State agency were review with QAPI officer (employee #10) and patient's rights representative officer (employee #16) on 11/16/2022 at 2:20 PM.

During this review it was identified that information provided to patient's and/or the patient's representative with procedures to file a grievance (complaint) and phone numbers to lodge a grievance with the State agency does not have the correct phone number. The information related with Hospital admission documents provided to patient's and/or the patient's representative when admitted to the facility date of last review was December 6, 2016.

2. Institutional Program Director (employee #1) stated on interview on 11/16/2022 at 2:55 PM that facility immediately proceed to seek for the correct and update phone number.

3. Facility was informed by surveyor on 11/16/2022 at 3:37 PM that once they correct the phone numbers to file a grievance (complaint) of the State agency they need to provide the information to all patient's and/or the patient's representative admitted at the facility receiving care and services.

Based on a Complaint investigation ACTS Intake PR00000673 & PR 00000674, observational tour on different of the facility and emergency department, observation of delivery of care, with facility emergency room manager (employee #4) and supervisor (employee #17), it was determined that the facility fail to promote patient privacy.

Findings include:

1. During observational tour performed on the emergency room on 11/15/2022 from 9:00 AM through 11:14 AM the followings findings were identified:

a. Cubicle #21 does not have a privacy curtain.

b. Room 638 call system cable not accesible for patient.

Based on a Complaint investigation ACTS Intake PR00000673, observational tour on the emergency department, observation of delivery of care, with facility emergency room manager (employee #4) and supervisor (employee #17) on 11/15/2022 at 10:35 AM documents review, and review of policies and procedures, with QAPI officer (employee #10) on 11/16/2022, it was determined that the facility fail to promote patient rights of physical privacy. This deficient practice was identified in 4 out of 8 cases observed receiving services at the acute emergency room area. (Case review #1, # 2, #3 and # 6).

Findings include:

1. During observational tour performed on 11/15/2022 from 9:00 AM through 10:55 AM the followings findings were identified:

a. Acute care adult emergency room area had 21 cubicles. On cubicle #8, # 7 and #17 were observed 2 females patients lying on stretchers receiving care and services. On cubicle #17 were observed 2 male patients lying on stretchers receiving care and services. No curtain was observed as part of those cubicles to be used to provide privacy while personnel intervene with patients.

b. Case review # 1 is a female patient located on cubicle #7- A is 64 years old who came to the emergency room on 11/14/2022 at 6:46 PM transferred from another facility with Congestive Heart Failure complications. She was triaged, evaluated by the physician on 11/14/2022 at 7:15 PM and admitted receiving services. She was still in the emergency room because she needs to be admitted to a telemetry area. Facility was waiting for the availability of unit of telemetry bed.

She was interview on 11/15/2022 at 9:20 AM and was asked if personnel provide direct care while she was located on this cubicle near the other patient located on cubicle #7 B and she stated that all personnel provide services (medical/nursing treatments) to her and to the other patient in the same cubicle, she also stated that personnel did not use curtain or privacy screen between her and the other patient.

c. Case review #2 is a female patient locate on cubicle #8- A is 72 years old who came to the emergency room on 11/14/2022 at 11:00 AM with Congestive Heart Failure complications. She was triaged, evaluated by the physician on 11/14/2022 at 12:55 PM and admitted receiving services. She was still in the emergency room because she needs to be admitted to a telemetry area. Facility was waiting for the availability of unit of telemetry bed.

She was interview on 11/15/2022 at 9:20 AM and was asked if personnel provide direct care while she was located on this cubicle near the other patient located on cubicle #7 B and she stated that all personnel provide services (medical/nursing treatments) to her and to the other patient in the same cubicle, she also stated that personnel did not use curtain or privacy screen between her and the other patient.

d. Case review # 6 is a female patient locate on cubicle #8- B is 33 years old who came to the emergency room transferred from another facility on 11/14/2022 at 3:22 PM with Abdominal Pain. She was triaged, evaluated by the physician at 11/14/2022 at 3:52 PM the physician diagnoses an Acute Pancreatitis and admitted receiving services. She was in the emergency room waiting for bed.

She was interview on 11/15/2022 at 9:35 AM and was asked if personnel provide direct care while she was located on this cubicle near the other patient located on cubicle #7 B and she stated that all personnel provide services (medical/nursing treatments) to her and to the other patient in the same cubicle, she also stated that personnel did not use curtain or privacy screen between her and the other patient.

e. Case review # 3 is a male patient locate on cubicle #17- A is 64 years old who came to the emergency room on 11/13/2022 at 7:13 PM with Cough and Shortness of Breath. He was triaged, evaluated by physician at 11/14/2022 at 7:39 PM the physician diagnoses Pleural Effusion and admitted receiving services. He was in the emergency room waiting for bed on the hospital.

His wife was interview on 11/15/2022 at 9:48 AM and was asked if personnel provide direct care while he was located on this cubicle near the other patient located on cubicle #17 B and she stated that all personnel provide services (medical/nursing treatments) to him and to the other patient in the same cubicle, she also stated that personnel did not use curtain or privacy screen between her and the other patient.

f. Policy for the accommodation of patients in the emergency room cubicles and privacy were review on 11/16/2022 at 3:00 PM with QAPI officer (employee #10). Accordingly with policy facility must use 1 cubicle per patient. If the quantity of patients increases or the emergency room area is overcrowded, they proceed to inform patient's and relatives the non-availability of cubicles and locate 2 patients on the same cubicle, if the patient or relative did not agree with this disposition could sign a relieve of responsibility and leave the emergency room.

This policy also stated that if they have 2 patients receiving services in the same cubicle and it is necessary to perform a procedure this patient must be moved to the gynecology, surgery, or orthopedic room to perform the procedure.

This policy did not establish provisions to ensure that when is needed to locate 2 patients in the same cubicle, patients are provided reasonable privacy during examinations or treatments, personal hygiene activities and discussions about their health status/care.

Based on an unannounced Complaint investigation ACTS Intake PR00000673 survey conducted on 11/15/2022 through 11/17/2022 twenty-three records reviewed (R.R.), review restraint of Policies and Procedures (P&P), with Quality Assessment Performance Improvement- QAPI Officer (employee #10), it was determined that the facility failed to promote patients' basic rights, ensure patient safety, and eliminate the inappropriate use of physical restraint. This deficient practice was identified in 1 out of 4 cases reviewed for compliance with physical restraint policies and procedures (RR #9).

Findings include:

1. On 11/16/2022 thru 11/17/2022 from 8:00 AM till 4:00 PM review of the five records related to patient restraint was performed with Quality officer (employee #10). Three of the cases are active cases, two were closed records. During the review it was identified the following:

a. RR #9 is a 91-year-old female patient who visited emergency room on 10/03/2022 at 11:51 AM with a chief complaint of low levels of hemoglobin and hematocrit. This patient had history of Essential Primary Hypertension, Chronic Obstructive Pulmonary Disease and Unspecified Dementia without behavioral disturbance. This patient was accompanied with a caregiver all time.

Patient was evaluated by the physician on 10/03/2022 at 12:55 PM diagnosed her with Symptomatic Anemia, order blood test, intravenous fluids and transfuse 2 units of Packed Red Blood Cells ( PRBCs ) and consult the case with Internal Medicine on 10/03/2022 at 3:44 PM.

The first unit of PRBC's was transfuse while patient was still in the emergency room on 10/04/2022 at 1:10 AM. On 10/04/2022 at 10:06 AM internal medicine physician document on the progress note that this patient had anemia and its presenting Melena and proceed to consult the case with gastroenterologist. Patient was admitted to the hospital and transferred to room 818-1 on 10/04/2022 at 8:40 PM.

On 10/05/2022 at 6:46 PM internal medical physician orders a CT scan due to patient assessment hypoactive and with dysarthria. CT scan results was evaluated by medicine internal physician and an MRI was recommended second unit of PRBCs was transfuse while patient was in the 8th floor on 10/06/2022 at 9:30 PM. On 10/06/2022 at 12:00 PM physician order to transfuse two additional PRBCs.

On 10/11/22 at 10:30 AM patient was schedule for a gastroscopy accordingly with physician order. The gastroscopy was performed accordingly with physician order, on 10/11/2022 and gastroenterologist recommends a colonoscopy.

On 10/12/2022 at 10:30 AM patient was schedule for a colonoscopy, 2 cleansing enemas and 1 gallon of Colyte (laxative solution that stimulates bowel movement) to prepare the patient for the procedures was ordered by physician. It was ordered by the physician on 10/12/2022 at 10:30 AM to insert a nasogastric tube to administer 1 gallon of Colyte for colonoscopy preparation.

On 10/12/2022 at 1:02 PM internal medicine physician was notified that MRI could not be perform on 10/11/2022 because patient did not cooperate.

During the review of the medical record on 11/15/2022 at 2:00 PM and accordingly with information provided by with QAPI officer (employee #10) on nursing progress notes dated 10/12/2022-shift 7 PM-7:00 AM it was documented that patient was on physical restriction.

No evidence was found on the medical record documentation of a physical restraint order. There is no evidence on the physician progress notes or nursing progress notes that patient was trying to avoid the nasogastric tube insertion or if she was resisting the Colyte administration for colonoscopy preparation and the procedure with 2 cleansing enemas.

There are no comprehensive individual patient assessment to determine whether the use of less restrictive measures could be implemented instead using a physical restraint.

There are no justification and documentation for the reasonable use of physical restraint in this case. Information found during the review of this case evidence that facility implement inappropriate use of physical restraint.

Based on an unannounced Complaint investigation ACTS Intake PR00000674 survey conducted on 11/15/2022 through 11/17/2022 twenty three records reviewed (R.R.), review of restraint Policies and Procedures (P&P), with Quality Assessment Performance Improvement- QAPI Officer (employee #10) it was determined that the facility failed to maintain evidence documented that physical restraint procedures are applied to patients when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This deficient practice was identified in 1 out of 4 cases reviewed for compliance with physical restraints policies and procedures (RR #10).

Findings include:

1. On 11/16/2022 thru 11/17/2022 from 8:00 AM till 4:00 PM review of the five records reviewed were related to patient physical restraint with Quality officer (employee #10). Three of the cases are active cases, two were closed records. during the review it was identified the following:

a. RR #10 is an 81-year-old male patient who was brought by ambulance to the emergency room due to seizures that begin on 08/27/2022 4:00 AM. Patient came to the emergency room on 08/27/2022 at 7:03 AM. Patient had history of Cerebrovascular Accident. While receive care and services at the emergency room present Respiratory Failure and it was necessary to intubate the patient and was put on mechanical ventilation. On 08/27/2022 at 9:40 PM was transferred to Intensive Care Unit on the second-floor bed 250-7.

Accordingly with information documented on the nurses' notes history and physical examination, patient was in a lethargic neurological state intubated connected to mechanical ventilation. In the skin assessment it was documented that patient had dry on all his body, no skin lesions were reported as part of patient physical assessment.
Patient continue receiving services at the intensive care unit; medical record documentation of days 08/28/2022, 08/29/2022, 08/30/2022 and 08/31/2022 include information that patient continues intubated on mechanical ventilation on lethargic neurological state.

Documentation on those days include information that patient skin is free of lesions and that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers.

On 09/01/2022 at 9:40 AM physician begin the patient on a Continuous Positive Airway Pressure (CPAP) trial, to proceed to extubate patient. On 09/01/2022 at 5:30 PM patient was extubated. On 09/02/2022 was and located on bed 250-9. Patient continue receiving services at the intensive care unit; medical record documentation of days 09/01/2022, 09/02/2022, 09/03/2022 and 09/04/2022 include information that patient continues receiving services that patient did not have skin lesions or ulcers and that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers.

On 09/05/2022 was documented on the medical record that patient had many pulmonary secretions that he was not able to expel them. On 09/05/2022 at 1:00 AM it was necessary to insert a nasogastric tube. It was documented on the medical record that patient was trying to remove nasogastric tube, nasal airway and Ventury oxygen mask.

An order for physical restriction on upper extremities was issued by the physician on 09/05/2022. It was documented on the medical record that patient on 09/05/2022 that patient begin to present redness on sacral area, it was documented that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers.

On 09/06/2022 it was documented on the medical record on shift 7 AM-7 PM that patient was on physical restraint, disoriented trying to jump the bed rails.

On 09/07/2022, 09/08/2022 shift 7 AM -7 PM and 09/09/2022 shift 7 AM the medical record include documentation that patient is unable to follow commands or instructions is disoriented and that continue on physical restraint.

On medical record it was documented that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers, and that skin is free of skin lesions or ulcers.

On 09/09/2022 shift 7 PM patient condition begins to deteriorate, accordingly with information documented on the medical record the Pneumologist order to intubate patient. Diprivan drip was prescribed in order to sedate the patient who accordingly with medical documentation continue combative and disoriented.

Patient continue on physical restraint, on medical record it was documented that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers, and that skin is free of skin lesions or ulcers.

On 09/11/2022 7 AM shift documentation includes information that patient begins to present purple coloring on sacral area, it was documented that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers.

On 09/11/2022 7 PM shift medical record includes information that patient present Atrial Fibrillation, there are no documentation found on the medical record of patient status related with physical restraints.

On 09/12/2022 7 AM shift there are no documentation found on the medical record of patient status related with physical restriction. On notes dated 09/13/2022 through 09/17/2022 patient was on physical restriction however there are not found a complete documentation on the medical record that include patient behavior that justify the use of physical restraint or that other less interventions have been determined to be ineffective to protect the patient.
There is no evidence documented or other alternatives attempted or the rationale for not using other alternatives instead physical restraints.

Based on a Complaint investigation ACTS Intake PR00000673, review of twenty-three medical records observation of delivery of care and interview with Director of Nursing (DON) (employee #11) during survey procedures on 11/15/2022 through 11/17/2022 from 8:00 AM thru 4:00 PM, it was determined that the facility fail to document outcomes that may be influenced by nursing inputs and interventions. This deficient practice was identified in 7 out of 28 cases reviewed (Case review #9, #10, #11, #13, #14, #15, and #21).

Findings include:

1. Facility failed to ensure that nursing personnel maintain pertinent documentation of the implementation of nursing care plan and activities related with nursing care and procedures. The following was identified during the review of cases (RR # 9 and RR #10) with QAPI officer (employee #10) on 11/15/2022 and 11/16/2022 from 1:30 PM through 4:00 PM:

a. RR #9 is a 91-year-old female patient who visited emergency room on 10/03/2022 at 11:51 AM with a chief complaint of low levels of hemoglobin and hematocrit. This patient had history of Essential Primary Hypertension, Hypertensive Heart Disease, Chronic Obstructive Pulmonary Disease and Unspecified Dementia without behavioral disturbance. This patient was accompanied with a caregiver all time. Patient was evaluated by the physician on 10/03/2022 at 12:55 PM and diagnosed with Symptomatic Anemia. Orders for blood test, intravenous fluids, and transfusion of 2 units of Packed Red Blood Cells (PRBCs) and consult with Internal Medicine was prescribed by physician on 10/03/2022 at 3:44 PM. On 10/04/2022 at 10:06 AM internal medicine physician document on the progress note that this patient had anemia and its presenting Melena and proceed to consult the case with gastroenterologist.

The physicians order related with type and cross match of PRBC's and transfusion for this patient documented on the medical record are to:

type and cross match for 2 units of PRBC's and hold on 10/03/2022 at 1:55 PM,
type and cross match for 2 units of PRBC's and transfuse 2 units on 10/03/2022, at 5:00 PM. Transfuse match for 2 units of PRBC's 10/06/2022 at 12:05 PM and to type and cross match for 1 unit of PRBC's and transfuse until Hemoglobin are equal or same to 9.5 mgs/dl.

The first unit of PRBC's unit number-W236522476760 and begins at 10/03/2022 at 9:50 PM and finish on 10/04/2022 at 1:10 AM.

The second unit number-W236322243785 and begins at 10/07/2022 at 9:30 PM and finish on 10/08/2022 at 1:10 AM.

The third unit number-W236422107650 and begins at 10/11/2022 at 12:30 AM and finish on 10/11/2022 at 4:00 AM.

A CBC post transfusion was taken on 10/11/2022 at 3:16 PM and the results reported on 10/11/2022 at 7:39 PM was and hemoglobin 10.6 mgs/dl.

Review of the medical record evidence that nursing personnel transfuse
1 unit of PRBC's while patient was on emergency room between 10/03/2022 and 10/04/2022 and two other units of PRBC's while patient was receiving services on room 818-1.

During interview on 11/16/2022 at 11:00 AM medical technologist (employee #7) stated on interview that facility had been experiencing blood components shortage since the month of September 2022. She stated that for them in the blood bank there is blood shortage when facility had less than 10 units of PRBC's. She stated that from September 2022 until October 29, 2022, facility had less than 10 units of PRBC's, and this is considered blood shortage. She stated that there is a decline in the number of people donating blood since the beginning of Covid-19 pandemic emergency. She stated that when blood bank experience blood shortage they have to be forced to make difficult decisions about who receives blood transfusions and who will need to wait until more products become available. These decisions include to transfuse patients that are actively bleeding or have a major emergency who requires prompt transfusion.

On this case in particular and accordingly with discussion maintained with the QAPI officer (employee #3) while reviewing the medical record on 11/15/2022 at 2:00 PM patient occult blood test taken on 10/03/2022 at 4:30 PM the result was negative, in addition to this patient apparently develop a reaction (antigen) while receive blood transfusion and due to this it was necessary to send the type and cross match to a reference laboratory on 10/08/2022.

No evidence was found documented (on the nursing progress notes 10/03/2022, 10/04/2022, 10/06/2022, 10/07/2022, 10/08/2022 and 10/11/2022) in relation of education to patient relatives about transfusion, documentation of patient status while receive blood transfusion, monitoring patients for adverse reactions and when was taken the sample of CBC post transfusion.

Deficiencies were cited on tag A396 due to facility failure to document outcomes that may be influenced by nursing inputs and interventions. Nursing personnel activate the plan of care for alteration in the hematopoietic system on 10/06/2022 at 9:30 PM.

No evidence was found documented on the nursing progress notes 10/07/2022 & 10/11/2022 in relation to education to patient relatives about transfusion, documentation of patient status while receive blood transfusion, monitoring patients for adverse reactions and sample of CBC post transfusion.

Nursing personnel activate the plan of care for alteration in the hematopoietic system on 10/06/2022 at 9:30 PM. No evidence was found documented on the nursing progress notes 10/07/2022 & 10/11/2022 in relation education to patient relatives about transfusion, documentation of patient status while receiving blood transfusion, monitoring patients for adverse reactions and sample of CBC post transfusion. The plan of care alteration in the hematopoietic system was not reviewed by nursing personnel after blood transfusion procedure was performed to the patient.

On 10/11/22 at 10:30 AM patient was schedule for a gastroscopy accordingly with gastroenterologist recommendations and physician order. The gastroscopy was performed accordingly with physician order, on 10/11/2022 and gastroenterologist recommends a colonoscopy or virtual colonoscopy to complete anemia work up, if she can prep with assistance.

On 10/12/2022 at 10:30 AM patient was schedule for a colonoscopy. Two cleansing enemas and 1 gallon of Colyte (polyethylene glycol- laxative solution that stimulates bowel movements) to prepare the patient for the procedure was ordered by physician. It was ordered by the physician on 10/12/2022 at 10:30 AM to insert a nasogastric tube to administer the gallon of Colyte for the colonoscopy preparation.

This patient begins a procedure of preparation for a colonoscopy with Colyte and cleansing enema, on 10/12/2022, no evidence was found documented (on the nursing progress notes of 10/12/2022- shift 7AM-7 PM and 10/13/2022- shift 7 PM) in relation to the education to patient relatives about enema administration and the intestinal preparation with Colyte, no evidence was documented on those progress notes in relation with patient status while was on intestinal preparation and during the administration with cleansing enemas. No evidence was documented on the nursing progress notes of 10/12/2022- shift 7AM-7 PM and 10/13/2022- shift 7 PM of patient status while receiving Colyte for intestinal preparation by nasogastric tube.

On 10/14/2022 at 8:15 PM patient was received to perform the colonoscopy procedure; however, the study could be not performed because accordingly with medical record documentation patient need better preparation for the procedure.

Gastroenterologist document on the progress notes dated 10/14/2022 at 8:25 PM that rectal exam prior to colonoscopy showed large black formed stool. He recommends preparation with Colyte again by nasogastric tube. Two Colyte were ordered, and the case are going to be reschedule once bowel preparation is done.

On 10/15/2022 at 9:47 AM patient was evaluated by Internal Medicine and in his assessment document in the progress note that patient colonoscopy is on hold due to incomplete preparation despite 2 gallons of Colyte and that patient was alert and do not have fever.

On 10/16/2022 at 10:14 AM was evaluated by Internal Medicine and in his assessment physician document on the progress note that patient was on colonoscopy preparation again.

On 10/16/2022 at 2:31 PM gastroenterologist assess the patient and document on his progress note that Colyte preparation for this patient is in progress. That patient already drank one gallon and was pending a second gallon, colonoscopy is pending for the next day.

No pertinent information related with patient status while was on intestinal preparation and during the administration with cleansing enemas and Colyte was found documented on nursing progress notes dated 10/15/2022 & 10/16/2022 shift 7 AM- 7 PM respectively in relation with patient status while was on intestinal preparation and during the administration with cleansing enemas ( how effective the preparation it was turning up and if the patient is tolerating the preparation) .

On 19/17/2022 at 9:45 PM internal medicine physician evaluates the patient and document in the progress note that colonoscopy is not performed because patient present hypokalemia.

On 09/18/2022 at 10:38 AM internal medicine physician evaluates the patient and document in the progress note that patient is receiving potassium replacement and the plan is to proceed with colonoscopy after potassium levels improve.

On 09/19/2022 at 4:23 PM internal medicine physician evaluates the patient and document in the progress note that patient continue with potassium replacement.

On 10/19/2022 at 2:05 PM the case was consulted with cardiologist, accordingly with information documented on the medical record on 10/19/2022 7:00 PM when cardiologist went to evaluate the patient it was informed that daughters and son of the patient who is a physician states that they prefer that patient to be discharge home the next day. Cardiologist document on the progress note that patient was hemodynamically stable.

On 09/20/2022 at 12:08 PM internal medicine physician evaluates the patient and document in the progress note that patient is tolerating diet well. That there is no evidence of complications and patient was discharge home.

b. RR #10 is an 81-year-old male patient who was brought by ambulance to the emergency room due to seizures that begin on 08/27/2022 4:00 AM. Patient came to the emergency room on 08/27/2022 at 7:03 AM. Patient had history of Cerebrovascular Accident. While receive care and services at the emergency room present Respiratory Failure and it was necessary to intubate the patient and was put on mechanical ventilation. On 08/27/2022 at 9:40 PM was transferred to Intensive Care Unit on the second-floor bed 250-7. Accordingly with information documented on the nurses' notes history and physical examination, patient was in a lethargic neurological state intubated connected to a mechanical ventilation. In the skin assessment it was documented that patient had dry on all his body, no skin lesions were reported as part of patient physical assessment.

Patient continue receiving services at the intensive care unit; medical record documentation of days 08/28/2022, 08/29/2022, 08/30/2022 and 08/31/2022 include information that patient continues intubated on mechanical ventilation on lethargic neurological state.

Documentation on those days include information that patient skin is free of lesions and that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers.

On 09/01/2022 at 9:40 AM physician begins the patient on a Continues Positive Airway Pressure (CPAP) trial, to proceed to extubate patient. On 09/01/2022 at 5:30 PM patient was extubated. On 09/02/2022 was and located on bed 250-9.

Patient continue receiving services at the intensive care unit; medical record documentation of days 09/01/2022, 09/02/2022, 09/03/2022 and 09/04/2022 include information that patient continues receiving services that patient did not have skin lesions or ulcers and that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers.

On 09/05/2022 was documented on the medical record that patient had many pulmonary secretions that he was not able to expel them. On 09/05/2022 at 1:00 AM it was necessary to insert a nasogastric tube.

It was documented on the medical record that patient was trying to remove nasogastric tube, nasal airway and Ventury oxygen mask.

An order for physical restriction on upper extremities was issued by the physician on 09/05/2022. It was documented on the medical record that patient on 09/05/2022 that patient begin to present redness on sacral area, it was documented that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers.

On 09/06/2022 it was documented on the medical record on shift 7 AM-7 PM that patient was on physical restriction disoriented trying to jump the bed rails. On 09/07/2022, on 09/08/2022 shift 7 AM -7 PM and on 09/09/2022 shift 7 AM-7 PM the medical record include documentation that patient is unable to follow commands or instructions is disoriented and that continue physical restriction.

On medical record it was documented that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers, and that skin is free of skin lesions or ulcers.

On 09/09/2022 shift 7 PM-7 AM patient condition begins to deteriorate, accordingly with information documented on the medical record the pneumologist order to intubate patient. Diprivan drip was prescribed in order to sedate the patient who accordingly with medical documentation continue combative and disoriented. Patients continue physical restriction, on medical record it was documented that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers, and that skin is free of skin lesions or ulcers.

On 09/11/2022 7 AM-7 PM shift documentation includes information that patient begins to present purple coloring on sacral area, it was documented that nursing personnel are providing preventive care to avoid the development of skin lesions and ulcers.

On 09/11/2022 7 PM shift medical record includes information that patient present Atrial Fibrillation. On 09/12/2022 shift 7 AM-7 PM it was documented that skin of sacral area were purple coloring is identified is broken and had measures of 13 cms x 14 cms without depth.

Skin assessment of this case was performed on 09/13/2022, on 09/14/2022, on 09/15/2022, on 09/16/2022, on 09/17/2022, on 09/18/2022 and on 09/19/2022 assessment had classification of pressure lesion, no stage was documented, appearance, and treatment provided was documented; however, no measures of the pressure lesion, was performed or documented.

Skin assessment of this case was performed on 09/20/2022, on 09/21/2022, on 09/22/2022, on 09/23/2022, on 09/26/2022, on 09/27/2022 and on 09/28/2022 assessment had classification of pressure lesion appearance, no stage was documented, treatment provided was documented, measures was documented as performed on 09/23/2022 (lesion is reported to measure 7 cms x 6 cms). No skin lesion assessment treatment was documented as provided on 09/24/2022 and on 09/25/2022.

Skin assessment of this case was performed on 09/29/2022, on 09/30/2022, on 10/01/2022, on 10/02/2022, on 10/03/2022, on 10/04/2022 and on 10/05/2022 assessment had classification of pressure lesion stage and measures was documented on 10/03/2022 and on 10/04/2022 (lesion is reported to measure 6.5 cms x 6.5 cms on 10/03/2022, on 10/04/2022).

Skin assessment of this case was performed on 10/06/2022, on 10/07/2022, on 10/08/2022, on 10/09/2022, on 10/12/2022, on 10/13/2022 and on 10/14/2022 assessment had classification of pressure lesion and stage however, no measures of the pressure lesion, was performed and documented. No skin lesion assessment or treatment provided was documented as provided on 10/10/2022 and on 10/11/2022.

Skin assessment of this case was performed on 10/15/2022, on 10/16/2022, on 10/17/2022 and on 10/18/2022, assessment had classification of pressure lesion and stage however, no measures of the pressure lesion, was performed and documented.

This patient dies on 10/18/2022. No skin lesion assessment or treatment provided was documented on 10/10/2022 and on 10/11/2022.

Accordingly with information provided by Nursing Director (employee #11) on 11/17/2022 at 2:45 PM skin lesion assessment must include complete and pertinent information related with the type and stage of lesion, localization appearance and treatment provided. She stated that this assessment must be performed on daily basis and that measures of the lesion in order to determine deterioration or improvement must be documented every 7 days.

The facility failed to include pertinent and complete information of patient RR #10 skin status in order to determine appropriateness of treatment provided and in order to determine if skin lesion was avoidable or unavoidable.


20423


2. Facility failed to ensure that nursing personnel maintain pertinent documentation of the implementation of nursing care plan and activities related with nursing care and procedures. The following was identified during the record review (R.R) of cases (R.R #11, #13, #14, #15, and #21) with DON (employee #11) on 11/15/2022 and on 11/17/2022 from 1:30 PM through 4:00 PM:

a. R.R #11 is a 93-year-old female patient who was admitted on 10/25/2022 with a diagnosis of Sacral Ulcer Infected, Sacral Osteomyelitis Anemia, the patient has history o of Parkinson Disease, Malnutrition, Neurogenic Dysphagia and Hypertension. This patient was accompanied with a caregiver all time. During interview with the care giver on 11/15/2022 at 9:50 AM state that patient have foley catheter #16 before the admission arrive with sacral ulcer. During the record review performed on 11/15/2022 at 11:30 AM, it was found the following:

On 10/25/2022 at 7:30 AM the physician ordered Type and Cross. Transfusion of 1 units of Packed Red Blood Cells (PRBCs), On 10/26/2022 at 4:12 AM patient was transfusing and finish at 7:10 AM the first fraction of the transfusion and the second fraction was transfused at 2:30 PM and finish at 5:30 PM.

However, no evidence was found documented on the nursing progress notes 10/26/2022 in relation education to patient relatives about transfusion, documentation of patient status while receive blood transfusion, monitoring patients for adverse reactions and sample of CBC post transfusion. The plan of care alteration in the hematopoietic system was not reviewed by nursing personnel after blood transfusion procedure performed to the patient.

On 10/29/2022 at 3:30 PM the physician places an order to place a nasogastric tube (NGT) #16, at 4:47 PM the nurse documented that a NGT was place however, no evidence was found that the plan of care was developed and implemented, and no documentation related to the nasal fosse that was place the NGT, its patient tolerate the procedure, it was in stomach.

On 10/26/2022, the skin specialist performed the initial evaluation and identification water bladder in the Left (Lt) and Right (Rt) shoulder and a Sacral Ulcer stage 4 with measure of 4.5 centimeter (cm) per (x) 3 cm x4 cm with undermined 12 o'clock of 6.5 cm, at 3 o'clock 4.5 cm.

No evidence was found of nursing implementation of the plan of care in the nurses note, no evidence was found of nursing documentation of nursing ulcer care on 10/26/2022, on 10/27/2022, on 10/28/2022, on 10/29/2022, on 10/30/2022, on 10/31/2022, on 11/01/2022, on 11/02/2022.

On 11/03/2022 the nurse documented the ulcer care Stage 4 with measure 4cm x6 cm x3 cm. No evidence of ulcer care and plan of care implementation since 11/04/2022 till 11/10/2022 that goes to the operation room for debridement.

No evidence was found that the nurse documented in the nursing progress note patient outcome due to debridement procedure. Until 11/12/2022, that the nurse documented sacral ulcer 10 cm x10 cm x 4.5 cm with undermined 12 o'clock of 3.5 cm, at 3 o'clock 2.5 cm and at 9 o'clock 3.5 cm.

On 11/01/2022 The patient was transfer to Operation room for place a Percutaneous Gastrostomy (PEG) #24 however no evidence was found that the plan of care was developed and implemented, no evidence was found that the nurse documented in the nursing progress note patient outcome assessment due to the PEG.

On 11/04/2022 at 8:31 AM the physician ordered transfusion of 1 units of Packed Red Blood Cells (PRBCs), the nurses documented at 8:18 AM in their progress note that transfusion was pending, unit available not done, at the moment by physician order due to low blood pressure (B/P) and physician re-evaluate and examine patient.

At 8:18 AM patient B/P was B/P 117/50 millimeter of Mercury (mm/Hg), No evidence of the low B/P.

Patient was transfused on 11/04/2022 at 10:05 AM and finish at 2:00 PM. However, no evidence was found documented on the nursing progress notes on 11/04/2022 in relation education to patient relatives about transfusion, documentation of patient status while receive blood transfusion, monitoring patients for adverse reactions and sample of CBC post transfusion. The plan of care alteration in the hematopoietic system was not reviewed by nursing personnel after blood transfusion procedure performed to the patient.

On 11/11/2022 at 7:00 AM the physician places an order to place negative pressure notified to skin care management team for bag system, on 11/12/2022 Start negative pressure bag therapy a no evidence was documented of the amount of pressure that was place the system, no evidence was found related to nurse documentation related to ulcer care since 11/12/2022 till 11/16/2022 that performed the record review

No nurse documentation related to the foley catheter since admission on 10/25/2022 until 11/02/2022 that the nurse documented that patient have a foley catheter and the plan of care was activated on 11/09/222, no evidence was found of the implementation of the plan of care.

b. R.R #13 is an 87-year-old male patient who was admitted on 10/12/2022 with a diagnosis of Decubitus Ulcer, Diabetes Mellitus, Malnutrition, End life Neurogenic Dysphagia, End Stage Alzheimer. This patient was accompanied with a caregiver all time. During the record review performed on 11/17/2022 at 10:00 AM, it was found the following:

On 10/14/2022 at 7:00 PM patient arrive to the 4th ward, the nursing history identified a Pressure lesion Sacral ulcer Stage 4, with measure of 18 cm x 11 cm x 1 cm Pressure lesion on Left shoulder, with measure of 2 cm x 4 cm x 0 cm, Penis Laceration, Pressure Lesion of the left Heel no classifiable.

However, no evidence was found documented on the nursing progress notes on 10/13/2022, on 10/18/2022, on 10/19/2022, on 10/24/2022, on 10/27/2022, on 10/28/2022, 10/29/2022, on 10/31/2022, on 11/01/2022, on 11/03/2022, on 11/04/2022, on 11/05/2022, on 11/06/2022, on 11/09/2022, on 11/12/2022, on 11/13/2022 related to the nursing ulcer care and/or the skin care management nurse re-evaluation.

d. R.R #14 is a 60-year-old male patient who was admitted on 09/22/2022 with a diagnosis of De NOVO Seizure, End Stage Renal Disease (ESRD) and Sacral Osteomyelitis Ulcer. This patient was accompanied with a caregiver all time. During the record review performed on 11/16/2022 at 1:00 PM, it was found the following:

On 09/22/2022 at 4:10 AM the nursing history identified a Sacral ulcer however did not classification the ulcer. However, no evidence was found documented on the nursing progress note since the admission at the present on 11/16/2022 that the record review was performed of the nursing ulcer care and the skin care management nurse evaluation.

e. R.R #15 is an 81-year-old female patient who was admitted on 10/27/2022 with a diagnosis of Cholelithiasis and Pancreatic Cancer. This patient was accompanied with a caregiver all time. During the record review performed on 11/16/2022 at 9:30AM, it was found the following:

On 11/08/2022 at 11:00 PM the physician ordered PRBCs transfusion complete per 2, on 11/08/2022 at 11:15 PM patient was transfusing the first unit and finish on 11/09/2022 at 3:00 AM.

However, no evidence was found documented on the nursing progress notes 11/08/2022 in relation education to patient relatives about transfusion, documentation of patient status while receive blood transfusion, monitoring patients for adverse reactions and sample of CBC post transfusion. The plan of care alteration in the hematopoietic system was not activate, developed, and implemented by nursing personnel after blood transfusion procedure performed to the patient.

f. R.R #21 is a 79-year-old female patient who was admitted on 11/12/2022 with a diagnosis of Aspiration Pneumonia, End Stage advance Dementia, Alzheimer, Diabetes Mellitus Sacral Ulcer and Hypertension. This patient was accompanied with a caregiver all time.

During interview with the care giver on 11/15/2022 at 11:00 AM he/she state that patient have foley catheter #16 and a Sacral ulcer at arrive to the hospital.

During the record review performed on 11/16/2022 at 10:30 AM, it was found the following:

On 11/16/2022 at 11:00 AM no evidence was found that nursing staff developed and implemented a plan of care related to alteration of the integumentary system due to the Sacral Ulcer and alteration in the urinary system due to the foley catheter. No evidence was found of the nurse documentation of the ulcer care and measure and intervention of the skin care management nurse. No evidence was found of the nursing intervention providing positioning change to release pressure area.

Based on an unannounced Complaint investigation ACTS Intake PR00000673 & PR 00000674, survey conducted on 11/15/2022 trought 11/17/2022, review of policies, procedures, and interview with facility engineer (employee #6), it was identified that facility failed to construct, arranged, and maintained all locations of the hospital and all inpatient locations in a manner that promote the safety of patients, all of which makes COP (42 CFR §482.41) Physical Environment Not Met. (Cross Reference Tag A 701 )

Based on a Complaint investigation ACTS Intake PR00000673 & PR 00000674, observational tour, and interview with the Engineer (employee #6) and Institutional Program Director (employee #1) on 11/15/2022, it was determined that proper maintenance is not provided to facility physical plant and to the overall hospital environment in such a manner that the safety and well-being of patients are assured. The deficient practice can affect 177 out of 177 patients and visitors.

Findings include:

1. Glass windows and other glass divisions are covered with green slimy texture dirt, on all the 9th floor structure.

2. Hallway on the first floor in direction to the X rays image center is observed with ceiling tiles with brown and black spots with appearance of humidity. The floor of this hallway was observed with black spots in need of cleaning and maintenance. Walls located in this hallway were observed peeling paint with appearance of humidity.

3. Vents where the air condition expels the air outside, located in the first-floor hallway in direction to the X rays image center and in front of elevators #3 and #4 were observed in need of cleaning and maintenance.

4. A door and walls located at the back side of the X rays on the first-floor image center were observed with humidity with peeling paint.

5. In front of elevator #3 on the first floor it was observed big black spots with appearance of humidity.

8. Some of the ceiling tiles in front of elevators #3 and #4 of facility on the first floor where the chapel sign is located, were observed with a downward curve (bulge) due to excessive weight of humidity accumulated on this area.

9. Clump of grass were observed surrounding exterior many cements sidewalk used for walking by patients and visitors on the hospital.

10. Many exterior cement sidewalks used for walking by patients and visitors on the hospital were observed with many stains, spills spots debris and dirt in need of a cleaning and maintenance.

11. Employees parking lot is filled with asphalt cracks, mud, and trash debris.

12. Patients and visitors multiple floor parking lot is observed in need of cleaning and maintenance.

13. No plan was provided with maintenance of parking lots luminaries.

During interview the engineer (employee #6) and Institutional Program Director (employee #1) on 11/15/2022 at 11:49 AM stated facility is in the process to recruit personnel to oversee cleaning all facility windows and provide maintenance and cleaning of all hospital areas.

14. However no plan for maintenance and improvement was provided to be review with projections and set priorities to identify resources and budget assigned to perform the maintenance and if the maintenance includes employee parking lots areas and the multiple parking lot areas.

15. During observational tour performed on the emergency room on 11/15/2022 from 9:00 AM through 11:14 AM the followings findings were identified:

a. Main hallway in direction to emergency room floor was observed with dark black spots in need of cleaning and maintenance.

b. Walking entrance had a unisex bathroom that was observed with the wooden door chipped, broken with weathered wood in need of cleaning and maintenance.

c. The double egress wooden door located at the entrance of the fast-track area it was observed with wooden chipped with weathered wood in need of cleaning and maintenance.

d. At the left side near the double egress wooden door located at the entrance of the fast-track area it was observed a hole on the wall.

e. Facility had an area where they locate patients who need to be on cohort precautions this area has 5 cubicles. Each one of those cubicles had a chair that was observed with broken vinyl, with rust in need of cleaning and maintenance. This area had division with glass who had metal edges on the bottom area, that permits to watch the patient without necessity to enter the room in each one of the cubicles. Each one of the division edges of the glass division was observed covered with blue color masking tape. Purpose to cover the glass metal division edges with masking tape was not explained or justified to surveyor when asked the emergency room manager (employee #4) and supervisor (employee #17) on 11/15/2022 at 9:45 AM.
The use of this blue masking tape on the edges of the glass division did not permit a proper cleaning and disinfection of this areas.

f. Fast track area cubicle #14 was observed with stain ceiling tiles with brown spots.

g. In the fast-track area near cubicle #16 it was observed a nursing station with Formica edges chipped on edges, near this nursing station it was observed a hand washing station that had rust in the back area.

h. Behind nursing station located on the fast-track area near cubicle #16 it was observed a storage room where employees' storage medical surgical materials. Some of the ceiling tiles of this room was missing, exposing medical surgical materials to the tubes, machinery and wires located on the ceiling and preventing a proper insulation and maintenance of proper temperature and relative humidity recommended by the medical surgical materials manufacturers.

i. Fast track area door of cubicle #16 door was observed with the wooden door chipped, broken with weathered wood in need of cleaning and maintenance.

j. Fast track area cubicle #18 was observed with stain ceiling tiles with brown spots. The floor of this cubicle was observed in need of cleaning and maintenance.

k. In the fast-track area the support arm of the chair to perform blood samples was observed with wooden chipped.

l. In the emergency room area in cubicle #5 it was observed a chair with broken vinyl. The towel paper dispenser located at the right side of the hand washing station it is not fixed on the wall it was observed loose hanging only in the left side of the wall. Two bumpers located on the back area of the stretcher used to prevent damage of the wall was observed broken in pieces. A dining table located in this cubicle was observed with yellow stains in need of cleaning. A bulletin board with cork material is located at the left side of the stretcher on cubicle #5. This cork material does not permit proper cleaning and disinfection of this item located in this cubicle.

m. In the emergency room area in cubicle #6 two bumpers located on the back area of the stretcher used to prevent damage of the wall was observed broken in pieces.

n. Patient bathroom at the same side where cubicle #5and #6 are located, was observed with a shower area with rust, a hole was observed at side of the toilet and the grab bar of the shower was observed loose on one of the sides.

o. Cubicle #9 was observed with wooden door chipped, broken with weathered wood in need of cleaning and maintenance. The area where the door lock must be located is observed without the lock with a hole. Two bumpers located on the back area of the stretcher used to prevent damage of the wall was observed broken in pieces. Skirting boards on the floor on this cubicle area missing on some areas.

p. In the cubicle #10 two bumpers located on the back area of the stretcher used to prevent damage of the wall was observed broken in pieces. Two stretchers located on this cubicle were observed with a lot of rust in need of maintenance.

q. Dirty equipment room is observed with ceiling tiles with black and brown spots and humidity appearance.

r. A broken ice machine located near the dirty equipment room was observed over a Formica base that had broken Formica. Near the Formica base where the broken ice machine is located a blue mopping bucket is observed, 2 mops were observed near the mopping bucket. The mops were observed located directly on the floor.

s. On the gynecology room it was observed a big water white calcification stain over the sink.

t. In the front area of cubicle #21 it was observed the wall with a hole.

u. In the entrance ambulance area near the door, the ceiling is observed with black humidity spots.


16. During observational tour performed on different areas of the facility on 11/16/2022 and 11/17/2022 from 9:00 AM through 3:30 PM the followings findings were identified:

a.Glass windows and other glass divisions are covered with green slimy texture dirt, on all the 9th floor structure.

b. Hallway on the first floor in direction to the X rays image center is observed with ceiling tiles with brown and black spots with appearance of humidity. The floor of this hallway was observed with black spots in need of cleaning and maintenance. Walls located in this hallway were observed with peeling paint with appearance of humidity.

c. Vents where the air condition expels the air outside, located in the first-floor hallway in direction to the X rays image center and in front of elevators #3 and #4 were observed in need of cleaning and maintenance.

d. A door and walls located at the back side of the X rays on the first-floor image center were observed with humidity with peeling paint.

e. In front of elevator #3 on the first floor it was observed big black spots with appearance of humidity.

f. Some of the ceiling tiles in front of elevators #3 and #4 of facility on the first floor where the chapel sign is located, were observed with a downward curve (bulge) due to excessive weight of humidity accumulated on this area.

g. Clump of grass were observed surrounding exterior many cements sidewalk used for walking by patients and visitors on the hospital.

h. Many exterior cement sidewalks used for walking by patients and visitors on the hospital were observed with many stains, spills spots debris and dirt in need of a cleaning and maintenance.

i. Employees parking lot is filled with asphalt cracks, mud, and trash debris.

j. Patients and visitors multiple floor parking lot is observed in need of cleaning and maintenance.

k. No plan was provided with maintenance of parking lots luminaries.



20423


During the initial tour to the 8th-Floor on 11/15/2022 from 9:30 AM till 12:00 PM with the Nurse Director (DON) employee #11, it was observed the following:

17. The entrance door for the rooms was observed with peeling wood and broken wood: Rooms 801,803, 806, 807, 810, 813, and 819.

18. It was observed roof leaks rooms 801.

19. It was observed the celling acoustic with evidence of humidity and black mold. Room 801, 813 and the hall near room 817.

20. It was observed the patient bed with rust and peeling paint in room 801, 803, 804, 806, 807.

21. It was observed the patients chair with peeled vinyl and the armchair broken in room 801, 806, and 813.

22. It was observed that room have lack of skirting boards in the wall in rooms 801 and 813.

23. It was found that the TV not working in room 801.

24. The window was observed with green mold that visibility to the outside is not allowed in room 801 to 820 and window in the hall.

25. The hall between rooms was observed with ceiling acoustic with black, brown stain and humidity.

26. It was observed IV stand with pilling paint and rust in room 807.

During the initial tour to the 4th-Floor on 11/15/2022 from 1:00 PM till 4:00 PM with the Nurse Director (DON) employee #11, it was observed the following:

27. The entrance door for the rooms was observed with peeling wood and broken wood: Rooms 402, 404, 405, 407, 408, 409, 412, 415, 417, and 419.

28. It was observed a leak in the bathroom washbasin rooms 421.

29. It was observed the celling acoustic with evidence of humidity and black mold. Room 403, and 404.

30. It was observed the patient bed with rust and peeling paint in room 404, 405, 408, 409, 412, 414, and 416.

31. The window was observed with green mold that visibility to the outside is not allowed in room 401 to 422 and window in the hall.

32. It was observed IV stand with pilling paint and rust in room in 401, 408, 409, 412, and 414.

33. It was observed rooms wall with pilling paint and bulging paint in rooms 401, 403, 404, 405, 408, 412, and 414.

34. it was observed the hallway floors dirty with black spots, near the room 408.



17959

During the infection control round on 11/15/2022 through 11/17/16 from 8:30 AM till 4:00 PM with the infection control nurse (employee # 3), Health Educator (employee #21) and Physical Plant Manager (employee #6) the following was observed:

At the 8th floor visit on 11/15/2022 at 9:10 AM :
1.Two portable air conditioning in corridor on front of the nursing station.

2. In the telemetry room the absence of acoustic, broken tiles, dirty floor with black spots
a. Door with evidence of dust accumulation, does not have an identification label.
b. Electrical panel room when open the door with dust particles came out.
c. The floor was observed in raw cement.
d . Absence of acoustics tile.

3. Room designated for cleaning and disinfection of laryngoscopes do not have identification label and was found open.
a. No hand soap, dispenser broken
b. No hand papers
c. Deteriorated paper with policies and procedures posted on the wall that las revision date was 05/2018

The infection control nurse stated that if there were no changes, it is left with the last date.

d. The tray is not labeled and does not indicate date and what kind of solution is used to clean and desinfect the laryngoscopes.

e. Biohazardous disposal with deteriorated label and condition, lid with white spots were observed.

f. Cover of the red electricity connector was observed broken.

4.Through corridors and patients rooms the following was observed:

a. Patients' rooms 802, 803, 804,805,806, 808, 810, 811, 812, 814, 815, 816, 817, 818 y 821. All glass windows have built up of green slime black and brown stains on the outside of the rooms making visibility impossible.

b .All of the interior of the rooms were observed with dust, dirty, humidity, absence of sockets, loose and dirty based board. Opaque floors without brightness.

c. All doors of the patients' rooms were observed with stains due to humidity dirt and dust, detachment of wood.

5. Room 804 empty due to problems with roof leaks. Inside the room three patients' beds, four resting chairs and three tables were observed. Inside the regular trash can a biohazard and regular trash was observed.
Around borders of the windows loose cement and pealing paint cause by humidity on all of the patients' rooms.

In all rooms and corridors, the dispenser for hand sanitizer were found empty because the hospital storage did not have hand sanitizer to fill them up.

Patient room 805, no light at the entrance to the room due to absence of bulb.

All of the bedroom closets were observed with dust, dirty wooden slots and lack of paint.

All the IV metal stands were observed to be dirty, pealing paint, dust, the wheels difficult to move, putting patient at risk of falls, lacks maintenance.

6. Room 806 emergency call system of the bathroom was found tied to the curtain tube. Urine was observed on the floor around the toilet.

Dirty floor and pieces of paper were observed. No hand soap in the dispenser.

A bed sheet was observed in the bathroom floor and absence of curtain hooks.

7. Room 808 sink hot water faucet not working.

8. Room 812 blocked, air does not work. In the closet two carts with stains and deteriorated conditions were observed inside clean bed sheets, blue pads, disposable diapers, and other materials used by nursing for daily care.
Two beds, one of the beds without mattress and presence of mold. Two tables and electrocardiogram machine. Dust and dirty room.

9. Room 814 above the wall lamp two used gloves were observed.

10. Stairs emergencies exit south area fire hose was observed, metal box was observed dirty with evidence of dust accumulation mold.

11. Room 817 empty toilet paper dispenser. Empty gallon for urine collection without a lid was observed in bathroom with the name of the patient who is not hospitalized in this room.

12. Room 818 absence of acoustic in the bathroom.

13. Room 821, IV stand with problems to move and deteriorated conditions. Broken protective cap temperature control. Patient refers television does not work and that the physical plant is a disaster. Reclining chair vinyl material was observed deteriorated. The patient refers that the hospital has a group of volunteers who rents them for thirty dollars, and this is not fair because the hospital should provide equipment's in good condition.

14. Medication room unpainted dusty and door maintain open. Dirty floor and walls absence of baseboards.
Three open dirty and deteriorated medication carts.

11:00 AM in the clean supplies room an unlabeled food refrigerator was observed dirty inside.

Under the sink a bag of sterile water for inhalations was found 1000 milliliters of respiratory therapy bags,

Sink with yellow stains. Found three bags of 0.45 Sodium Chloride 500ml expired on May 2022. Expired red blood sample tube on 9/30/2022.

15. The 7th floor was visit on 11/15/22 at 1:30 PM with the Infection Control Nurse and the 7th floor nurse manager and the following was observed:

Ice machine no maintenance record, notes deteriorated no cleaning log.

Room 701 not in use as refers by nurse supervisor employee # 18 she does not have the key noe knows why is closed.

703 the patient reports that the regular trashcan is not emptied frequently.

The patient refers that he has been hospitalized for sixteen days and only on two occasions have they brought toilet paper and there is no hand sanitizer. Housekeeping staff reports that there is no toilet paper in the storage.

Call system in wall panel loose.

Room 704- 706 and 707-bathroom acoustic with humidity, leaking wall and bulky paint.

Eating table used by patient is missing a wheel.

Faulty bed rails problems getting up down.

Windows are with moisture building and peeling paint.

Bathroom door stays close lock problem.

Room 706-707:

Wall with peeling paint
No hand sanitizer
IV stand dirty and deteriorated condition loose TV cable cover

Warehouse side A corridor in front of patients room and electrical panel , room does not have identification sign.

Room 708

The patient refers that at night the acoustic in the bathroom fell completely due to presence of water.

He refers that he has not used the toilet, that relives his needs outside and that his wife bath him in bed. Today at 2:45 PM they placed the acoustic and there is presence of humidity again.

Bed rail on the right side missing screws.
Bed with mold
IV stand with deteriorated condition.
Window wall with building paint due to humidity

Acoustic of main entrance with humidity due to water outlet from the air conditioning.
Column on the right side entrance to the bathroom has an absence of cement material, loose metal.

Room 711 Isolation room has no lighting.
No hand sanitizer
Air-condition extractor with abundant accumulation of dust, wall around with open space due to absence of cement
Bed with mold
Shower does not have a tube and curtain

Rooms 712-714-715-717-718-721-722 main entrance with presence of water.

Bed with presence of mold
Absence of sockets
No hand sanitizer

During the visual round at the patient room 712

There is no curtain, patient refers that the sun enters through the window and hits his face all day. This situation was evidence during the round.

It is observed that the window area does not have a curtain. The patient refers that since his admission three days ago.

This room did not have hand sanitizer.

The IV stand has problems to move wheels do not roll and was observed with deteriorated conditions

On 11/16/22 at 10:50 AM as observed at the sixth floor

634 B
Emergency call cable was observed tied up in the IV stand
IV 0.9 % Sodium Chloride 500 ml, it was observed not labeled.

Patient beds was observed with mold.
The wall light only works the upper bulb the bulb bellow does not work.
Acoustic bathroom with dark stains due to humidity. Absence of two acoustic tiles.

11/16/22 at 10:15 AM was observed

The ice machine was observed with white spots and supervisor employee #20 at six floor reports that it is damage, reports that the enginer was notified who reported that has a damage part and that they are waiting for the part. The nurse supervisor refers that the family member goes up to the seventh floor to get some ice, if the patients does not have a family member the nurse goes up and get the ice for them.

10:20 AM The medication room on the 6th floor was observed in poor condition, holes on the wall.
Dirty floor
Lid and medication container was observed on the floor.

On 11/16/2022 from 11/18/2022

All fire extinguishers at the hospital were observed with an inspection date from January to December 2020.

In an interview with a physical plant manager employee #6 he stated that he recently started at the hospital facility and that he performs monthly checkups. However, the facility did not provide evidence of having carried out procedures at the administrative level and puts the safety and life of the population in general at risk.

The ice machine located on the six floor was observed with white spots and dirty. The nurse supervisor (employee #20) reports that it is damaged. She reports that the Engineer who reported that has a damaged part and that they are waiting for part. The nurse supervisor refers that a family member goes upnto the seventh floor to took for ice, if the patient does not have family member, the nurse goes up to the seven floor and supplies the ice.

Room 638

Uncomfortable bathroom as refer by the patient and that toilet is very short. It does not have safety rails.
No hand sanitizer Floor with dark stain.

The call system cable is outside the patient's bed, not accessible.
Acoustic entrance ceiling with dark and yellow stains due to humidity.

Edge of the column on the left side of the corridor main entrance to the room with no cement.

During the Infection Control rounds on 11/15/2022 through 11/17/2022 from 8:30 AM till 4:00 PM accompanied with the Infection Control Nurse (employee # 3), Health Educator (employee #21) and Physical Plant Director (employee #6) at the Eight -Floor, Seven Floor, Six Floor, Four Floor, Second Floor, Intensive Unit and Biomedical Waste area it was observed the following:

1. The 8th floor was visit on 11/15/2022 at 9:10 AM and the following was observed:
Two portable air conditioning in corridor in front of nursing station.

2. In the telemetry room the absence of acoustics, broken tiles, dirty floor with black spots.

a. Door with evidence of dust accumulation does not have an identification label.

b. Electrical panel room when opening the door dust particles came out.

c. The door was observed in raw cement.

d. Absence of acoustics.

3. Room designated for cleaning and disinfection of laryngoscopes does not have identification label and was found open all the time.

a. No hand soap dispenser was broken.

b. No hand paper.

c. A deteriorate paper with policy and procedures posted on the wall the last revision date was on (05/2028). The infection control nurse (employee #3) refers that is there were no changes, it is left with the last date.

d. The tray is not labeled and does not indicate date and what kind of solution used to cleaning and disinfected the laryngoscopes.

e. Biohazard garbage disposal with deteriorate label and condition, lid with white spots were observed.

f. The cover of the red electricity connector was observed broken.

Based on an unannounced Complaint investigation ACTS Intake PR00000673 & PR 00000674, survey conducted on 11/15/2022 trought 11/17/2022, observations, review of documents and interview with the facility's Infection Control Nurse (employee #3) on 11/17/2022 at 2:00 PM, it was determined that facility failed to maintain and document an effective infection control program that protects patients, families, visitors, and personnel by preventing and controlling infections and communicable diseases. This condition "Not Met". (Cross reference Tags 750).

Based on an unannounced Complaint investigation ACTS Intake PR00000673 & PR 00000674, survey conducted on 11/15/2022 through 11/17/202 2from 8:30 AM till 4:00 PM, observations, review of documents and interview with the facility's Infection Control Nurse (employee #3) on 11/17/2022 at 2:00 PM, it was determined that facility failed to monitor and maintain a safe clean sanitary environment and document an effective infection control program which include surveillance and prevention to protect patients, families, visitors, and personnel to prevent and control infections and communicable disease which can affect 177 out of 177 admitted patients staff and visitors. (Cross refer Tag A701)

Findings include:

During the infection control round on 11/15/2022 through 11/17/16 with the infection control nurse (employee # 3), Health Educator (employee #21) and Physical Plant Manager (employee #6) the following was observed:

1. Room designated for cleaning and disinfection of laryngoscopes visit on 11/15/2022 at 9:10 AM do not have identification label and was found open.

No hand soap, dispenser broken

No hand papers

Deteriorated paper with policies and procedures posted on the wall that las revision date was 05/2018.

The infection control nurse stated that if there were no changes, it is left with the last date.

The tray is not labeled

In deteriorated condition Biohazardous disposal with deteriorated label, lid with white spots.

2. It was observer through the hospital lack of cleaning, sanitation and in all patients' rooms and areas including storage areas with medical supplies, beds, chairs and equipment, and the disposal of biohazard waste with regular trash through corridors and patients' rooms.

a. In all rooms and corridors, the dispenser for hand sanitizer were found empty. The hospital storage did not have hand sanitizer to replace them. As informed to the surveyor the facility is changing the company that supplies the hand sanitizer and yet has not replaced the dispenser nor had provided hand sanitizer.

b. On 11/16/22 at 10:15 AM was observed Ice machines no maintenance record, notes deteriorated, no cleaning log.

c. Room 703 the patient reports that the regular trashcan is not emptied frequently.

The patient refers that he has been hospitalized for sixteen days and only on two occasions have they brought toilet paper and there is no hand sanitizer. Housekeeping staff reports that there is no toilet paper in the storage.


3. Room 718 patient #29 with diagnostic of Sacral Ulcer R/O CVA at 3:30 PM nursing personnel was entering the patient's room, they brought gloves in their pockets they did not wash their hands, they put on gloves to manage the IV pump, machine and line.

4. On 11/16/22 at 10:50 AM as observed at the sixth floor 634-B,

IV 0.9 % Sodium Chloride 500 ml, it was observed not labeled.

Patient with Angio catheter on the right hand and her IV fluids it was observed without identification label.

Patients' daughter refers that her mother was admitted on Saturday and since that day no one has check her Angio catheter and her IV fluids.

5. All the reclining chairs vinyl material was observed deteriorated condition.

The Physical Plant Manager (employee #6) stated that the hospital did not have staff to clean the reclining chairs. This situation constitutes a high risk of cross contamination because peeling vinyl makes it difficult to clean and disinfect.