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Based on complaint investigation ACTS Intake PR00000556 medical record reviewed (RR), it was determined that the facility failed to provide Medicare recipients "An Important Message from Medicare" (IM) two days before discharge to execute their rights to appeal facility's discharge for 2 out of 16 records reviewed (RR. #6 and #7).
Findings include:

1. R.R. #6 is 73 years old male who is admitted on 03/09/16 with a diagnostic of Entero-cutaneous Fistula, Infected Inguinal Mesh, Klebsiella Pneumoniae, High Blood Pressure (HBP) and Congestive Heart Failure (CHF). The record was review on 07/21/16 at 1:52 pm. The Important Message from Medicare was provided upon admission on 03/09/16 and for a second time on 3/10/16 however the two days prior discharge Important Message from Medicare was not provide. The patient was discharge home on 03/24/16. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

2. RR #7 is 85 years old male who was admitted on 01/28/16 with a diagnosis of Bilateral Groin Abscess and Cellulites, Peripheral Vascular Disease (PVD) and Pelvic Perianal Pain. The record was reviewed on 07/21/16 at 3:36 pm. The Important Message from Medicare was provided upon admission, the two days prior discharge Important Message from Medicare was also provide and signed however it was not dated. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient's discharge providing the rights to appeal their discharge. The rule also requires that the IM must be signed and dated by the patient to acknowledge receipt.

Based on complaint investigation ACTS Intake PR00000556, the review of Facility Admission and Pre admission Manual and the Grievance Manual with Customer Service Officer (employee #1), it was determined that the facility failed to ensure that patient and their relative know whom to contact to file a grievance related to update phone numbers.

Findings include:

During the admission's process the patient receives an admission packet with all required document to execute their rights during hospitalization. On 7/20/16 at 10:00 am during the survey the following was found, brochure of Complaints and Grievances Process, provided to the patient at admission contains all require phone number of outside agencies, SARAFS Licensing Division, Medicare Division and Medicare Regional Office, where the patient and family can call if they want, to file a complaint with those agency out of the hospital. As evidence, phone number for the Department of Health, Licensing Division and Medicare as for the Secretariat were not updated in the brochure and in the poster information in each room called Mechanism to file complaints "Mecamismo para presentar Querellas.

Based on a complaint investigation ACTS intake PR00000556 and review of fifty-six (56) complaints reports with the Customer Services Officer(employee #1), it was determined that the facility governing body failed to ensure the effective operation of the grievance process, and must review and resolve grievances and inform each patient the result of the investigation.

Findings include:

During the review of fifty-six (56) grievance report from February 2016 through July 2016 with the Customer Services Officer (employee#1) person on charge of the grievance process from 7/20/16 at 10:30 am thru 3:00 pm the following was identified:

1. On February 2016 the facility receive sixteen (16) patient complaint related to services received, medical services, waiting time, cleaning room, room temperature and other concern. Evidence was provide related to the different concern that the patient had about the services received, however no evidence was provided related to the investigative process, interview to the personnel involve in the complaint and final disposition and resolution of the complaint.

During Interview with the Customer Services Officer (employee#1) on 7/20/16 at 11:00 am state that "when she receive a complaint she refers it to the person in charge of the area that the complaint comes to (nursing services, physician services, etc) they initiate the investigation, perform personnel involve interview and resolve the complaint of the patient but not send evidence of interview or resolution of the investigation".

During the review of the 56 complaint the employee #1 explain each complaint and the process of the investigation performed.

During interview with the Risk Management Coordinator (employee #2) on 7/21/16 at 9:30 am stated that she investigate all incident reported, " I go to the different areas of the events and performed the investigation, but I do not document all the investigation. I performed rounds all days and question to the supervisor related to the different event pending to investigate, they inform to me but do not document it " .

2. No evidence was provided related to grievance committee meeting.

Based on a complaint investigation ACTS Intake PR00000556, sixteen medical records reviewed (R.R) with "Do Not Resuscitate" (DNR) orders and " Do Not Intubate" (DNI), review of DNR and DNI protocols and policies/procedures, it was determined that the facility failed to ensure that policies and procedures related to advance directives for DNR and DNI orders are followed for 1 out of 16 records reviewed with DNR and DNI orders (R.R #5).

Findings include:

1. One out sixteen records reviewed (R.R) on 07/21/16/ from 8:42 am till 6:00 pm with the Director of the Corporative Compliance (employee #3) of patients with DNR orders provided evidence that the facility failed to follow DNR Protocols:

a. R.R #5 is a 75 years old female, admitted on 02/08/16 with Pneumonitis due to Inhalation, Sepsis, Respiratory Failure, liver disease and Hepatic Failure as reviewed with the Director of the Corporative Compliance (employee #3) on 07/21/16 at 11:03 am. A DNR physician's order was found on the medical record, a consent to " Do Not Resuscitate " was found signed by a patient relative on 02/11/16 at 1:50 am, however no evidence was found in the physician's progress notes related to the reason for this decision at the time the order and the consent was signed.

b. The Facility policy: " Policy of no application of resuscitative measures of patient (DNR, DNI) " states in item #5 of the procedure: " In the DNR/DNI consent must be written the name of the physician that educated the patient and family and the patient ' s physician. The consent, the physician medical order and the physician progress note must be signed by the patient ' s physician when it is taken by an intern or resident in or before twelve hours (12hrs). " However there is no evidence of the intern or resident progress note related to the DNR reason. The consent and the DNR order are signed by the intern or resident and the patient ' s physician however the patient ' s physician signature is not dated.

c. The facility " Section 18.2- Do Not Resuscitate Policy " , in paragraph (d) Physician ' s Orders part (i), states: " Do Not Resuscitate Order shall entered in the order sheet and shall bear the signature to the Attending Physician. The medical reasons for the order, the circumstances regarding consent and discussions with the family and all consultations shall be recorded in the progress notes. " In paragraph (d) Physician ' s Orders part (i) section (1.), states: " One of the following orders should be used to convey the decision that cardiopulmonary resuscitation is inappropriate: " DO NOT ATTEMP TO RESUSCITATE " , or " DO NOT RESUSCITATE " , or " RESUSCITATION IS CONTRAINDICATED " . The order Should include a reference to de Physician ' s Progress Notes in the patient ' s chart (for example: " Do Not Resuscitate- Progress Note 2-1-82 " . There is no evidence in the progress noted related to the reason for the DNR.

Based on a complaint investigation ACTS intake PR00000556 and sixteen (16) medical record reviewed (R.R), it was determined that the facility failed to ensure that all medical record are legible, complete, dated, timed, and authenticated in written by the person responsible for providing or evaluating the service provided for 6 out of 16 record review (R.R. #3, #9, #10, #11, #13 and #14)

Findings include:

1. R.R #3 is a 79 years old female admitted on 2/18/16 with a diagnosis of Pelvic Abscess with History of Diabetes Mellitus, Hypertension and Coronary Artery disease admitted at surgeon service. Accordance to the review of medical record performed on 7/21/16 at 10:00 am with the Corporate Compliance Director employee #3, it was found the following:

a. On 2/16/16 at 11:35 pm the RN of delivery room documented that receive patient from ER to be consult with gynecology Vital Sign (V/S): Blood Pressure (B/P): 141/75 millimeter of mercury (mm/Hg), Pulse (P): 83 beat per minute (bpm), R: 18/min, Temperature (T): 36 grade centigrade (°C). However, no evidence was found that the RN of ER documented when patient was transferred to the delivery room to be evaluate by the gynecology and no evidence of an assessment previous to the transfer.

b. On 2/17/16 at 10:00 am the physician ordered Humalog 10 unit Subcutaneous (S/C) in AM and 10 units S/C in PM, Humulin N 50 units S/C in AM and 30 units S/C in PM. The RN signs the physician order. On 2/17/16 at 12:08 pm the physician ordered Insulin Regular 8 unit S/C per one dose, Humalog 10 units S/C with lunch and Diabetic Diet, the RN sign the order. However did not documented the date and hour that took the order as facility policy and procedure (P&P) Physician Order item #3 The Nursing Personnel takes and will perform the physician order. a) Write the dates, hour, sign, license number and the acronym below or next to the signature of the physician.

b. The nurse's note performed on 2/17/16 at 8:25 am documented that the glucose level quick test destrostix (Dxt.) was 303 milligram per deciliters (mg/dl) the physician was notified and ordered Insulin. At 9:30 am the RN administrated Humulin R 10 units S/C and Humulin N 40 units S/C. However, when physician writes the order, at 10:00 am ordered Humulin N 50 units S/C in am and 30 units S/C in pm. The RN failed to administer Insulin dose as ordered by the physician.

c. At 12:00 pm the nurse documented the Dxt: 378 mg/dl. In the Diabetic Chart the nurse documented Dxt: 379 mg/dl. The RN documented in the nurses note that the physician was notified an ordered Insulin R 10 units that was administrated. Then at 12:08 pm the physician ordered Insulin Regular 8 units S/C per one dose, Humalog 10 units S/C with lunch, Diabetic Diet. The RN signs the order but did not write the date and hour of when signed. At 12:15 pm the RN documented in the medication administration register (MAR) that Insulin R 8 units S/C was administrated. The RN failed to document congruent information related to the amount of Insulin administrated, due to in the nurse's note provide different dose of the MAR.

d. On 2/17/16 at 3:00 pm the RN documented in the nurse's note that patient was oriented, alert in the observation area of delivery room, continue with Ringer Lactated (R/L) at 125 milliliter per hour (ml/hr) in the right forearm free of edema or redness. However, no evidence was found of a physician order for the R/L at 125 ml/hr.

e. On 2/17/16 at 6:40 pm the physician ordered Vulva Abscess culture. However, the nurses did not document if the vulva culture was taken.

f. On 2/17/16 at 8:30 pm the nurses documented that the Dxt was 385 mg/dl the physician was notified and ordered Insulin R 6 unit S/C. However, no evidence was found related to Physician order for Insulin R 6 units S/C.

g. On 2/17/16 at 3-11 shifts at 8:50 pm the RN documented that patient was transfer to the emergency room with security measure, Intravenous (IVF) patent with accompanied by escort. However, no evidence was found of ER RN documentation from 2/17/16 at 3-11 shifts, at 11-7 shift, on 2/18/16 at 7-3 shift. No evidence was found related to ER RN intervention (nurses notes) since patient be transferred from the delivery room on 2/17/16 at 8:50 pm until 2/18/16 at 6:57 pm that performed the admission process (approximated 22 hour lacked of information about patient condition). No V/S, No Dxt, No medication administration, No pain assessment, No nursing assessment, etc.

h. On 2/18/16 at 1:30 pm the surgeon ordered admitted the patient at surgeon services, an ordered: IVF's 0.9% Normal Saline Solution (NSS) 100 ml IV to run at 20 ml/hr, and Vancomycin 500 mg every 12 hour. However, the surgeon failed to write a complete order due to did not write the route of administration of the Vancomycin and dilution. At 6:57 pm the RN takes the order and document in the Admission nurses note in the 3-11 shifts that patient was admitted to the medicine ward, patient and relative be oriented, Medication transcribed to the MAR. At the time the patient is on intravenous treatment 0.9% of NSS with an angio #18 at a rate of 20 ml/hr in left forearm. At 6:50 pm Vancomycin 500 mg IV was administrated. However, no evidence was found that the RN transcribes the NSS 0.9% at 20 ml/hr.

i. On 2/19/16 at 9:00 am the RN documented in the MAR that the medication Diflucan 100 mg was omitted. However, no evidence was found related to the reason for the omission and if the physician was notified of the omission.

j. On 2/19/16 at 11:00 am the RN documented in the diabetic chart sheet that patient was in a study. At 11:20 am physician telephonic order was taken by nurse to started stat in Low Salt Diabetic Diet. At 12:00 pm the License Practice Nurse (LPN) documented in the V/S sheet that patient was in a study. No evidence was found if the diet was notified to the dietary department and if patient was oriented related to the diet. No evidence was found the hour when patient was transfer to the X-ray department and when return.

Record review reveal that at 12:02 pm X-ray report the result of Chest AP was sign the radiology with an impression of no convincing radiograph evidence of acute cardiopulmonary process identified. However, no evidence was found that the V/S and Dxt was taken when arrive from the X-ray department. No evidence was found dietetic department send the diet to patient and if patient ingest and tolerated the diet after return from the study.

k. On 2/19/16 at 2:00 pm the RN documented in the diabetic chart sheet Dxt 244 mg/dl. However, no evidence was found that patient was cover with the dextrose cover ordered by the physician.

l. On 2/19/16 at 6:00 pm the RN documented in the MAR that Vancomycin 500 mg IV was omitted due to patient refuse them. However, no evidence was found that the RN notified the physician of the omission.

m. According to the Medication Reconciliation list that was performed on 2/16/16 at 5:47 pm. Patient was taking at home Humalog 15-20 units S/C three time at day (TID), Humulin R 10-20 units S/C TID, Zantac 300 mg per Mouth (PO) daily, Catapres 1 mg PO daily, Losartan 100 mg PO daily, Lipitor 40 mg PO daily, Norvasac 10 mg PO daily Plavix 75 mg Po daily and Cymbalta 60 mg PO daily. However during the admission process on 2/18/16 at 1:30 pm no evidence was found related to the medication that patient was taking at home. No evidence was found if the RN notified to the physician related to the reconciliation medication list.

n. Evidence was found that on 2/18/16 at 12:20 pm the physician at ER wrote a consult for Internal Medicine, the consult was notified on 2/19/16 at 1:23 pm. No evidence was found of the justification to notify the Internal medicine physician 12 hour after consulted. The internal physician documented the consult with the V/S similar to the V/S taken at 8:00 am by the LPN. This documentation has a different type of letter of the letter of the addendum in the consult sheet that refers "unable to exanimate the patient. Patient and family member want to leave against medical advice", however, the physician that document the Internal Medicine consult did not document the date and the hour of this event. The consult has two different letters written.

o. No evidence was found of nursing evaluation V/S after patient leaves the ward. on 2/19/16 after 7:00 pm. No evidence was found related to the hour when patient left against medical advices.

p. On 7/21/16 at 1:00 pm, the medical record did not have the vulva abscess culture result. The employee #3 review at medical record department and founded, the result reveal that patient has a Methicillin Resistant Staphylococcus Aureus (MRSA). However no evidence was found that the Infection Control Officer was notified or if patient was notified about the result of the culture.


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2. R.R #9 is a 17 years old female admitted on 3/12/16 with a diagnosis of Pilonidal Cyst with Abscess admitted at surgeon service. Accordance to the review of medical record performed on 7/20/16 at 3:45 p. m. with the Security and Hygiene Official (employee #5), the following was found:
a. The medication reconciliation was performed on 3/12/16 no evidence of the date, the physician signature and license number.

b. The surgery consent form was performed on 3/13/16 at 10:30 a. m. no evidence of the physician surgeon signature and license number.

c. On 3/13/16 at 2:45 p. m. the pre-operative assessment was performed by the nurse the document provides evidence that the patient was accompanied by her mother however no evidence of her mother name. The pre-operative assessment was signed by the register nurse however the nurse signature and the license number were illegible.

d. On 3/13/16 the ''Hoja de cotejo '' was performed and signed by the anesthetist nurse, the surgeon and the anesthesiologist however no evidence of the hour when signed the document.

e. On 3/13/16 at 10:30 a. m. a telephone orders was taken however, the illegibility of the signed did not identify who is the nurse that signed the telephone order.

f. On 3/14/16 at 11:00 a. m. a telephone order to '' discontinue IV fluids and heparin lock and Discharge to home '' was taken, however the telephone order is not legible and according of the patient record the patient was discharge home without surgeon evaluation.

g. The nurse note performed on 3/14/16 on shift 7:00 a. m. till 3:00 p. m. lacks of nurse signature.

h. The transfusion consent form signed by patient mother lacks of date and hour when patient mother signed the document.

3. R.R #10 is a 56 years old female admitted on 7/18/16 at 6:14 p. m. with a diagnosis of Sepsis / Aplastic Anemia admitted at surgeon service to '' Right basilic vein peripherally inserted catheter sonogram guide.'' Accordance to the review of medical record performed on 7/21/16 at 1:50 p. m. with the Nurse Supervisor (employee #4), it was found the following:

a. The patient record provide evidence that on 7/18/16 at 5:55 p. m. a consult was request however a consultation record did not provide the name of the physician who request the consult the date and the hour.

b. The transfer note of operating room performed on 7/20/16 at 9:00 p. m. did not provide evidence of pain assessment, the name of the nurse who transferring the patient and the name and license number of the nurses who received the patient was illegible.

c. The consent form of operating room performed on 7/20/16 at 11:10 a. m. is not signed by the patient or legal tutor and lacks of surgeon name, license number and signature.


d. The physician orders form for '' Hemodialysis Standard Procedure Orders'' signed by the nurse on 7/20/16 at 11:10 a. m. lacks of the date and the hour when the physician ordered the treatment, lacks of the provisional diagnosis, drug allergies and did not signed by the physician and lacks of license number.

e. The transfer note of hemodialysis treatment to medicine ward performed on 7/20/16 at 3:05 p. m. lacks of the name of the nurse who received the patient. The designated area indicated if the patient is diabetic, if the patient received treatments and interventions were maintained in blank.

f. The hemodialysis treatment sheet performed on 7/20/16 at 11:10 a. m. lacks of pain assessment, the designated area indicated if the patient is received medications during the treatment was maintain in blank and lacks of the physician signature and license number.

g. The patient record provide evidence that on 7/19/16 at 10:30 a. m. a consult was request however a consultation record did not provide the name of the physician who request the consult.

4. R.R #11 is a 58 years old female admitted on 7/12/16 at 3:24 a. m. with a diagnosis of Sepsis / Left Leg Cellulites. According to the review of medical record performed on 7/21/16 at 2:55 p. m. with the Nurse Supervisor (employee #4), it was found the following:

a. The '' Admission Report of the Emergency Room '' performed on 7/12/16 at 6:00 a. m. lacks of patient vital signs and nurse license number. The designated area for canalization was maintained in blank.

b. The anesthesia record performed on 7/14/16 lacks of post-anesthesia vital signs.

c. The assessment and re-assessment form for pain control used per nursing department was maintain in blank only signed by the nurse however the signed was not legible.

5. R.R #13 is a 54 years old male admitted on 2/6/16 at 2:41 p. m. with a diagnosis of Cutaneous Abscess of Neck. According to the review of medical record performed on 7/21/16 at 4:35 p. m. with the Nurse Supervisor (employee #4), it was found the following:
a. The surgery consent form was taken on 2/8/16 at 7:00 however did not established if a. m. or p. m.

b. The Nursing Pre-op Procedure performed on 2/8/16 at 1:15 p. m. was signed by the nurse however the signature and the nurse license were illegible.

c. The nursing pre-operative checks list performed on 2/7/16 was signed by the nurse however the signature and the nurse license was illegible.

d. The nursing intra-operative note performed by the nurse on 2/8/16 provide evidence that the patient enters the operating room #1 at 3:00 p. m. for incision and drainage of left neck abscess gets out of the operating room at 3:50 p. m. however the designated area to write at what area the patient was transfer was maintain in blank. The nurse signature and license number was illegible.

e. The recovery room note performed on 2/8/16 at 4:50 p. m. provide evidence of pain assessment '' yes '' however lacks to indicate if the patient did not have pain and the intensity. The nurse signature and license number was illegible.

f. The '' Transfusion Consent form '' signed by the patient on 2/8/16 at 7:00 (did no indicated if a. m. or p. m.) and according of the document the patient did not consent administration of blood or components for his treatment, this consent lacks of the name of the physician on the designated area of the third paragraph and lacks of physician name and license number.

g. The ''Assessment and Re-assessment for pain control '' was maintained in blank and the nurse signature and license was illegible.

6. R.R #14 is a 40 years old male admitted on 2/18/16 with a diagnosis of Per-Anal Abscess. According to the review of medical record performed on 7/21/16 at 10:55 a. m. with the Nurse Supervisor (employee #4), it was found the following:

a. The patient reconciliation medication form was performed on 2/17/16 and lacks of the physician signature.

b. The ''Anesthesiology Consent '' on the second page paragraph number four indicated that the patient received '' spinal anesthesia the date of the surgery, however on space designated to write the physician name was maintain in blank.

c. The ''Assessment and Re-assessment for pain control '' was maintained in blank and the nurse signature and license was illegible. According of the nurse note performed on 2/18/16 at 3:00 p. m. revealed that the patient developed pain and received Demerol 25 mgs. and Phenergan 25 mgs. intramuscular and was maintain in observation; however no evidence of re-assessment post treatment.

d. The form designated ''Admission Report Emergency Room did not indicated at what department and room number the patient was transfer, not indicated who is the person accompanied the patient, what kind of transport used to transport the patient, if the patient has radiographies or studies performed, if the patient has pending laboratories, medications, procedures, consults or others, if the patient has pending others treatments and in what side the patient have a canalization area.