HospitalInspections.org

Based on the review of administrative documents with the Executive Director (employee # 13) on 03/13/14 at 10:30 a.m., it was determined that the facility failed to ensure that the hospital have an update license in compliance with State Law # 101 of June 26, 1965, as ammended know as the Law of the Health Facilities, that regulated licensure requirements in Puerto Rico.

Findings include:

1. The State license of the facility expired on February 7 of 2014. According to state licensure requirements, the facility should have submitted all documents requested by the State licensure office with three (3) months before the renovation date. The documents that were not submitted were: certified document explaining how the hospital comply with policies and procedures to prevent infant abduction, Executive Director's membership of the "Colegio de Administradores de Servicios de Salud" Administrators College, Executive Director's updated license and registry number, updated Medical Professional Liability and Commercial Property Liability Insurances.

a. Some of these documents were submitted during the survey process. Meanwhile, at 03/14/14 the facility has not updated the State license.
2. Interview with the Executive Director (employee #13) and the Director of Nursing (employee #1) it was determined that the facility failed to review and update the organizational chart and policies and procedures (P&P's) as required under the State Law Rules and Regulations Number 117 of December 1 of 2004, Chapter 12, Article 6, Section 6, step 2a..

3. The organizational chart shows the Respiratory Therapy Program, Nutritional Services and the Physical Therapy and Rehabilitation Program under the Nursing Services.

During interview to employee #1 on 03/12/14 at 9:00 am, she stated: " I ' m in charge of the Respiratory Therapy Program, the Nutritional Services and the Physical Therapy Program. I have to observe that those programs comply with the institutional policies and procedures. I'm in charge to do the annual evaluation."

During interview performed to employee #13 on 03/13/14 at 11:30 a.m., he stated: " I decided to put these services under the Nursing Services. I don't have the structure and enough income for organizing these departments".

a. The Respiratory Therapy Program is under contracted services and has their professional personnel. No evidence was found of a Pneumology physician in charge of this program. This program has a Supervisor who is a Respiratory Therapist.

a.i. The Physical Therapy and Rehabilitation Program have their professional staff but no evidence of a Physician Director in charge was found. This program has a Supervisor who is a physical therapist.

a.ii. The annual evaluation and competency evaluations of the respiratory and physical therapists should be done by the same professional. The DON does not have experience in providing care according to standard procedures of respiratory and physical therapy.

a.iii. The Supervision of Respiratory therapy and Physical therapy should be done by qualified administrative personnel.
b. The Nutritional Program is an institutional program. The annual evaluation and the competency evaluation of the Nutritionist is not done by a qualified administrative personnel. The DON does not perform duties according to the standard of practice of the nutritionist.

Based on the review of the State Law License regulations and the review of nursing, physicians, respiratory therapists, anesthetics nursing, radiology personnel, two radiologist and escort services credential files (C.F.), it was determined that the facility failed to updated personnel credential files for lack of, annual evaluations cardio pulmonary Resuscitation certificates (CPR), competency of personnel, health certificates, license, professional registry, Hepatitis B vaccine and for 69 out of 76 credential files, ( Nursing C. F . #1, #2, #3, #4, #6, #5, #7,# 10, #13, Respiratory Therapists C.F. #2, #3, #5, #13 and #16, Medical staff C.F. #1 thru #40, Anesthetic Nursing C.F. #1, #2, #4, #5 and #6), Radiology staff ( CF#1 to #10) and Radiologist (CF #2),
Findings include:

1. The Human Resources Office has developed different forms that evaluate employees ' performance. However, they do not develop specific competency forms related to professional standards of practice. As observed during C.F. review on 03/14/14 from 2:00 pm thru 3:30 pm, there are no competency evaluations for all nursing personnel related to hand washing techniques, ulcer or wound care, Foley catheter insertion, tracheal care, catheter suction, gastrostomy care and other procedures that nursing staff do on a daily basis during patient care.

a. Six (6) out of fifteen (15) nurses CF did not show handwashing , Foley catheter insertion, gastrostomy care, tracheal care, venipuncture procedures, drugs administration competencies,(CF # 1, #2, #3, #5, #7, and #13).

b. Three (3) out of three (3) nurses assigned to Wound Care Program, do not show ulcer and wound care competencies (CF #3, #4 and #5).

c. Two (2) out of three (3) nurses that assist in the Hyperbaric Chamber Program does not provide competencies in patient care in hyperbaric chamber treatment, (CF #3 and #5).

2. Two (2) out of fifteen nurses CF reviews do not show an updated full time contract with the hospital and no evidence of the discussion of their duties, (CF #3 and #4).

a. CF #3 has a contract for a probationary period of three months from May 3, 2010 thru August 2, 2010 but it has not been updated after this probationary period.

b. CF #4 has a contract for probationary period of three months in 2010 but it is not updated after the probationary period.

c. CF #3 and #4 do not have evidence of the discussion of their duties as Wound Care and Hyperbaric Chamber nurses.

3. Two (2) out of eighteen (18) nurses CF reviews showed an expired CPR certification. The due date of it was on 10/28/13, (CF #10 and #18).

4. Two (2) out of fifteen nurses CF reviews do not show an updated health certificate, (CF #6 and #7).

a. CF #6, #17 and #18 does not provide evidence of Hepatitis B vaccination.

b. CF # 7 does not provide evidence of an Influenza vaccination or exoneration consent performed by the employee. The facility does not comply with Department of Health Administrative Order Number 244 of October 10, 2008.

5. The escort services have 18 employees. They are under contracted services and the Supervisor of this group has to perform the annual evaluation. However, neither the annual evaluation form nor the CF of these employees was available for review during the survey.

During interview with the escort coordinator, performed on 02/14/14 at 8:45 am, she stated: " I do the annual evaluation to our employees. However, I do not have annual evaluation. My boss has to do it but he did not perform my evaluation".

6. The facility failed to ensure that the employees of the escort services comply with policies and procedures if they do not perform the annual evaluation.


20423

7. One out of seventeen respiratory therapists credential files reviewed on 3/14/14 at 12:20 pm provide evidence of the provisional license #7750-3 was expired on 12/17/13 not in accordance to the state Law # 24 from June 4, 1987 that Regulates the Respiratory Care Practice in PR. (C.F #2).

8. Four out of seventeen respiratory therapists credential files reviewed on 3/14/14 at 12:20 pm did not provide evidence of the updated police penalty antecedent (C.F.s #2, #3, #13 and #16)

9. One out of seventeen respiratory therapists credential files reviewed on 3/14/14 at 12:20 pm did not have evidence of their Influenza vaccine or responsibility exoneration according to the Health Department Administrative Order # 244 of October 10, 2008. (C.F. #3)

10. One out of seventeen respiratory therapists credential files reviewed on 3/14/14 at 12:20 pm did not have evidence of their annual competencies evaluation. (C.F. #5).

11. Sixteen out of forty medical staff's credential files provided evidence of expired Health Certificates (C.F #1 (from 5/21/13), #2 (from 5/22/13), #3 (from 1/16/14), #4 (from 2/3/14), #5 (from 3/4/14), #6 (from 1/31/14), #9 (from 12/2/13), #13 (from 3/6/14), #15 (from 7/19/13) #21 (from 1/12/13), #25 (from 8/21/12), #28 (from 3/4/14), #32 (from 10/11/13), #34 (from 2/22/14), #37 (from 11/16/13) and #39 (from 2/14/14).

12. One out of forty medical staff's credential files provided evidence of expired cardio-respiratory certificates (C.Fs #23 (from 2/22/14).

13. Forty out of forty medical staff's credential files did not have evidence of their Influenza vaccine or responsibility exoneration according to the Health Department Administrative Order # 244 of October 10, 2008 (C.Fs #1 through #40) due to, in the Medical By law was not requested to the medical Staff as required.

14. One out of forty medical staff's credential files did not have evidence of their updated medical association (C.Fs #32).

15. Anesthetist credential files were reviewed on 3/12/14 from 1:00 pm till 2:00 pm, the following was found:

a. Five out of six anesthetist nursing credential files do not provided evidence of an updated anesthetist competencies the last competencies evaluation was performed on 1/22/13,(C.F
#1, #2, #4, #5 and #6).



34043

16. Review of documents provided by human resource director (employee # 26) and eleven credential files (C.F) on 3/12/14 at 9:00 am , it was determined that the facility failed to ensure that credential files of the Radiology Department staff are updated for 10 out of 11 credential files (C.F) and 2 out of 2 physicians files reviewed. 6 of 11 staff files lacked updated Cardio Pulmonary Resuscitation certificates (CPR), (C.F #2, #4, #5 #7, #8, and #9), 4 out of 11 lacked the annual performance evaluations (C.F #1, #2, #3, and #10), 6 out of 11 did not have evidence of their annual competencies (C.F #1, #2,#3, #4, #8, and #10), 2 out of 11 did not have evidence of their license and registry (C.F #2 and #3), 2 out of 11 did not contain evidence of their Hepatitis B vaccine (C.F #5 and #8) and 1 out of 2 physician did not have an update health certificate ( CF #2).

a. Six out of eleven radiology employee credential files were reviewed on 3/12/14 at 9:00 am with the human resource officer (employee #) provided evidence that C.F #2, #4, #5 #7, #8, and #9 did not have updated cardiopulmonary certificate.

b. Four out of eleven radiology employee credential files provided evidence that (C.F #1, #2, #3, and #10) did not have updated performance evaluations.

c. Six out of eleven X-Ray personnel credentials files did not contain evidence of their annual competencies C.F #1, #2, #3, #4, #8, and #10.
d. Two out of eleven X-Ray personnel credentials files did not contain evidence of their license and registry C.F #2 and #3.
e. Two out of eleven X-Ray personnel credentials files did not contain evidence of their Hepatitis B vaccine C.F #5 and #8.
f. One of two physicians ' personal credentials files did not contain evidence of their Hepatitis B vaccine.
g. One of two physicians personal credential files did not contain evidence of the Health certificate. (CF #2)

Based on the review of medical records, policies and procedures, documents, observations, tests and interviews from 3/11/14 through 3/14/14 from 8:00 am till 4:00 pm, it was determined that the Governing Body failed to carry out its responsibility for the operation and management of the hospital. The Governing Body failed to provide the necessary oversight and leadership as evidenced by the lack of compliance with: Governing Body (42 CFR 482.12), Nursing Services (42 CFR 482.23), Physical Environment (42 CFR 482.41), Infection Control (42 CFR 482.42).

Based on documents reviewed and interviewed with the Executive Director (employee # 13) it was determined that the facility failed to ensure that the contracted services are updated.

Findings include:

1. The facility has the escort services and the respiratory therapy under contracted services. During review of the contracted services, performed on 03/13/14 at 1:00 pm with the Executive Director, it was found that these contracted services have expired.

a. Both services began on March 9 of 2012 and the term of the contract says: it begins on the date when it was signed and it's valid for twelve months, until March 14 of 2013".

Based on review of the admission packet and informal interviews to patients admitted at the hospital during the survey process from 3/11/14 till 3/14/14 from 9:00 am till 4:00 pm accompanied by facility staff nurse coordinator (employee #5), nurse supervisor (employee #3) it was determine that the facility failed to promote and inform each patient's their rights as hospital patients.

Findings include:

1. During the admission's process the patient receives an admission packet with all required document to execute their rights during hospitalization. On 3/11/14 at 10:00 to 3:00 pm the during the survey the following was found, The "Manual de Orientacion a Paciente y Familia" Manual for Patient and Family Orientation, and " Derechos de Pacientes " Patients Rights, on page 32, 33 and 34 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 manual.

2. On page 34 of the manual contains QIO and CMS RO information, address and phone number and was also not updated. The facility failed to ensure that all Government Agency Local and Federal are updated in their manuals to ensure patients and families have accesses to an update phone number.

3.The facility had a census of 55 patients of which 47 informal interviews were performed during the survey on 3/11/14 to 3/14/14 from 9:00 am till 3:00 pm, the patient ' s and patients relative stated that a package was given to them upon admission but it was not explained, they were only given a piece of paper to sign and they did not know they had the rights to appeal and did not know who to file a complaint to at the facility.
4. During the initial tour at different clinical unit in the hospital, patients were asked about their rights and the packet provided at the admission. Also the medical record included documentation that stated " the patient is provided with a notice of rights during the admission to the hospital and the patient has the information package " .

5. As observed at the medicine unit on 3/13/14 at 10:00 am, a blackboard is located on the wall at the front of each bed. When surveyors ask patient and relative who they can contact to file a complaint or if they knew the name of the unit ' s supervisor, some responded they did not know. Surveyor read the names that were written on the board to the patients, that contain patients primary physicians name and the supervisors name and they stated they did not who they were.
6. The facility failed to explain to patients or representative their rights in a language or in a manner that the patient or patient's family can understand to execute their rights and re enforce the orientation while at the hospital during the length of the hospitalization.

Based on medical record reviewed and interviewed with the patient, it was determined that the facility failed to provide Medicare recipients "An Important Message from Medicare" (IM) at the admission and two days before discharge to execute their rights to appeal facility ' s discharge, failed to sign, date, provide the two forms, or provide the second form and inform patients of the IM requirements for 4 out of 77 records reviewed (RR) (RR. #38, #39, #58, and #60).
Findings include:

1. R.R. # 38 is a 73 years old male who is admitted on 03/10/14 with a diagnostic of Congestive Heart Failure (CFH), Coronary Artery Disease (CAD), and Renal Failure. The record was review on 3/13/14 at 9:00 am with the nurse coordinator employee #5. The Important Message from Medicare was provided upon admission 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 signed and dated by the patient to acknowledge receipt as per requirement.

2. RR # 39 is a 72 years old male who was admitted on 03/11/14 with a diagnosis of Atrial Fibrillation. The record was reviewed on 3/14/14 at 9:50 am with the Nurse Coordinator employee # 5. The Important Message from Medicare was provided upon admission on 03/11/14 however, it was signed by the patient but 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 signed and dated by the patient to acknowledge receipt as per requirement. The patient was discharge on 3/14/14. The facility failed to provide the second IM with two days in advance of the discharge. The second IM was found in the medical record however, was not sign and dated by the patient. During interview with the patient perform on 3/14/14 at 10:00am patient stated" I will be discharge today but no one has talk to me about my right to appeal my discharge".

3. R.R. # 58 is an 86 years old male who is admitted to intermediate unit on 3/01/14 with a diagnosis of Congestive Heart Failure (CHF). The first Important Message from Medicare was provided upon admission as observed during the R.R. with the Medicine unit supervisor employee # 3 on 3/13/2014 at 8:50 am it was found that the medical record had three forms (IM) however, two were not sign or dated and the third form was dated 3/12/14 one day before discharge. 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 patients ' discharge providing the rights to appeal their discharge.
4. R.R. # 60 is a 67 years old female who is admitted on 3/05/14 with a diagnosis of Bronchitis, Chronic Obstructive Pulmonary Disease (COPD). The record was reviewed on 3/13/14 at 9:00 am with the surgery unit nurse supervisor employee #6. The first Important Message from Medicare was provided upon admission as observed during the R.R. The form was sign and dated 3/5/14 and a second form was sign and dated 3/6/14, both were in the medical record. The second IM was in the medical record however was not sign nor dated as evidence. The patient was discharge on 3/13/14 at 9:00 am. The facility failed to provide the second IM two days before discharge. 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 patients ' discharge providing the rights to appeal their discharge.
During interview with the patient on 3/13/14 at 9:30 am the patient stated " I am discharge today, I ' m better now. I had respiratory problems but I am glad I can go home today " . When ask by the surveyor if she knew of the IM, she stated " No, I did not know and no one has talk to me about it, but thank now I know I have a right to appeal if I need to do so in a future".

Based on the observations, review of hospital security policies, protocols and interview with Physical Plant Manager (employee #12 ) and Security Officer (employee #28 ) it was determined that facility failed to promote the right of each patient to receive care in a safe setting.

Findings include:

1. During the observational tour performed during survey process on 3/12/14 from 8:55 am through 2:39 pm the following was identified:

a. Outside contractors were accessing the seventh floor (Pediatric ward) to work on the facility flat roof. As facility policy all outside contractors who comes to work at the facility must report to the engineering department to register. However the engineering department does not include on the registry of each outside contractor the areas were those personnel are going to work. Personnel who access the flat roof through the seventh floor (Pediatric ward) did not have any identification badge that identifies the name and company of the person that works. Facility failed to put in place policies and procedures to enhance security in key areas were hospital environment should be constantly assessed to prevent infant abduction.



33725

During an interview on 3/12/14 at 9:00 am with the security officer (employee #28) he reported that the facility's infant electronic abduction security system devices ( grillete ) designed to alert staff if an infant is taken out of the department was not functioning due to the expiration of the contract since 2011.
2. Alternative security measures were put in place since the date the infant abduction (electronic) security system is taken out. Facility had a written proactive infant abduction prevention policy and response plan, that extent beyond security and the maternity and pediatric units. However physical security assessment risk certifying the function and pertinence (strategic location of cameras) of security cameras, controlled access locks and alarms was not performed.

Based on review of policies and procedures (P&P) related to the restraint protocol, it was determined that the facility failed to ensure that all forms of restraints are included on the facility's restraint protocol, " Restriccion o Inmovilizacion Flexible de Pacientes " , " Educacion A Paciente y Familia Sobre Restricciones " Education To Patient and Family About Restring and " Forma de Estimado/Orden Restriccion Paciente Adulto " Assessment Form/Restraint Order for Adults, related to the use of four side rails as a matter of restraint when medically need .

Finding includes:

1. The facility's P& P , restraint form/order, consent form and patient education packet was reviewed 3/13/14 at 9:00 am with the medicine unit supervisor employee# 3 and Intermediate unit coordinator employee #5 and it revealed that the use of side rails was not address on the facility ' s restraint protocol, P&P, order and education packet.
2. The restrain protocol mentions on page 2 Method of restriction #4 " side rails up (two on the superior part of the bed). As observed during the tour at the Intermediate unit and Medicine unit from 3/11/14 till 3/14/14, the beds at the Intermediate unit have only two upper side rails, which are maintain up while patients is in bed which do not fall in the definition of restraint. However the medicine unit beds have four side rails. The facility's restraint protocol does not address the use of four side rails as a method of restraint when medically needed.
3. The restraint consent form " Permiso de Restricción " revealed that " patient and family authorized or do not authorize the use of restraint for safety " . The facility failed to provide patient and facility a consent form that includes as restraint the use of side rails, when applicable and when medically needed based on regulation requirement under patients rights to be free from all forms of restraint.
During interview with employee #3 and #5 they stated on 3/13/14 at 9:30am they did not know that the side rails were consider restraint, and that an order is needed when the four side rails are up. They also stated that in some cases the patient or family pulls all the side rails up for safety.

Based on the review of forty medical staff credential files, it was determined that the facility failed to examine credential files (C.F) to ensure that medical staff have updated Health Certificates, Cardio-pulmonary Resuscitation Certificates (CPR) and 2014 medical association for 15 out of 40 medical staff's C.Fs (C.F #1, #2, #3, #4, #5, #6, #9, #13, #15, #21, #23, #25, #28, #32 and #37.

Findings include:

1. During the review of forty medical staff credential files with Medical Staff secretary (employee #24) on 3/13/14 from 8:45 am till 9:30 am the following was found:

a. Sixteen out of forty medical staff's credential files provided evidence of expired Health Certificates (C.F #1 (from 5/21/13), #2 (from 5/22/13), #3 (from 1/16/14), #4 (from 2/3/14), #5 (from 3/4/14), #6 (from 1/31/14), #9 (from 12/2/13), #13 (from 3/6/14), #15 (from 7/19/13) #21 (from 1/12/13), #25 (from 8/21/12), #28 (from 3/4/14), #32 (from 10/11/13), #34 (from 2/22/14), #37 (from 11/16/13) and #39 (from 2/14/14).

b. One out of forty medical staff's credential files provided evidence of expired cardio-respiratory certificates (C.Fs #23 (from 2/22/14).

c. Forty out of forty medical staff's credential files did not have evidence of their Influenza vaccine or responsibility exoneration according to the Health Department Administrative Order # 244 of October 10, 2008 (C.Fs #1 through #40) due to in the Medical By law was not requested to the medical Staff.

d. One out of forty medical staff's credential files did not have evidence of their updated medical association (C.Fs #32).

Based on the review of Medical Staff Rules and Regulations, it was determined that the facility failed to ensure that services provided by the medical staff have protocols which address "Do Not Resuscitate" (DNR) administrative protocols.

Findings include:

During the review of Medical Staff Rules and Regulations on 3/13/14 at 4:30 pm with the Executive Director (employee #13), no evidence was found of written bylaws for "Do Not Resuscitate" (DNR) administrative protocols.

Based on clinical records reviewed (R.R.) with the operation room supervisor (employee #21), it was determined that the facility failed to ensure that the medical staff comply with the rules and regulation related to the medical history and physical examination (H&P) is documented by a physician for each patient no more than 30 days before or 24 hours after admission or registration for 2 out of 77 medical record (R.R # 47 and # 48).

Findings include:

1. R.R #47 is a 68 years old male admitted to the facility on 3/11/14 with a diagnosis of Right Knee Total Joint Replacement. During the record review performed on 3/12/14 at 2:25 pm it was found that the patient entered the operating room on 3/11/14 to perform a Right Knee Total Joint Replacement and requiring anesthesia services.

However, the H&P was performed by the patient's physician on 1/30/14, forty (40) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

2. R.R #48 is a 76 years old male admitted to the facility on 3/11/14 with a diagnosis of Right Knee Total Joint Replacement. During the record review performed on 3/12/14 at 2:50 pm, it was found that the patient entered to the operating room on 3/11/14 for a Right Knee Total Joint Replacement and requiring anesthesia services.
However the H&P was performed by the patient's physician on 1/30/14, forty (40) days before the surgery. No evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

Based on ten medical records reviewed (R.R.) with the operation room supervisor (employee #21), it was determined that the facility failed to ensure that the medical staff comply with the rules and regulation related to the medical history and physical examination (H&P) is documented by a physician for each patient and updated prior to surgery or procedure requiring anesthesia services when the H&P was performed within 30 days before admission or registration for 6 out of 10 medical record (R.R#41, #44, #45, #46, #47 and #48).

Findings include:

1. R.R #41 is a 70 years old male admitted to the facility on 3/3/14 with a diagnosis of Recurrent Right Inguinal Hernia. During the record review performed on 3/12/14 at 10:45 am it was found that the patient entered to the operating room on 3/3/14 to perform a Repair of Recurrent Right Inguinal Hernia and requiring anesthesia services.

However the H&P was performed by the patient's physician on 2/10/14, twenty (21) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

2. R.R #44 is an 89 years old male admitted to the facility on 3/10/14 with a diagnosis of Cataract Right eye. During the record review performed on 3/12/14 at 1:35 pm it was found that the patient entered to the operating room on 3/10/14 to perform a Cataract right eye and requiring anesthesia services.

However the H&P was performed by the patient's physician on 2/28/14, nine (9) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

3. R.R #45 is a 70 years old male admitted to the facility on 3/3/14 with a diagnosis of Chronic Cholecystitis. During the record review performed on 3/12/14 at 2:00 pm it was found that the patient entered to the operating room on 3/3/14 to perform an Exploratory Laparostomy Cholecystectomy and requiring anesthesia services.

However the H&P was performed by the patient's physician on 2/25/14, six (6) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

4. R.R #46 is an 81 years old male admitted to the facility on 3/10/14 with a diagnosis of Conjuntival Mass in Left eye. During the record review performed on 3/12/14 at 2:10 pm it was found that the patient entered to the operating room on 3/10/14 to perform a an Excision of Conjuntival Mass in left eye and requiring anesthesia services.

However the H&P was performed by the patient's physician on 2/24/14, fourteen (14) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

5. R.R #47 is a 68 years old male admitted to the facility on 3/11/14 with a diagnosis of Right Knee Total Joint Replacement. During the record review performed on 3/12/14 at 2:25 pm it was found that the patient entered to the operating room on 3/11/14 to perform a Right Knee Total Joint Replacement and requiring anesthesia services.

However the H&P was performed by the patient's physician on 1/30/14, forty (40) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

6. R.R #48 is a 76 years old male admitted to the facility on 3/11/14 with a diagnosis of Right Knee Total Joint Replacement. During the record review performed on 3/12/14 at 2:50 pm, it was found that the patient entered to the operating room on 3/11/14 to perform a Right Knee Total Joint Replacement and requiring anesthesia services.
However the H&P was performed by the patient's physician on 1/30/14, forty (40) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

Based on observations, records reviewed (R.R) and review of documents, policies/procedures and interviews from 3/11/14 through 3/14/14 from 8:30 am till 4:00 pm, it was determined that the facility failed to ensure that the hospital has a well-organized nursing service related to, evaluating the weekly nursing, supervision of nursing services, educational program referrals, updated nursing forms for documentation, infection control surveillance, Quality Program indicators, medication record documentation and verbal orders, drugs administration procedure and the lack of nursing documentation related to the patient's status in the medical record makes the Nursing Condition of Participation "Not Met". (cross refer Tag A 386, 396, 405, and 408).

Based on observations, records reviewed (R.R) and documents reviewed, policies/procedures and interviews from 3/11/14 through 3/14/14 from 8:30 am till 4:00 pm, it was determined that the facility failed to ensure that the hospital has a well-organized nursing services.

Findings include

1. The Director of Nursing (employee #1) failed to evaluate the weekly nursing staffing program. It was found that care units, such as: Medicine, Medicine Intermediate, Surgery, OBGYN, Intensive Care Unit and Nursery have nurses with an associate degree without the supervision of nurses of bachelor degree. This action does not meet the rules and regulations established on the State Law #9 of October 1987, which establish the nursing standard of practices.

2. The educational plan for years 2013 and 2014 does not show activities related to Documentation on the clinical record using Focus PAR, Errors in the Administration of Medications, Documentation on the Medication Administration Record (MAR), Nursing Intervention in the PIXYS System for the Administration of drugs and biological and Abuse and Neglect.

a. It was found that employee #1 failed to identify with her Supervisor staff educational nursing needs.

b. The facility has an educational program that receives nursing personnel by referral from the Nursing Supervisors of different care units. The purpose of this program is to teach the nursing staff if they failed in nursing procedures during patient care. It was found during the survey process many errors in drug administration, documentation on the clinical record, following infection control procedures, administration of medications but the Supervisors are not referring the employees.

According to interview performed with the employee #17 on 03/14/14 at 10am, last year she received by referral four (4) nurses for errors in drugs and narcotics administration.

During the first three months of this year, employee #17 received by referral one nurse and one medical technologist for errors identifying the correct patient. However, no evidence was found of a referral form and a certification of employee compliance form for evaluation. Employee #17 said that she has the forms but was not approve by the Executive Director.

b.i. During survey process in the Medicine Unit, it was found that an RN had a suspension from work because she did not meet the nursing procedures.

During interview with employee #3 on 03/14/14 at 2:00 pm it was found that the RN came back to work and the referral was not send to the educational program. According to employee #17, the employee #3 had to do the referral to the educational program before the RN begins her work at the Medicine Unit. Employee #1 is aware of these issues but failed to establish a plan of action to make agile the referral process.

3. During RR of seventy seven (77) records it was found the following:

a. Nursing forms for documentation not updated, such as: Initial Assessment, plan of care, re-assessment daily sheets, and nursing protocols (wound care, restraint, etc.). The nursing staff leaves blank spaces, does not identify all patients ' problems, does not complete the Initial Assessment, and does not review the plan of care daily, the progress notes are not written with legible handwriting, the progress notes do not show the patient's response according to the care provided.

4. Employee #1 failed to establish a plan of surveillance to assure compliance with the infection control measures.

5. Failed to establish an effective plan of correction if nursing staff does not comply with the Quality Program indicators.

a. The quality reports sent quarterly by the Nursing supervisors from different care units have been evaluating some indicators such as: patient care in telemetry, High risk patient care with wound care, referrals to Life Link (OPO program), adequate intervention with enteral feeding, patients weight registry in the electronic record, adequate documentation in the clinical record and other indicators showing none compliance. Employee #2 is in charge of receiving and evaluating the quality reports but the same problems continue each quarterly period and no improvement is shown.

During the survey process it was confirm that these problems are consistent and the plan of correction is ineffective. The quality reports do not show other measures that assure compliance with the policies and procedures.

6. There is no surveillance on medications errors. There is lack of documentation in the medication record and no evidence was found of what is the cause of this issue.

Based on medical record reviewed (RR) performed on 03/11/14 thru 03/14/14 with the Nursing Supervisor (employee #3) and the Nursing Coordinator (employee #4) of the Medicine unit, it was determined that the facility failed to assure that the nursing staff and other professionals are planning their interventions on the plan of care according to the patient's needs, for 2 out of 77 records reviewed. (RR # 59 and # 74).

Findings include:

1. The facility has developed an interdisciplinary plan of care where all professionals that provide patient's care have to identify all active problems. This is part of the "Focus Par" that the facility established in their policies and procedures (P&P's) of documentation. However, the nursing staff and other professionals are not identifying the active problems in the plan of care, as follows:

a. RR # 59 was performed on 03/14/14 at 1:30 pm. The patient was admitted on the Medicine Unit on 02/15/14 with diagnose of Left Leg Cellulites, Urinary Tract Infection (UTI), Hypertension and Diabetes Mellitus. Patient has Cellulites in left leg. The RN identified the problem of skin integrity and activated the problem on 03/16/14. However, the nursing staff did not review the plan of care daily. As observed, the review of skin integrity problem was reviewed on 02/19, 02/23, 02/27 of 2014.

During interview with employee #3 and employee #4 at 2:00 p.m. on 03/14/14, it was found that the ward clerk divided the record and put aside the plan of care. None of the nursing staff was aware or observed this issue and the plan of care was not updated daily.

a.i. The patient was having high blood pressure in a range between 156/70 to 183/83 since admission. The Hypertension problem was not identified in the plan of care.

a.ii. The patient had a Foley catheter since admission and had urinary infection but the problem was not identified in the plan of care.

a.iii. The patient is having high levels of glucose requiring the administration of Regular Insulin 10 units subcutaneous with each feeding and Lantus 30 units subcutaneous before sleep and the problem was not identified in the plan of care.

a.iv. The Wound and Ulcer Care Program physician, ordered on 03/06/14 to provide wound care daily with Hydrogel and elevation of the leg. The same physicians ordered on 03/08/14 at 11:00 am to provide wound care with normal saline and apply Calcium Alginate plus Hydrogel with Vaseline gauze to leg wound.

However, no evidence was found of the nursing staff, from the Wound Care Program planning their interventions according to their goals on the plan of care.

a.v. Patient went to surgery for an ulcer debridement on 03/07/14 at 8:00 am. However, the skin integrity problem on the plan of care does not show the update nursing interventions after the surgery.

b. RR #74 was performed on 03/12/14 at 1:40 p.m. The patient was admitted on 02/25/14 with diagnoses of Dysphagia and Odinophagia. The secondary diagnoses are: Anorexia, Chronic Obstructive Pulmonary Disease( COPD), Transient Ischemic Attack ( TIA), Malnutrition, High Blood Pressure, had prostate surgery, has SOB episodes (shortness of breath), has a Foley catheter, has left side hearing loss and progressive eye lid dropping. The nursing staff failed to identify the problems in the plan of care, such as: Hypertension, respiratory pattern difficulty, difficult in swallowing food (nutritional pattern), Foley catheter care, enteral feeding protocol and other active problems that the patient had.

b.i. On 03/10/14 at 3:00 pm, the RN identified the problem of nutritional issues. At the top of the plan of care, the RN has to write the initial diagnose. The RN wrote PEG instead of Dysphagia. The patient is receiving enteral feeding with Pulmocare. The RN did not identify to improve the nutritional status as part of the goals.
In the interventions column, the RN did not identify the following: measurement of the gastric residual content, to irrigate the PEG (percutaneous enteral gastric tube) every time when the feeding is finish and after the drug administration, to integrate and complete the enteral feeding protocol, to measure intake and output every 8 hours. This problem was not updated daily as the P&P's for documentation establish.

Based on record reviewed (R.R.) performed with the Nursing Coordinator (employee # 5) of the Medicine Intermediate Unit, it was determined that the nursing staff failed to administer the medications according to the physician's orders and patient's needs for 1 out of 77 records reviewed, (RR #40).

Findings include:

1. RR #40 was performed on 03/14/14 at 3:30 pm. The patient was admitted to the Medicine Intermediate Unit on 03/10/14 with a diagnosis of Congestive Heart Failure (CHF), Coronary Artery Disease (CAD) and Diabetes Mellitus (DM). The patient was having high levels of glucose and the physician ordered an Insulin Dose Scale that guides the nursing staff for the Administration of Regular Insulin (RI). The administration of the RI was not found for the following days:

a. On 03/10/14 at 4:06 pm patient with a glucose level of 246 mg/dl that required 8 units of RI,

b. On 03/12/14 at 11:04 am 252 mg/dl, at 4:07 pm with 217mg/dl and 9:02 pm with 188 mg/dl that required 10 units, 8 units and 4 units of RI, respectively.

2. Employee # 5 had to access the PIXYS program to determine if the Regular Insulin was administered to the patient. This action does not assure safety measures during the administration of medications, (cross reference TAG A 491).

Based on medical records reviews (R.R.) from 03/11/14 thru 03/14/14 with the Nursing Supervisor (employee #3) and the Nursing Coordinator (employee #4) of the Medicine Unit, it was determined that the facility failed to ensure that the nursing staff comply with policies and procedures (P&P's) established for verbal orders and orders made by telephone for 2 out of 77 records reviewed (RR # 40 & #74).

Findings include:

1. RR #40 was performed on 03/14/14 at 3:30 pm. The patient was admitted to the Medicine Intermediate Unit on 03/10/14 with diagnoses of Congestive Heart Failure (CHF), Coronary Artery Disease (CAD) and Diabetes Mellitus (DM). It was found on the admission order an administration of Plavix 75 mg 1 tab by mouth daily. The medication administration record (MAR) was reviewed and the RN wrote the following: "the physician ordered to hold the medication until (patient) is evaluated by the surgeon". However, it was not found in the record a verbal or telephone order written by the RN with the read back method or the physician's order.
2. RR #74 was performed on 03/12/14 at 1:40 p.m. The patient was admitted on 02/25/14 with diagnoses of Dysphagia and Odinophagia. The secondary diagnoses are: Anorexia, Chronic Obstructive Pulmonary Disease COPD, Transient Ischemic Attack (TIA), Malnutrition, and High Blood Pressure.

A physician ' s order on 02/26/14 at 1:35 pm was found that read: "Chest CT Scan w/o without contrast " . The RN who took the verbal order did not use the read back method.

The policies and procedures (P&P's) for Verbal orders establish on step 2, as follows: "The nurse has to write "telefónica"(telephone order) and has to write what the physician is saying and should read back the physician's order. A second nurse has to sign the telephone order". However, the RN did not comply with this P&P's.

On 02/26/14 at 8:30 pm, the physician ordered by telephone the following:
1. FFN Xopenex 1.25 mg/Atrovent 2.5 stat, then every 4 hours,
2. ABG-stat,
3. CXR (Chest X-rays) stat portable,
4. Solumedrol 80 mg IV stat".
It was found that the Atrovent dose was incomplete and this order was not signed and dated by the physician. According to the P&P's of Verbal orders and orders made by telephone do not establish a time frame for the signature of the physician, (cross reference TAG A 454).

Based on the observational tour of the medical records department through the central file area with the medical record administrator (employee #27), it was determined that the facility failed to properly secure the central file of the medical record department, it is completely full to capacity and incomplete clinical records within 30 days following discharge.

Findings include:

1. The central file of active records was visited on 3/12/14 from 11:00 am till 11:55 am and was found completely full to capacity. The physical area does not have extra space available for new records to be filed. The facility maintains active and closed records in the same area.

During the observational tour it was observed two cabinets with five shelves on the right side of the main entrance. The shelves were observed with approximately one hundred or over medical records. The records located on the last shelve were touching the ceiling. One of the cabinets was observed with a screw to the wall and the other cabinet was not screw to the wall which with a movement could expose the employees to accident.

2. Approximately a total of one hundred (100) records ware observed directly on the floor near the cabinets and the secretary ' s ' desk. The medical record administrator stated that the records were maintained on this area to be complete by the Urology Clinic physician.

3. During the observational tour of the medical record area located on the first floor and the basement with the Medical Record Administrator (employee #27) on 3/12/14 at 11:20 am, it was found that this area has many boxes directly on the floor which contain medical records, the entire area was dusty (on shelves, boxes and floor) and other medical records were observed over the top of the last shelves and the records were touching the ceiling not permitting visibility of the '' sprinkle head and the smoke detector.''

4. The medical record administrator (employee #27) was interview on 3/12/14 at 11:30 am related to the great amount of medical records and she stated: '' Two years ago the facility contracted a Print company that eliminated records. As of today I calculated approximately fifty hundred records to inactivated and shred. Active and closed records are mixed and maintain in the medical record department however at system level all records can be identified by terminal digits".

5. The facility has two trailers located at the exterior of the hospital to archive closed records but the trailers lacks of the shelves to put and organized the medical records. Additional the facility has two additional trailers on hospital periphery with emergency room clinical records. The facility has other section of medical records located on a first level ''basement'' the records are of Emergency Room Department years from 2012, 2013 and 2014.

6. The facility did not have a destruction method approved by EPA to destroy the inactive records when they reach the established time as required.

7. The medical record department lacks of '' Emergency lights'' on the first floor.

8. The incomplete medical record report reviewed on 3/13/14 at 5:00 pm revealed that there are 1,049 incomplete records over 30 days by the physician and 2,428 incomplete records over 30 days by the nursing staff and other disciplines. There is an average of 584 monthly discharges.

9. The facility failed to ensure the proper storage and placement of medical records in the medical record department, in the two storage trailers and on the two floors, related to boxes with records directly on the floor, records on top of the last shelves and the records touching the ceiling not permit visibility at the '' sprinkles and the smoke detectors, records exposed to dust and records exposed to possible water damage.

Based on closed and active clinical records reviewed (R.R), it was determined that the facility failed to ensure that the patient medical records contain complete information and documentation regarding evaluations, interventions, care provided, services, care plans, discharge plans and the patient's response to those activities for 17 out of 77 records reviewed (R.R #1, #2, #3, #4, #5, #7, #10, #11, #13, #14, #16, #17, #18, #20, #21, #22 and #23).

Findings include:

Seventeen (17) out of seventy-seven clinical records reviewed (R.R #1, #2, #3, #4, #5, #7,
#10, #11, #13, #14, #16, #17, #18, #20, #21, #22 and #23) reviewed during the survey performed from 3/11/14 from 3/14/14 did not contain complete information and documentation related to consults, physician history and physical examination, nurse history, nurses notes, post anesthesia follow up, physician's orders, physician's progress notes, nurse medication kardex, radiology reports, vital signs, discharge planning initial evaluation and other information and documents in the patient medical record that are not accessible.

Based on closed and active clinical records reviewed (R.R), it was determined that the facility failed to ensure that medical staff, nursing personal or other entries in the medical record that maintain legible entries for 23 out of 77 records reviewed (R.R #1, #2, #3, #5, #7, #9, #10, #12, #13, #14, #15, #16, #17, #18, #20, #21, #23, #24, #25, #26, #29, #31 and #32).

Findings include:

Twenty three out of seventy-seven clinical records reviewed (R.R #1, #2, #3, #5, #7, #9, #10, #12, #13, #14, #15, #16, #17, #18, #20, #21, #23, #24, #25, #26, #29, #31 and #32) reviewed during the survey performed from 3/11/14 from 3/14/14 contained portions that are not legible. Most notable were the diagnosis, consults, operative reports, informed consent forms, anesthesia reports, physician's orders, signatures (physicians) and nursing personal, physician's progress notes and other entries in the medical record that are not legible.

Based on the review of policies and procedures (P &Ps), it was determined that the facility failed to ensure that telephone orders are countersigned by the physician within the first twenty-four hours after the order is issued according to State Law Rules and Regulations Number 117 of December 1 of 2004.


Findings include:


During P&P's review performed on 03/13/14 at 3:00 pm, it was found that the physician's order by telephone does not establish time frame for the signature of the physician. The State Law Rules and Regulations Number 117 of December 1 of 2004, Chapter 12, Article 6, Section 6, step 2a, establish the following: " The verbal orders and the orders made by telephone should be written with date, hour and physician's signature, the one who dictated the order, during the 24 hours that the order was issue " .

Based on medical records reviewed (R.R.) with the operating room supervisor (employee #21) and medical record director (employee #27), it was determined that the facility failed to ensure that medical history and physical examination (H&P) is documented by a physician for each patient no more than 30 days before the admission, or 24 hours after admission or registration prior to surgery or a procedure requiring anesthesia services for 5 out of 77 medical record (R.R #1, #3,#14, #47 and #48).

Findings include:

1. R.R #47 is a 68 years old male admitted to the facility on 3/11/14 with a diagnosis of Right Knee Total Joint Replacement. During the record review performed on 3/12/14 at 2:25 pm it was found that the patient entered to the operating room on 3/11/14 to perform a Right Knee Total Joint Replacement and requiring anesthesia services.

However the H&P was performed by the patient's physician on 1/30/14, forty (40) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

2. R.R #48 is a 76 years old male admitted to the facility on 3/11/14 with a diagnosis of Right Knee Total Joint Replacement. During the record review performed on 3/12/14 at 2:50 pm, it was found that the patient entered to the operating room on 3/11/14 to perform a Right Knee Total Joint Replacement and requiring anesthesia services.
However the H&P was performed by the patient's physician on 1/30/14, forty (40) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.


17959

3. R.R #1 is a 67 years old male admitted to the facility on 1/27/14 with a diagnosis of Cataract Left Eye. During the record review performed on 3/13/14 at 2:25 pm it was found that the patient entered to the operating room on 1/27/14 to perform a Cataract Surgery with Intraocular Lens Implant Left Eye and requiring anesthesia services. The H&P was performed by the patient's physician on 1/22/14 at 9:10 a.m., seven (7) days before the surgery, the record provide evidence that the physician performed the History & Physical Examination previous to the surgery. However no evidence was found of information related to Past Medical History, Family History and medications used by patient.

4. R.R #3 is a 70 years old female admitted to the facility on 11/18/13 with a diagnosis of Cataract Right Eye. During the record review performed on 3/13/14 at 2:30 pm it was found that the patient entered to the operating room on 11/18/13 to perform a Cataract Surgery with Intraocular Lens Implant Right Eye and requiring anesthesia services. The H&P was performed by the patient's physician on 11/05/13 at 10:00 a.m., thirteen (13) days before the surgery, the record provide evidence that the physician performed the History & Physical Examination previous to the surgery. However no evidence was found of information related to Past Medical History, Family History and medications used by patient.

5. R.R #14 is a 21 years old female admitted to the facility on 11/25/13 with a diagnosis of IUP Cesarean. During the record review performed on 3/13/14 at 2:35 p.m. it was found that the patient entered to the operating room on 11/25/13 to perform a Cesarean with Sterilization and requiring anesthesia services. The H&P was performed by the patient's physician on 11/21/13 at 8:00 a.m., four (4) days before the surgery, the record provide evidence that the physician performed the History & Physical Examination previous to the surgery. However no evidence was found that the physician updated H&P previous to the surgery for any change in patient condition.

Based on medical records reviewed (R.R.) with the operation room supervisor (employee #21), it was determined that the facility failed to ensure that the medical history and physical examination (H&P) is documented by a physician for each patient and updated prior to surgery or procedure requiring anesthesia services when the H&P was performed within 30 days before admission or registration for 6 out of 77 medical record R.R#41, #44, #45, #46, #47 and #48.

Findings include:

1. R.R #41 is a 70 years old male admitted to the facility on 3/3/14 with a diagnosis of Recurrent Right Inguinal Hernia. During the record review performed on 3/12/14 at 10:45 am it was found that the patient entered to the operating room on 3/3/14 to perform a Repair of Recurrent Right Inguinal Hernia and requiring anesthesia services however the H&P was performed by the patient's physician on 2/10/14, twenty (21) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

2. R.R #44 is an 89 years old male admitted to the facility on 3/10/14 with a diagnosis of Cataract Right eye. During the record review performed on 3/12/14 at 1:35 pm it was found that the patient entered to the operating room on 3/10/14 to perform a Cataract right eye and requiring anesthesia services however the H&P was performed by the patient's physician on 2/28/14, nine (9) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

3. R.R #45 is a 70 years old male admitted to the facility on 3/3/14 with a diagnosis of Chronic Cholecistitis. During the record review performed on 3/12/14 at 2:00 pm it was found that the patient entered to the operating room on 3/3/14 to perform a Exploratory Laparostomy Cholecystectomy and requiring anesthesia services however the H&P was performed by the patient's physician on 2/25/14, six (6) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

4. R.R #46 is an 81 years old male admitted to the facility on 3/10/14 with a diagnosis of Conjuntival Mass in Left eye. During the record review performed on 3/12/14 at 2:10 pm it was found that the patient entered to the operating room on 3/10/14 to perform a an Excision of Conjuntival Mass in left eye and requiring anesthesia services however the H&P was performed by the patient's physician on 2/24/14, fourteen (14) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

5. R.R #47 is a 68 years old male admitted to the facility on 3/11/14 with a diagnosis of Right Knee Total Joint Replacement. During the record review performed on 3/12/14 at 2:25 pm it was found that the patient entered to the operating room on 3/11/14 to perform a Right Knee Total Joint Replacement and requiring anesthesia services however the H&P was performed by the patient's physician on 1/30/14, forty (40) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

6. R.R #48 is a 76 years old male admitted to the facility on 3/11/14 with a diagnosis of Right Knee Total Joint Replacement. During the record review performed on 3/12/14 at 2:50 pm, it was found that the patient entered to the operating room on 3/11/14 to perform a Right Knee Total Joint Replacement and requiring anesthesia services however the H&P was performed by the patient's physician on 1/30/14, forty (40) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

Based on medical records reviewed (R.R), it was determined that the facility failed to ensure that 8 out of 77 records contain appropriate documents related to consult evaluations and appropriate findings by clinical and others staff involved in the care of the patient (R.R #1, #2, #3, #4, #7, #13, #16 and #23).

Findings include:

1. R.R #1, #2, #3, #4, #7, #13, #16 and #23 were reviewed on 3/13/14 at 1:30 pm through 4:00 p.m. and failed to provide evidence of documentation of a consultation requested for the patient.

Based on medical records reviewed (R.R), it was determined that the facility failed to ensure that 23 out of 77 seven records contain appropriate documents related to informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law, if applicable to require written patient consent (R.R's #1, #2, #3, #6, #7, #8, #9, #12, #15, #16, #14, #17, #20, #41, #42, #43, #44, #45, #46, #47, #48, #49 and #50).

Findings include:

The records was reviewed on 3/13/14 and 3/14/14 at 1:30 pm through 4:30 p.m. and failed to provide evidence of important documentation related to procedures and treatment and lacks of signature of patient, patient family, legal tutor or patient representative.


1. R.R #1 is a 68 year old male with diagnosis of Cataract of Left Eye. The consent form for procedures and treatments signed by the patient on 1/22/14 at 9:00 am lacks of the name of the anesthesiologist who administrated the anesthesia. The patient signed the consent form to accept transfusion however; it did not provide information related to the risks if the patient received transfusion during the surgery intervention. The anesthesia consent form provided evidence that the anesthesia department has two anesthesiologist specified on item #1 of the consent form. However the consent did not specified the designated anesthesiologist who administers the anesthesia during the surgical procedure.

2. R.R #2 is a 62 year old female with diagnosis of Post Menopause Complex Ovarian Cyst. The consent form for procedures and treatments signed by the patient on 11/06/13 lacks of the hour when the patient signed the consent. The consent form lacks of the name of the anesthesiologist who administrated the anesthesia. The patient signed the consent form to accept transfusion however; it did not provide information related to the risks if the patient received transfusion during the surgery intervention. The anesthesia consent form provided evidence that the anesthesia department has two anesthesiologist specified on item #1 of the consent form. However the consent did not specified the designated anesthesiologist who administers the anesthesia during the surgical procedure.

3. R.R #3 is a 70 year old female with diagnosis of Cataract Right Eye. The consent form for procedures and treatments signed by the patient on 11/05/13 at 10:00 am lacks of the name of the anesthesiologist who administrated the anesthesia. The patient signed the consent form to accepted transfusion however; it did not provide information related to the risks if the patient received transfusion during the surgery intervention.

4. R.R #6 is an 8 year old male with diagnosis of Acute Abdominal Pain Leucocytosis Dehydration. The consent form for treatments was signed by the patient mother; however the consent form lacks of the date and the hour and did not provide the name of the patient mother. The form lacks of the date and the hour when the facility ' s designated employee signed the consent.

5. R.R #7 is a 10 months old male with diagnosis of Fever. The consent form for treatments signed by the patient mother lacks of the date and the hour when the patient mother signed and did not provide the name of the patient mother on the first line of the form as required. The form lacks of the date and the hour when the facility ' s designated employee signed the consent. The form lacks of the official designated employee name and the hour when the employee signed the form.


6. R.R #9 is a 1 year and 5 months old male with diagnosis of Pneumonia and Respiratory Distress. The consent form for treatments was signed by the patient mother on 2/13/14. The form specified on the first line to write the name of the person who consent voluntary the patient treatment, in this case the patient is one year and five months old and his mother is the legal tutor, however the name of the mother is not written in the first line of the form, it had the baby's name not the mother name.

7. R.R #8 is a 10 months old male with diagnosis of Acute Bronchiolitis. The consent form for treatments was signed by the patient mother on 10/29/13. The form specified on the first line to write the name of the person who consent voluntary the patient treatment, in this case the patient is a minor and his mother is the legal tutor. However the name written on the first line of the form is the baby's name not the mother name. The line number three and number four lacks of patient mother authorization.

8. R.R #12 is a 21 year old female with diagnosis of intra uterine pregnancy (IUP) in Labor. The consent form for medical treatment lacks of patient name. The consent form was signed by the patient on 5/12/13, the form lacks of hour when the patient signed the consent (the form did not provide for hour). The form lacks the date when the witness signed the consent. The consent form for surgery intervention or medical procedures lacks of patient name and was signed by the patient on 5/13/13 at 11:17 am. The form lacks of the name of the anesthesiologist who administered the anesthesia. The form lacks the risk of the surgery procedure. The patient signed the consent form to accept transfusion however; it did not provide information related to the risks if the patient received transfusion during the surgery intervention. The radiographic consent form lacks of patient name, medical record number and the hour when the patient and the radiology personnel signed the consent.

9. R.R #14 is a 21 year old female admitted with diagnosis of Cesarean with Sterilization.
The consent form for surgery intervention or medical procedure was signed by the patient on 11/21/13. The form provides to write the name of the physician authorized by the patient to perform the surgery, however no evidence of the physician name. The consent form lacks the name of the anesthesiologist who administered the anesthesia. The consent form lacks of the risk of the surgery procedure. The patient signed the consent form to accept transfusion however; it did not provide information related to the risks if the patient received transfusion during the surgery intervention. The consent form for sterilization procedure signed per patient and witness, however lacks the date when the patient and witness signed, the form did not provide the hour when consent was signed.

10. R.R #15 is a 33 year old female admitted to sterilization procedure. The consent form for surgery intervention or medical procedures was signed by the patient on 1/22/14 at 2:15 p.m, the form lacks of the name of the anesthesiologist who administered the anesthesia. The consent form lacks the risk of the surgical procedure. The patient signed the consent form to accept transfusion however, did not provide information related to the risks if the patient received transfusion during the surgery intervention. The consent form for treatment lacks of patient name, the form did not provide to write the hour when the patient and the physician signed the consent.

11. R.R #16 is a 31 year old female with diagnosis of Abdominal Pain Appendicitis.
The consent form for surgery intervention or medical procedure was signed by the patient on 12/09/13 at 8:00 a.m. The form provides to write the name of the physician authorized by the patient to perform the surgery however, the physician name was not written clearly. The consent form lacks of the name of the anesthesiologist who administered the anesthesia.
The consent form lacks of the risk of the surgery procedure. The patient signed the consent form to accept transfusion however, did not provide information related to the risks if the patient received transfusion during the surgery intervention. The anesthesia consent authorization form lacks of the patient name, the date and the hour when the patient and the anesthesiologist signed the consent. The anesthesia consent form provide evidence that the anesthesia department has two anesthesiologist specified on item #1 of the consent form. However the consent did not specified the designated anesthesiologist who administers the anesthesia during the surgical procedure.

12. R.R #17 is a 60 year old male admitted with diagnosis of Hemorrhoids.
The consent form for surgery intervention was signed by the patient on 12/19/13 at 2:30 p.m., the form provide to write the name of the physician authorized by the patient to performed the surgery however, the form only provide the physicians' last name. The consent form lacks of the name of the anesthesiologist who administrated the anesthesia. The form lacks of the risk of the surgery procedure. The patient signed the consent form to accept transfusion however; it did not provide information related to the risks if the patient received transfusion during the surgery intervention.

13. R.R #20 is a 57 years old male admitted with diagnosis of Ureteriolitiasis Hydronephrosis. The consent form for surgery intervention or medical procedure was signed by the patient on 1/19/14, no evidence of the hour only provide the word p.m. The form provide to write the name of the physician authorized by the patient to perform the surgery, however the form only provided the physicians ' last name. The consent form lacks of the name of the anesthesiologist who administrated the anesthesia. The form lacks of the risk of the surgery procedure. The patient signed the consent form to accept transfusion however; it did not provide information related to the risks if the patient received transfusion during the surgery intervention.


20423

14. R.R. #41 is a 70 years old male admitted with diagnosis of Recurrent Right Inguinal Hernia. The consent form for surgery intervention or medical procedure was signed by the patient on 2/6/14. The consent form lacks of the name of the anesthesiologist who administrated the anesthesia. The form lacks the risks of the surgery procedure. The patient signed the consent form to accept transfusion however, did not provide information related to the risks if the patient received transfusion during the surgery intervention and lack of risk of the surgery.

15. R.R. #42 is a 63 years old female admitted with diagnosis of Soft Tissue Tumor Back. The consent form for surgery intervention or medical procedure was signed by the patient on 2/22/14. The consent form lacks the name of the anesthesiologist who administrated the anesthesia. The form lacks the risks of the surgery procedure. Lacks if patient accept transfusion and did not provide information related to the risks if the patient received or not received transfusion during the surgery intervention.

16. R.R. #45 is a 63 years old male admitted with diagnosis of Cholecystitis. The consent form for surgery intervention or medical procedure was signed by the patient on 2/20/14. The consent form lacks of the name of the anesthesiologist who administrated the anesthesia. The consent form lacks the risk of the surgery procedure. Lack if patient accept transfusion and did not provide information related to the risks if the patient received or not received transfusion during the surgery intervention.

17. R.R. #46 is an 82 years old male admitted with diagnosis of Left Eye Conjunctival Mass. The consent form for surgery intervention or medical procedure was signed by the patient on 2/24/14. The consent form lacks the name of the anesthesiologist who administered the anesthesia. It did not provide information related to the risks if the patient received transfusion during the surgery intervention.

18. R.R. #49 is a 29 years old female admitted with diagnosis of Cholelithiasis. The consent form for surgery intervention or medical procedure was signed by the patient on 3/11/14 the consent form lacks the name of the anesthesiologist who administered the anesthesia. The consent form lacks of the risk of the surgery procedure. Did not provide information related to the risks if the patient received transfusion during the surgery intervention.

19. R.R. #50 is a 63 years old female admitted with diagnosis of Soft Tissue Tumor Back. The consent form for surgery intervention or medical procedure was signed by the patient on 3/10/14. the consent form lacks the name of the anesthesiologist who administered the anesthesia. The consent form lacks the risks of the surgery procedure. Did not provide information related to the risks if the patient received or not received transfusion during the surgery intervention.

20. During the review of ten medical records on 3/12/14 from 11:00 am till 3:00 pm the anesthesia consent form did not provide evidence of the name of the physician that administered the anesthesia and the type of anesthesia that was provided to the patients.

a. One out of ten medical records was incomplete for the anesthesia consent due to the lack of type of anesthesia given to the patient (R.R. #47).

b. Ten out of ten medical records were incomplete for the anesthesia consent due to the lack the name of the anesthesiologist's that administered the anesthesia (R.R. #41, #42, #43, #44, #45, #46, #47, #48, #49 and #50).

Based on records reviewed (R.R) with the Management Information Director, it was determined that the facility failed to ensure that clinical records have documentation related to consult evaluations, history and physical examination, nursing history, nurse's notes, physician's progress notes, surgery or treatment consent, physician orders, treatment report, medication treatment record, radiology report, pathology report, vital signs, discharge summary report, discharge planning, final diagnosis and anesthesia follow up for 33 out of 77 records reviewed (R.R #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #59, #74 and #76).

Findings include:

1. During the review of fifty closed clinical records (R.R) on 3/12/14 through 3/14/14 from 9:00 am till 4:00 pm, the following was determined:

a. R.R #1, #2, #3, #4, #7, #13, #16 and #23 did not have the patient's consult evaluation.
b. R.R #1 the physician did not completed the physical examination in the first 48 hours of admission.
c. R.R. #3 the physician did not performed the physical examination in the first 48 hours of admission.
d. R.R. #1, #3 and #14 the physician did not complete the history in the seven days of admission.
e. R.R #16, #18, #20 and #21 the register nurse did not complete the nurse history.
f. R.R #17, #18 and #20 the register nurse did not complete the nurse's flow/treatment sheet.
g. R.R #5 did not have progress notes by the physician.
h. R.R #1, #2, #3, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #20, #26 and #29 did not have or completed the consent form for operating room or treatment consent.
i. R.R #5 the physician orders was incomplete lacks of hour, date or physician signature.
j. R.R #5 has incomplete treatment report by the physician.
k. R.R #3 and #4 did not have the medication kardex.
l. R.R #4 and #13 did not have radiology report.
m. R.R. #1, #3, #4 and #20 did not have the pathology report.
n. R.R. #4 did not have the vital signs on the graphic chard.
o. R.R. #2, #10, #12, #15 and #25 did not have pain assessment on the vital signs measures register form.
p. R.R #1, #4 and #13 did not have the physician discharge summary.
q. R.R. #1, #2, #3, #4, #7, #10, #11, #13, #16, #17, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and#31 did not have discharge planning intervention, not re-assessment or did not provide what kind of orientation provided at family caregiver.
r. R.R. #1, #2, #3, #13 and #18 did not have final diagnosis on 30 days of the discharge to home.
s. R.R. #12 and #13 did not have anesthesia follow up.


33356

2. During the RR performed from 03/11/14 thru 03/14/14, it was found that the nursing staff is not identifying all active and potential problems that patient have. The progress notes do not show all the interventions made by the nursing staff that help to resolve patient's problems. Also, the nursing staff do not show the patient's response according to the care provided. The policies and procedures (P&P's) for nursing documentation establish that the nursing staff has to write in "Focus Par" but the nursing staffs do not comply with these P&P's. These deficiencies were found in three (3) out of seventy seven (77) records, (RR # 76, #59 and #74).

a. RR #76 was performed on 03/13/14 at 10:40 am. The patient was admitted to the Medicine Unit on 02/16/14 with diagnose of Cancer. He was bedridden with a Foley catheter, a gastrostomy and enteral feeding. It was found that the physician ordered Intake and Output every 8 hours and chart. The Licensed Practical Nurse (LPN) writes the urinary output in quantity (how many times patient has urinated) instead of milliliters.

a.i. No documentation of urinary output was found on 02/23/14-11pm/ 7am shift, 02/25/14-7 am/ 3pm shift, 02/27/14-3pm/ 11pm shift, 02/28/14-3pm/11pm shift and 03/01/14-3pm/11pm shift.

a.ii. The LPN writes the vital signs on the graphic chart. As observed, the LPN staff continuously leaves blank spaces in the vital signs graphic chart and sometimes do not connect the points in the temperature graphic.

a.iii. The vital signs graphic chart allows to write vital signs for four days. In the graphic chart of week 02/26/14 thru 03/01/14, the LPN of the 3pm/11pm and 11pm/7am shifts did not write the vital signs. On the same day, the vital signs of 7am/3pm shift were not documented on the same graphic chart. The LPN of this shift documented the vital signs in another graphic chart form. No explanation was given to found double graphic chart forms of the same week in the medical record.

a.iv. The physician ordered on 02/22/14 at 2:50 pm Procrit 40,000 unit subcutaneous, once a week. On the medications record it was found that the medication was given on 02/24/14 at 5:00 pm. No written justification was found on the nurses notes of why this medication was not administer the same day as ordered.

a.v. It was found a physician's order from 03/05/14 at 12:15 pm, saying the following: "Omit transfer orders. Continue with previous treatment". The physician did not write a complete order with specific steps that the nursing staff has to follow and allows providing total care.

b. RR # 59 was performed on 03/14/14 at 1:30 pm. The patient was admitted on the Medicine Unit on 02/15/14 with diagnose of Left Leg Cellulitis, Urinary Tract Infection (UTI), Hypertension and Diabetes Mellitus.

b.i. The Reconciliation of Medications Form was not signed by the physician and lack of date and hour when it was signed. Usually, this form is filled during the admission process or monthly.

b.ii. The educational plan for patients with pain management was filled and signed by the RN and the patient's caregiver. This form has a yellow copy but this was not given to the caregiver. This educational plan establishes a combination of respiratory exercises and relaxation techniques to manage pain.

b.iii. The Wound and Ulcer Care Program physician ordered on 03/06/14 to provide wound care daily with Hydrogel and elevation of leg. The same physicians ordered on 03/08/14 at 11:00 am provide wound care with normal saline and apply Calcium Alginate plus Hydrogel with Vaseline gauze to leg wound. However, no nursing notes, including the nursing staff of the wound care program, were found describing the wound and the interventions made since these orders were placed on the record. There is no documentation of patient's response to the treatment.

b.iv. The RN who made the admission process did not write observations in the Gastrointestinal and Reproductive Systems of the Initial Assessment. Blank spaces were left in the form.

b. v. Patient went to surgery for an ulcer debridement on 03/07/14 at 8:00 am. The RN who made the transfer to OR (operating room) did not write on the progress notes how was the patient before leaving her unit. The RN did not write the cognitive status of the patient, the respiratory status, vital signs, who accompanied the patient during transfer to OR and other important observations. At 2:00 pm, the patient returned from OR and the RN in charged wrote: "Patient came from OR". No description of how the patient arrived to her unit was written nor description of the cognitive, respiratory status. It was not found a description of the condition of the bandage that the surgeon placed over the ulcer. The nursing staff of shifts 3pm/11pm and 11 pm/7am did not include in their progress notes observations and interventions according to patient's active problems. As observed, it was difficult to determine how the care was provided and how was the patient's response due to lack of information.

c. RR #74 was performed on 03/12/14 at 1:40 p.m. The patient was admitted on 02/25/14 with diagnoses of Dysphagia and Odinophagia. The secondary diagnoses are: Anorexia, Chronic Obstructive Pulmonary Disease (COPD), Transient Ischemic Attack (TIA), Malnutrition, High Blood Pressure, had prostate surgery, has left side hearing loss and progressive eye lid dropping.

c.i. The Reconciliation of Medications Form was signed and dated on 03/12/14 but does not have the initials of the professional. In this form the physician and the RN write information of the medications that the patient is taking.

c.ii. The physician placed an order on 02/25/14 at 11:20 am: "Vital signs every 4 hours, intake and output every 8 hours". However, no evidence was found of vital signs written on the graphic chart on 02/25/14 at 8:00 pm, 02/26/14 at 4:00 am, 12:00 noon, 8:00 pm, 02/27/14 at 4:00 am. Also, no evidence was found of intake documentation on 02/25/14-3pm/11pm shift. No evidence of urinary output was written on 02/25/14 11pm/ 7am shift, 02/26/14 at 12 midnight, 8:00 am and 4:00 pm. The LPN staff instead of writing the urinary output in milliliters, they write using Roman numbers the many times that patient urinated. Example: 02/25/14 urinary output II. This kind of documentation does not allow that the physician and other professionals, like the Nutritionist, can determine if the intake and output are adequate.

c.iii. The RN, who performed the admission, activated with date and initials the Wound Care Protocol but in the Initial Assessment he did not identified skin disorders.

c.iv. The RN who performed the Risk Falls Assessment during the admission process he has to make a circle over the risk item, but he made circles over two risk items and was difficult to determine the exact risk item he wanted to apply. He did not add the risk items to obtain a total number and place the patient in a risk fall scale.

c.v. On the Initial Assessment, the nursing staff has to write the patient's problems, establish goals and a plan of care. This patient main problem was difficulty swallowing food that affected his nutritional status. However, it was difficult to understand what the RN establishes as goals (illegible handwriting). As part of his planning he wrote: "to administer medications". This statement is not the main intervention to work with the nutritional problem. On the section named mouth, nose throat the RN did not identified swallowing difficulty, which is one of the active problems that the patient has.

c.vi. On the Transfer Patient Form, it was found that patient was transferred to the Intensive Care Unit on 02/27/14 because he does not have improvement in his respiratory system and he was connected to a respiratory ventilator. The RN who made the transfer wrote in the transfer form that patient does not have symptoms when he was with fatigue. Also, wrote in the genitourinary status that patient does not have symptoms when he has a Foley catheter. The RN in the Intensive Care Unit which receives the patient wrote on the Transfer form that the patient does not has symptoms on the cardio respiratory status when he shows fatigue and is in a respiratory ventilator. This RN did not write the parameters of the respiratory ventilator.

Based on records reviewed (R.R), it was determined that the facility failed to ensure that 3 out of 77 records contain appropriate documents related to discharge summary with outcome of hospitalization, disposition of case and provisions for follow up care (R.R's #1, #4 and #13).

Findings include:

1. R.R #1, #4 and #13 was reviewed on 3/13/14 at 1:30 pm through 4:00 p.m. and failed to provide evidence of discharge summary.

Based on records review (R.R), it was determined that the facility failed to ensure that 5 out of 77 records contain appropriate documents related to final diagnosis (R.R's #1, #2, #3, #13 and #18).

Findings include:

1. R.R #1, #2, #3, #13 and #18 was reviewed on 3/13/14 at 1:30 pm through 4:00 p.m. and failed to provide evidence of final diagnosis with completion of medical records within 30 days following discharge.

Based on the review of pharmacy reports of inspections of the controlled drug areas with the Pharmacy Director (employee #10) and interview, it was determined that the facility failed to comply with policies and procedures which govern pharmaceutical services, related with
lack of evidence of an approved by the pharmacy and therapeutics committee and the hospital governing body and medical faculty medication formulary, failed to maintain strict adherence to safe injection practices during medication management and administration, failed to ensure that medications are stored in a locked mobile medication cart and failed to comply with Chapter <797>; Pharmaceutical Compounding - Sterile Preparations requirements accepted professional principles and national standards.

Findings include:

1. During the review of pharmaceutical services administrative duties and responsibilities with the Pharmacy Director (employee #10) on 13/3/14 from 9:00 am through 1:41 pm the following was found:

a. Pediatric, Medicine, OB-Gyn and Medicine ward had available prescription formulary to specify particular medications that are approved to be prescribed at the facility.
However the document does not include information of the date when was prepared and approved by the pharmacy and therapeutics committee and the hospital governing body and medical faculty.

b. At the surgery ward it was observed one 100 milliliters .9 saline solution bag at the top of the medication cart. Bags of intravenous solutions are used as a common source of supply for more than one patient .Nursing personnel (employee #30 ) stated that this saline solution are used to dilute intravenous medication. Facility failed to maintain strict adherence to safe injection practices during medication management and administration.

c. At the surgery and medicine ward it was observed the medication cart unlocked unattended on hallway while the nurse administer medication on patient rooms. Pharmacy Director (employee #) stated that pediatric, medicine and OB-Gyn medication carts locked does not function properly. Facility failed to ensure that medications are stored in a locked mobile medication cart.

d. Hospital pharmacy sterile IV compounding room must be certified each 6 months according to UNITED STATES PHARMACOPOEIA, INC. U.S. PHARMACOPOEIA 27. Chapter <797>; Pharmaceutical Compounding - Sterile Preparations. The last sterile IV compounding room certification date was June 11, 2013. Facility failed to comply with Chapter <797>; Pharmaceutical Compounding - Sterile Preparations requirements accepted professional principles and national standards.


33356

2. During the review of the narcotics registry performed on 03/11/14 at 11:30 am with the Nursing Supervisor (employee #3) of the Medicine Unit it was determined that the nursing staff do not follow the instructions that the Pharmacy Services has establish for the narcotics registry.

a. The instructions from the Pharmacy Services establish that for each new box of medications (example Percocet 325 mg) or new bottles of medications (example Luminal 65 mg/ml) there is a controlled drug medication record. However, the nursing staff continues documenting a controlled drug administration record if the medication has finished.

a.i. The remaining dose of Luminal 65 mg/ml documented on the registry of controlled drugs that the nursing staff fills in each shift says that there are available 25 doses. On the controlled drug administration record says that there are 22 doses available. There are missing 3 doses of Luminal.

a.ii. The Pharmacist was interviewed the same day at 1:00 p.m. and she showed that the remaining doses were wasted dosages that she picked up at the end of the month of February. The nursing staff began using a new bottle of Luminal 65mg/ml and continues documenting the administered doses in the same controlled drug record sheet, the one that was finished in February, instead of starting the documentation in a new controlled drug form.

b. There is no evidence of a plan of correction from the Pharmacist and the Nursing Supervisor to avoid this bad practice of documentation from the nursing staff.

During interview with the Nursing Coordinator (employee # 5) of the Medicine Intermediate Unit, performed on 03/14/14 at 2:00pm it was determined that the pilot program for the PIXYS system does not provide safety measures during the administration of the medications.

3. The PIXYS pilot program develop in this unit consist of the following steps:

a. After the physician writes the order, the RN sends it by fax to the Pharmacy services. Each nurse has her own password to enter the system.

a.i. The Pharmacist enters the order on the PIXYS. Then, the assistant pharmacist goes with the medications to the unit. This procedure occurs Monday ' s thru Friday ' s. During the weekends, holidays and during week nights the nursing staff has to transcribe the order in blank spaces of the medication administration record (MAR). If they do not have the desire medication they have to call the General Supervisor to look for it. Next working day, the Pharmacist enters the medication on the PIXYS.

a.ii. Every working day, in the morning, the Pharmacist send to the Intermediate Unit a printed MAR with the active medications that each patient receives. During review of the printed MAR of patient # 40, it was found that each medication has three columns with dates of the week and below hours of administration: example: Lasix 40 mg IV every 12 hrs. 03/11/14 03/12/14 03/13/14
2100 900, 2100 900, 2100

a.iii. The RN has to sign over each hour of administration according to the medication that was administered. During the review of the MAR of patient #40 it was found that the RN has two MARS with the same dates, hours and medications but not all hours of the administration of the medications were signed by the RN.

a.iv. According to interview performed with employee #5 03/14/14 at 2:20 pm, she stated: " I don't like this system. It's very confused. Each working day morning, we receive a printed form of the MAR and the nursing staff gets confused because they sign in both printed forms or when I review the documentation I find some medications without the nursing initials, the one who administered the medication. Then, I have to go to the PIXYS to verify if the medication was given. Right now, I have three admitted patients and on the screen of the PIXYS you can not see information of the medications ordered by the physician. The screen turns black. I have to do an override function to enter to the medications list and I have to select the medication that was ordered by the physician, assuring that I'm selecting the correct dose. When I'm not here, the RN in charge of the medications has to do the same steps. Another thing is, the MAR does not include the Insulin dose administration scale when is ordered by the physician. The RN has to write this scale in blank spaces of the MAR and in every administration of Insulin the RN has to write his/her initials. They have to write this scale in the two printed MAR forms to assure that the information is included. If a form is misplaced they have the other form to continue the documentation".

b. The actual operating system of the PIXYS is not secure because the software of the program is not allowing that the RN to access the ordered medications that each patient has.

b.i. The RN can confuse medications or doses of the medication if they enter with the override mode to select the patient's medications. This can cause errors in the administration of medications.

b.ii. Having two or three printed MARS can cause double documentation of the administration of the medications, misplaced of one of the printed forms or omission of the medication.

Based on observation tour and review of operation room (OR) suite anesthetist cart in seven operation room suite with the operation room supervisor (employee # 21), it was determined that the facility failed to ensure that all drugs and biological in the operation room anesthetist cart are kept secure and locked when the operation room suite was in operation on 6 out of 7 anesthetist cart. (OR Anesthetist Cart on Suite #1, #2, #3, #4, #5 and #6)

Findings included:

During the observation tour in the operation rooms suites performed on 3/11/14 from 9:50 am till 12:00 pm with the OR supervisor (employee #21) the following was found:

1. On 3/11/14 at 9:50 am the anesthetist cart in suite #1 it was found unlocked and unattended by the anesthetist nurse.

2. On 3/11/14 at 10:00 am the anesthetist cart in suite #2 was found unlocked and unattended by the anesthetist nurse.

3. On 3/11/14 at 10:20 am and 10:50 am the anesthetist cart in suite #3 was found unlocked and unattended by the anesthetist nurse. The anesthetist cart has the following drugs:

a. 2 vials of Anectine 200 milligrams (mg) g/ 10 milliliters (ml)
b. 1 Ampule of Physostigmine Sallcylate Injectable 1 mg/ml
c. 2 Ampule of 1 ml of Ephidrine Sulfate Injectable 50 mg/ml
d. 1 Syringe opened of Atropine sulfate 1 mg.
e. 1 vial of 1 ml of Phenylephrine HCL Injectable 10 mg/ ml
f. 1 vial of Naloxone 0.4 mg/ml.
g. 3 vials of Lidocaine HCL 2%.
h. 1 vial of Neostigmine Methylsulfate 1:1000 1 mg/ml.
i. 1 vial of 10 ml of Neostigmine Methylsulfate 1:2000 5 mg/10 ml
j. 1 vial of 5 ml of Flumazenil Injectable 0.5 mg/5 ml.
k. 1 vial of 20 ml of Diprivan (propofol) 1%) 10 mg/ml.
l. 2 vial of 5 ml of Ahacurium 50 mg/5 ml.
m. 3 vials of Rocoironium Bromide Injectable 100 mg/10 ml.

4. On 3/11/14 at 10:20 am and 10:50 am the anesthetist cart in suite #4 it was found unlocked and unattended by the anesthetist nurse.

5. On 3/11/14 at 11:15 am and 11:25 am the anesthetist cart in suite #5 was found unlocked and unattended by the anesthetist nurse. The suite #5 was not used this day. The anesthetist cart has the following drugs:

a. 1 vials of Oxytocin Injection 10 unit /ml
b. 5 vials of Lidocaine HCL 2% 20 mg/ml.
c. 1 vial of 10 ml of vial of Neostigmine Methylsulfate Inj 1:1000 1 mg/ml.
d. 1 vial of Glycopyrrolate Inj 0.4 mg/2 ml.
e. 1 vials 10 ml of Succinylchloline Chloride Inj 200 mg.
f. 4 vial de 10 ml of sterile water.
g. 1 vials of Rocoironium Bromide Injectable 100 mg/10 ml.
h. 1 vial of 20 ml of Diprivan (propofol) Inj 1% 10 mg/ml.
i. 2 Ampule of 1 ml of Ephidrine Sulfate Injectable 50 mg/ml.
j. 1 Syringe of 10 ml opened of Atropine sulfate 1 mg.

6. On 3/12/14 at 10:00 am the anesthetist cart in suite #6 it was found locked with the key and unattended by the anesthetist nurse.

Based on round observation, review of policies and procedures (P&Ps) and interviews to the Director of Nursing (DON-employee #1) the Nursing Supervisor (employee #3) and the Pharmacist (employee #10), it was determined that the facility failed to ensure safety locked system where there are medications, biological and narcotics medication boxes.

Findings include:

1. As observed during the morning round at Medicine Unit on 03/11/14 thru 03/14/14, at different hours (9:00 am, 11:00 am, 12:00 pm and 1:00 pm), the Registered Nurse (RN) in charge of the administration of medications, takes out the medication cart from a room that is not near the Nursing Station. They have two (2) medications carts where both are bigger and they do not have space on the medications room that is in the Nursing Station. The room where they place the medication carts is not locked. The door remains open all the time. It was observed that there is a continuously coming in and going out of physicians, nursing staff and housekeeping personnel. The facility failed to assure that the door of this room has a safety lock system.

2. The medication room is inside the Nursing Station. In this room they have the PIXYS medication carts and refrigerators. Also, they have the narcotics medication box. However, the door does not have a safety lock system, allowing unauthorized people to enter to the medication room.

a. The policies and procedures (P&P's) for Administration of Medications says that the medications box will be locked and the RN has to carry the keys of the medication room and narcotic medication box. As observed, nursing staff do not comply with this P&P's.

3. According to interview to employee #1 performed on 03/12/14 at 9:30 am, she stated: "we do not have enough space for the medications carts. Once, I presented a proposal to the Engineer and to the Executive Director of expanding the medication room. It was a good idea but the facility cannot do that job now."

4. As observed during morning round performed on 03/12/14 at 10:30 am at the Medicine Unit, the medications carts placed in the room without a locked system, it was found piggy bags with medications that were not administer to patients.

a. During interview with employee #3 performed on 03/12/14 at 10:45 am, he stated: "if the RN left medications on the medication cart drawer is because the patient was not in the room because of a study that was ordered (by the physician)".

b. According to interview performed on 03/13/14 at 11:00 am to employee #10, if a medication was not administer no matter the reason, the RN has to put back the medication on the Pixy ' s medication cart. The system allows that the RN can return the medication and to justify why it was not administered. However, the nursing staff is not returning the medications to the PIXYS system.

c. The P&P's for Security Measurements for the Administration of Medications says on step #6: "Serve the medications at the moment of administering them, do not keep prepared medications without the authorization of the Pharmacy". However the nursing staffs failed to comply with this P&P's.

Based on observation tour on the operation Rooms (OR) suites with the OR supervisor (employee #21) it was determined that the facility failed to ensure that Outdated, mislabeled, or unusable drugs and biological are not available for patient use on the anesthetist cart and in the crash cart on 1 out of 7 anesthetist cart and 2 out of 3 emergency crash cart (Anesthetist cart in OR suite # 1 and Emergency crash cart of recovery room and emergency crash cart #3).

Finding included:

During the observation tours in the operation room suites on 3/11/14 from 9:15 am till 12:00 pm with the operation room supervisor (employee #21) the following was found:

1. On 3/11/14 at 9:50 am it was found in the crash cart placed in the recovery room it was found 2 Infant Sodium Bicarbonate at 4.2% 5 mEq (miliequivalent) 0.5 mEq/ml with an expiration date 3/1/14 available to patient use. Evidence was found in the crash cart nurse registration review that this medication expired on 12/14 and evidence was found that pharmacy personnel review the crash cart on 3/7/14.

2. In the anesthetist cart placed on the operation room #1 it was founded opened unattended and with one vial of 10 ml of Esmololol Hydrochloride 100 mg/ 10 ml labeled that was opened on 3/11/14 at 8:00 am and the vial expiration date was 2/14. This medication was expired and available for patient use.

3. On 3/11/14 at 11:00 am it was found in the crash cart #3 placed near the operation room suite 6, two (2) Infant Sodium Bicarbonate at 4.2% 5 mEq (miliequivalent) 0.5 mEq/ml with an expiration date 3/1/14, 4 vial of Vasopressin 20 unit /ml with an expiration date on 2/14 available for patient use. Evidence was found in the crash cart nurse registration review that this medication expired on 12/14 and evidence was found that pharmacy personnel review the crash cart on 3/7/14.

Based on the observational tour and review of policies/procedures, it was determined that the facility failed to ensure that the X-ray department is free from hazards for patients and personnel as evidenced by sharp containers directly on the floor without security base, emergency decontamination kit with trash inside and inoperative nurses call on the patients bathrooms.

Findings include:

1. A five gallon sizes sharp containers was observed on 3/11/14 at 9:00 am without security base during the observational tour of the X-Ray department in the CT room with biohazardous materials. Security bases are needed to protect the sharp containers from unauthorized removal and prevent the containers from tipping over.

2. Two sharp containers (three and five gallon sizes) were observed on 3/11/14 at 9:00 am without labels with the assigned hospital's identification number and the facility's name to ensure responsibility related to its contents, protection and disposition and date it was place in the security bases during the observational tour of the X-Ray department in the CT room and nuclear medicine room with biohazardous materials

3. Two crash carts were check at the radiology department with the radiology director employee # 10 on 3/11/14 at 11:25 am, one located in the CT room and the other at Conventional radiology, both had medications expired;
a. Crash cart at CT room have the following medications expires.
Two vials of Metropolol 5mg/ml IV 03/01/14 and Two syringe of Sodium Bicarbonate 4.2% Infant 10 ml (0.5Meq/ml) 03/01/14
b. Crash cart at Conventional radiology
Two syringe of Sodium Bicarbonate 4.2% Infant 10 ml (0.5Meq/ml) 03/01/14, Three vials of Metropolol 5mg/ml IV 03/01/14, One 0.9nss 500ml IV 02/ 14, One 5% Dextrose 500 ml IV 01/14 and One Epinephrine 1:1000 1ml 1mg/ml SC
4. As observed at the Nuclear medicine bathroom on 3/11/14 at 9:30 am the emergency decontamination kit was found with the cover unsecure. When the surveyor opens the kits' lid, used hand tissue paper was inside the emergency decontamination kit.
5. Three bathrooms were observed on 3/11/14 at 1:55 pm with nurses ' call inoperative. Located at the Sonography, Conventional medicine and Radiology patient waiting area.

1. Based on direct observation, manufacturer's instructions, temperature records review, laboratory director, general supervisor and testing personnel interview on 03/20/2014 at 11:50 AM, it was determined that the laboratory failed to follow manufacturer's instructions when patient specimens were tested for routine chemistry and endocrinology tests by the Dimension system.

The findings include:

a. The Bio-Rad manufacturer ' s instructions establish that the control materials will be stable until the expiration date when stored unopened at -20 to -70 °C.

b. The records showed that the laboratory used the following Bio-Rad control materials

1. Multiqual levels 1 and level 3; since May 2, 2013.

2. Liquicheck Cardiac Markers; since November 7, 2012.

3. Liquichek Immunoassay; since May 31, 2012.

c. The laboratory's temperature records showed that the laboratory did not store those control materials at minus 20 degrees Celsius the following dates:

1. From January 1, 2012 to May 25, 2012.

2. From August 1, 2012 to August 20, 2012.

3. From September 17, 2012 to October 7, 2012.

4. From December 1, 2012 to December 7, 2012.

5. From January 17, 2013 to January 27, 2013.

6. From April 1, 2013 to April 22, 2013.

7. From May 1, 2013 to May 12, 2013.

8. From September 18, 2013 to October 5, 2013.

d. The 2003 annual test volume showed that the laboratory processed 328,000 tests in the chemistry area.

e. The laboratory director confirmed that the laboratory did not store the control materials at minus 20 degrees Celsius those dates.

2. Based on quality control records review, general supervisor and testing personnel interview on 03/20/2014 at 10:45 AM, it was determined that the laboratory failed to include one control material each 8 hours of operation when manual cell counts were performed.

The findings include:

a. The laboratory performed the manual cell counts by the hemocytometer method.

b. From 01/26/2013 to 02/26/2014, the testing records showed that the laboratory did not include one control material each 8 hours of operation when two patients ' specimens of spinal fluid were processed for manual cell counts on 11/07/2013 and 02/16/2014.

c. The laboratory general supervisor confirmed on 03/20/2014, that the laboratory did not include one control material each 8 hours of operation when those manual cell counts were performed.

3. Based on review of procedures manual, manual cell count testing records review, laboratory director, general supervisor and testing personnel interview on 03/20/2014 at 10:45 A.M. , it was determined that the laboratory did not assure the positive identification for the patient spinal fluid specimens.

The findings include:

a. From 01/26/2013 to 02/26/2014, the manual cell count testing records showed that the laboratory did not include the identification number of 18 spinal fluid patients ' specimens. The laboratory only utilized the patient ' s names and last name for the identification of those specimens.

b. The laboratory director confirmed on 03/20/2014, that the laboratory did not include the patient's identification number in these records.

Based on the observational tour of the facility's kitchen that prepares the patient's meals (contracted service), review of menus, policies/procedures and interview, it was determined that the facility failed to label food on dry storage room, did not promote safe procedures to defrost chicken and fish, precautions were not followed to diminish environmental and cross-contamination, failure to wash hands and change gloves after touching raw products and cooked items, walk in freezer floor in poor condition, dirty and broken paper towel dispenser, hand washing sink without hot water, no instructions that indicate the appropriate procedure for hand washing were posted at the side of each kitchen sink, no policy for the use of plastic sponges and cleaning cloths, inside kitchen a storage area were full of un used kitchen items, degreaser solvent and spray paint, pots, pans and trays were observed with a lot of grime, food scales were observed with rust on the base, personnel does not have knowledge of the correct procedure to perform the strip test to determine sanitizing solution levels on the three compartment sink, dry food storage was in bad condition, dry food storage and enteral feeding ceiling tiles was found with brown stains, lack of evidence of ice machine maintenance documentation and lack of safety procedures during the change of fluorescent light tubes.

Findings include:

1. The following was found during the observational tour of the kitchen contracted service with kitchen supervisor (employee #34) and administrative dietitian (employee #31) of the hospital on 3/14/14 from 8:30 am till 11:55 am:

a. Food items were stored without any date to indicate when it was received. Two packages with ten packages of three pounds of rice each one; and a box of evaporated milk cans was observed on the dry food storage without information of the date when the product was received. Facility failed to have in place a food storage system to identify which is the oldest item in order to use the oldest item first.
b. In the dry food storage area it was observed a five drawer metal file box with some documents inside. According with information given by the kitchen supervisor (employee #34) they were going to discard this file box soon. Facility failed to maintain dry food storage free of unnecessary furniture.

c. Dry food storage door is observed in bad condition. Facility failed to have kitchen environment in good condition.

d. Approximately 30 pounds of chicken legs with thighs in a plastic container and a box with 40 pounds of fish fillets were observed located on the counter at the side of the production area, where a two compartment sink were located. Located in the left side sink compartment area approximately 15 pounds of chicken wings inside a plastic container, were observed receiving running water. In the right side sink compartment area was observed approximately 10 pounds of fish fillets inside a plastic container, receiving running water. No kitchen staffs were observed in charge of defrost procedures, in order to be sure that water stays cold or changing the water every 30 minutes. The chicken legs with thighs located on the plastic container were observed dripping blood. Facility failed to ensure that safe procedures to defrost meat and fish are followed.

e. Hand washing sink located in front of tray line area does not had hot water A sign that include information of the procedure for hand washing were not available in the area. The paper towel dispenser located over the sink wall was observed broken. Paper towel roll were observed located on the upper side of the dispenser. Facility failed to have appropriate handwashing sink that has running water at 110oF or hotter, handsoap, and single-use towel dispenser. Facility failed to ensure that hand washing facilities are maintained in good condition.

f. A lot of rust was found on the refrigerator left wall and walk-in freezer floor. Facility failed to ensure that kitchen equipment was maintained in a good condition.

g. Some pots, pans and trays were observed with a lot of grime. This promote that food does not cook as evenly, and severely damaged cookware pose a health hazard.

h. According with information given by the facility administrative dietitian (employee #31) on
3/14/14 at 9:45 am, the facility has a process to sanitize wiping cloths after use. This process includes placing the wiping cloths in a bucket of water with sanitizer before use; wiping cloths must be maintained in the sanitizing water bucket before use. However a policy and procedure was not provided during survey.

i. Plastic sponge was observed used by kitchen personnel (employee #36) to scrub pots and pans in the washing sink. Policy and procedure that include information of the materials were sponges are for what tasks are used was not provided during survey. Facility failed to establish policies and procedures for the use of sponges in the kitchen.

j. Kitchen personnel (employee #32) took off a tray with cooked fish fillets from the oven. She put the tray at the side of the production area sink, without covering the food, and then proceeds to put a tray with raw fish fillets on the oven. While the cooked fish fillets was observed located at the side of the sink, another kitchen personnel (employee #35) is washing scoops at the sink, the water of the sink could easily splash on the cooked fish fillets. Facility failed to follow safe food handling practices.

k. In the production area approximately 20 pounds of raw seasoned chicken wings were observed on a stainless steel bowl. These chicken parts are located at the side of the stove for more than an hour, from 10:45 am through 11:55 am. Facility failed to maintain safe procedures during the management of raw poultry.

l. Kitchen personnel (employee #33) was observed managing cooked fish fillets, she had two pairs of gloves on the hands. When she finished with the fish fillets she took off one pair of gloves, remain with the other pair of gloves and begun to manage raw poultry. Facility failed to maintain safe procedures when switching from working with a raw food to cooked food.

m. Kitchen personnel (employee #32) had a pair of gloves while she was managing potatoes and vegetables at the production area. She took off the glove of the right hand, went to the three compartment sink area and takes a package of imitation crab seafood. Then she goes with the package of imitation crab seafood put in the refrigerator and returns to the production area. Once on the production area she put a glove on the right hand without hand washing and continues cooking potatoes. Facility failed to promote hand washing and gloves change when and while performing one task and change to another while preparing food.

n. Handyman was observed changing the fluorescent tubes of the ceiling lamp located at the left side of the area were kitchen personnel defrost food and cut vegetables. While he was changing the tubes one of the tubes felt to the floor near the area were personnel were preparing foods and right at the side of a tray full of bread pieces to be used on the lunch tray line assembly. Fluorescent tubes contain small amounts of mercury which are released as poisonous vapors if the tubes are broken. Facility failed to maintain safe environment in the kitchen when personnel were preparing food.

p. Two scales to measure food were observed with rust on the base. Facility failed to ensure that kitchen equipment was maintained in a good condition.

q. At the side of the housekeeping room area inside the kitchen a storage area were observed full of unused kitchen equipment and items, two gallons of degreaser solvent and spray paint bottles. Facility failed to ensure that kitchen environment is free of unnecessary items.

r. Kitchen personnel (employee #35) were observed washing hands on sink located at the side of the tray line area. She took a towel paper roll to dry hands and put the roll in the production area, near the place were cooked fish tray are located. Facility failed to ensure that personnel follow appropriate hand washing procedures.

s. Dry storage ceiling tiles were observed with brown stains. Facility failed to ensure that kitchen environment is maintained in a good condition.

t. A freezer was observed located at the side of the area were personnel cut vegetables and defrosts meat and other products. According with information given by the facility kitchen supervisor this freezer are malfunctioning and facility are going to discard the equipment. Facility failed to ensure that kitchen environment is free of unnecessary items.

u. Kitchen personnel (employee # 32) were asked about the procedure for the use of sanitizing solution on the three compartment sink. Personnel do not demonstrate the correct procedure to perform the strip test to determine sanitizing solution levels on the three compartment sink. Facility failed to ensure that personnel had knowledge of policies related with the three compartment sanitizing procedures and use.

v. Kitchen personnel (employee #33) took two stainless steel little trays directly from the second sink of three compartment sink area and then procedure to rinse the trays in a sink located on the production area, Facility failed to comply with three compartment sink sanitizing procedures were the three compartment procedure indicates that items must be rinsed with a sprayer or immersed in clear, hot water then assure that when the water becomes dirty or soapy, personnel change it.
w. Enteral feeding room ceiling tiles were observed with brown stains. Hand washing sink located in this room lack of instructions of the procedure for the correct procedure for handwashing. The paper towel dispenser was observed broken and dirty. Facility failed to ensure that hand washing facilities are maintained in good condition.

x. Kitchen had available one ice machine. According with information given by the facility kitchen supervisor (employee #34) machine filter must be change twice a month when environmental personnel clean the machine. However a registry that evidence the cleaning schedule and filter change was not provided during survey procedures.

Based on tests performed on equipment, observations and interviews made during the survey of the physical environment on 3/11/14 through 3/14/14 from 8:00 am till 4:00 pm with the facility's Engineer (employee #11), Physical Plant Manager (employee #12) and Safety Environment Manager (employee #28), the physical structure and care areas failed to allow the staff to provide care, in a safe manner ensuring the well being of patients receiving services related to the nurses calls system in the 7th floor rooms # 702,703,706,708,714 and 718. In the bathroom of room #708 the nurse ' s call box besides the toilet was attached to the wall with two rusty nails and the one located in the shower does not have the cover and the cables are exposed. A lot of mold in the bathroom accessories was observed; this condition repeats thru all the bathrooms on this floor and all the bathrooms on floors (3, 4, 5, and 6). On the 7th Floor there is a movies room " Sala de Pelicula " . The bathroom of the movie room does not have the nurses call system installed. Also the 7th floor has a Play room. The bathroom of the playroom does not have the nurses call system install either. At the entrance of room #717 there is an air conditioning duct without its grill cover. Room #720 it is use for storage. In there are 5 beds out of service waiting to be fixed by the biomedical. The access to the roof is thru the 7th floor. The hospital rent spaces on the roof to various communications contractors. During the walk thru of the roof it was observed the following: The door to access the roof opens to the inside of the building and the door latch it ' s not the correct one for an exit door. The roof looks much deteriorated; there are depressions on the roof slab in a lot of places. At this time this depression areas were filling with dirt and vegetation. Some walls presented spots of leaks from the roof. All the rooms ' doors in all the floors are wood doors. None of them has the label that indicated there fire retardant time. (Cross reference to tag A0701, A0709, A0724 and A0726). Also it was determined that the facility failed to meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101, cited tags are K0018, K0038, K0066, K0069, K0072, K0075,K0104, K0130 and K0141. All of the above findings make this condition "Not Met".

Based on tests performed to equipment, observations and interviews made during the survey of the physical environment with the facility's Engineer (employee #11), Physical Plant Manager (employee #12) and Safety Environment Manager (employee #28), it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well-being of patients receiving services related to all maintenance nurses call systems, personnel does not have a device to open bathroom door in the event that a patient needs assistance, no evidence was found of the facility's routine and preventive maintenance and testing activities are not incorporated into the hospital's Quality Assessment Performance Improvement program, the diesel tank is located in an area that makes it accessible to non-authorized persons, loose door latches in patients rooms, obstruction of an access corridor, overcrowding in the observation and hydration rooms in the emergency room

Findings include:

1. In rooms # 702,703,706,708,714 and 718 the nurses call system does not function. In the bathroom of room #708 the nurse's call box besides the toilet was attached to the wall with two rusty nails and the one located in the shower does not have the cover and the cables are exposed.

2. On the 7th Floor there is a movies room " Sala de Pelicula". The bathroom of the movie room does not have the nurses call system installed. Also the 7th floor has a Play room. The bathroom of the playroom does not have the nurses call system install either.

3. A lot of mold in the bathroom accessories was observed; this condition repeats thru all the bathrooms on this floor and all the bathrooms on floors (3, 4, 5, and 6).

4. At the entrance of room #717 there is an air conditioning duct without its grill cover.

5. Room #720 it is use for storage. In an interview with the head nurses (employee #29) performance on 03/12/2014 at 10:05 am she said there are 5 beds out of service waiting to be fixed by the biomedical. In the mid-time the room without one bed it is uses as semi private room.

6. On the 5th floor the room #502 the two (2) beds are out service and in room # 512 (1) bed is out of service too. They are broken and waiting for parts to be repair by the biomedical company.

7. The door latches in Rooms #504, 506, 507, 513 and the escort department door are loose.

8. No evidence was found on 3/14/14 at 4:30 pm of a record for the test and maintenance weekly and monthly of the negative pressure for the Isolation rooms in the emergency room area.

In the interview performed to the emergency nurse coordinator (employee #32) she stated they do not have a policy to assure the functioning and the operational quality of the negative pressure.

9. No evidence was found on 3/13/2014 at 9:15 am of routine and preventive maintenance and testing activities incorporated into the hospital's Quality Assessment Performance Improvement program.

10. Patient's bathrooms in the emergency room area can be locked from the inside and personnel do not have readily accessible keys or a device to open the door.

11. Patient ' s bathrooms in the emergency room the nursing call without pull cord.

12. The diesel tanks used to store and provide diesel to the essential electrical system (EES) was found out in the open and not separated or protected by a fence as observed on 3/12/14 at 8:30 am. The diesel tanks are located in an area that makes it accessible to non-authorized persons.

13. Two (2) Electricity Generators located between parking and entrance to the medical office do not have the appropriate sign posted. During the touring on 03/12/14 at 8:00am there are a lot of leafs, cigarettes butts around the diesel tanks. Cars parks near the 10,000 gals of diesel tank.

14. In the medical records room it was observed records cover the top of the last shelves and the records touching the ceiling not permitting visibility to the '' sprinkles and the smoke detector.''
15. The faucet of the lavatory in room # 507 does not work. On the escort department room, there are two (2) roof tiles missing.


33356

16. As observed during a tour in the Medicine Unit with the Nurse Supervisor employee # 3 and the Nurse Coordinator employee # 4 on 03/11/14 at 9:00 am, it was found that the facility failed to maintain a physical environment free of hazards.

17. On the 6th floor, there is a room where an ice machine is installed. Besides it, there was an open wastebasket which places risk of cross contamination.

a.i. The Ice machine does not have a sign with safety instructions for its use for patients, family members, visitors or personnel.

a.ii. Behind the Ice machine, the floor and walls tiles have an excessive dust.

18. On the dirty utilities room, it was observed medical equipment, such as: one air mattress, a grasp device for oxygen tank used during transport and one TV (television) control that were not identified if were soiled or recently clean and disinfected.

a. There was a big black plastic container without a sign with instructions for its use.

During interview performed on 03/11/14 at 9:15 am with the Nursing Supervisor employee # 3, he stated: "we use this container for recycling glass bottles and vials." According to the policies and procedures review, named as " Handling of Needles, Puncture Objects and Glass vials" ( Manejo de Agujas, Instrumentos Punzantes y Envases de Cristal), step 12 says: "All glass objects will be place in a resistant container, clearly sign and put aside".

19. The cart that is used for transporting soiled bed linens to the laundry room does not have a sign identifying its use.

20. On the Supply room, where they have pads, bed linens, gowns, diapers and other materials, it was found two (2) straw baskets: one with hygiene products and the other with gauzes, tape, scissors and band aids.

a. The use of baskets made of straw does not allow cleaning and disinfecting the surface of the baskets.

21. There were two (2) pairs of clean fabric drapes placed over a shelf. These fabric drapes come from the laundry room without a plastic wrapper, in risk of cross contamination.

a. All shelves are made of wood, which are not recommended because of high risk fire hazard.

22. On the IV room, the nursing staffs have different kind of intravenous solutions (IV). The recommended temperature by the manufacturers is 77 Fahrenheit (F) grades. The temperature that the thermometer shows is 68 F grades. On the wall, there is a temperature registry that has three temperature parameters: Medications: -36 F to 4 F, Freezer: -13 F to 14 F, Warmer: 37 F grades. This registry was develop by the Pharmacist but has not been updated.

23. All sharp containers placed in patients rooms, nursing medication room and the ones in the medication carts are not labeled with date, hour and initials of the registered nurse who placed them.

24. As observed, there are two (2) medication carts used by the nursing staff. Those carts were not clean. They showed heavy dust and black sticky spots related to dressing tape used for IV bandages.

25. Room number 606 remains closed because the nurse call is not functioning. Also, the emergency called placed beside the toilet is not functioning.

26. The two (2) beds placed in this room are not in use because one does not have a mattress and the other one; the mechanism that allows the ups and downs of the bed is broken. Two (2) weeks has passed and neither has been repair.

27. As observed, it was found in the bathroom emergency calls with the strings to short. They are not having the six (6) inches distance from the floor: Rooms 603, 605, 619, 620.621, 622, 623.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Engineers (employee #11) , physical environment supervisor (employee #12) and the security officer (employee #28), it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed from 3/11/14 through 3/14/14 from 8:00 am till 4:00 pm for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0018, K0038, K0066, K0069, K0072, K0075, K00104, K0130, and K0141).

Based on observations made during the survey for the physical environment with the facility's Physical Plant Supervisor (employee #12), it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to maintenance closets with mops and brooms placed upward and the emergency call system in the 7th floor did not work.

Findings include:

1. Mops and brooms were observed maintenance closets of the 1st floor on 3/13/14 leaning up against the wall (mop heads up and the poles down) and inside of a trash can. This procedure contaminates the walls and allows water from the wet mops to leak down the poles and is not an acceptable practice related to infection control standards.

2. In rooms # 702,703,706,708,714 and #718 the nurses call system does not function. In the bathroom of room #708 the nurse ' s call box besides the toilet was attached to the wall with two rusty nails and the one located in the shower does not have the cover and the cables are exposed.
3. On the 7th Floor there is a movies room " Sala de Pelicula". The bathroom of the movie room does not have the nurses call system installed. Also the 7th floor has a Play room. The bathroom of the playroom does not have the nurses call system install either.

Based on observations made during the survey for the physical environment with the facility's Engineer (employee #11), it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas which are not equipped with an air disinfection system (such as ultraviolet lights).

Findings include:

The emergency room (adult and pediatric) was visited on 3/14/14 from 4:30 am through 5:45 pm and provided evidence that the waiting area, triage area and the observation area of the adult and pediatric emergency room are not equipped with an air disinfection system (for example: Ultraviolet lights). According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) the triage area is the point of entry of undiagnosed and untreated airborne infections and should be designed and ventilated to reduce exposure of staff, patients and families to airborne infectious diseases. Through the facility's infection control program, determinations must be made related to general ventilation and air disinfection similar to inpatient requirements for airborne infection isolation rooms according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". The waiting area and observation area are other areas to provide protection with an air disinfection system.

Based on the observational tour with the facility's infection control assistant (employee #43) interviews and review of policies/procedures (P&P), it was determined that the facility failed to promote sanitary and safe care through its infection control program in the Intensive Care Unit, Medicine Department, Surgical department, Physical Therapy Department and Medical Record Department related to improper infection control procedures, failed to maintain a sanitary physical environment in the housekeeping general department and failed to implement policies and procedures that address infection control hospital staff related measures which makes this condition of participation "Not Met". (cross refer Tag A049)

Based on the observational tour with the facility's infection control assistant (employee #43) interviews and review of policies/procedures (P&P), it was determined that the facility failed to promote sanitary and safe care through its infection control program in the Intensive Care Unit, Medicine Department, Surgical department, Physical Therapy Department and Medical Record Department related to improper infection control procedures, failed to maintain a sanitary physical environment in the housekeeping general department and failed to implement policies and procedures that address infection control hospital staff related measures.

Findings include:

The following was observed in the hospital environmental areas on 3/11/14 from 9:30 am till 3:30 pm through 3/13/14 from 9:30 am till 4:00 pm with the infection control assistant (employee #43) related to infection control procedures:

1. During the observational tour of the Physical Therapy area with the facility's physical therapist (employee #41) on 3/13/14 at 8:35 am, located on the first floor of the facility the following was observed:

a. The air conditioning ventilator of the medical records room is broken.

b. The metal divisions of the ceiling were observed with rust.

c. On the housekeeping room use to keep physical therapy equipment two carpets, two infrared lamps and two basins used per the physical therapist to supply the water at the hydrocolator used for patients ' therapy were observed. The housekeeping room has two faucets, this area is not properly ventilated nor is it designed to maintain electric and cleaning equipment. On this area is observed with dust, humidity, peeling paint was observed and lacks of illumination.

d. The Gyn area used for patients to received physical therapies lacks of ''sprinkles and emergency lights''. The ceiling lamp on the storage room of the Gyn lacks of plastic cover lacks of illumination due to defective of the bulb. This storage room area of the Gyn have an open wood cabinet with shelves used to place a Christmas tree, chairs, crutches, pillows and others materials.

e. On the right side of the main entrance of the physical therapy department one small oxygen tank directly on the floor without security rack, two sphygmomanometers and one walker were observed. It was found with its front door unlocked and accessible to non authorized persons.

2. During the observational tour of the Intensive Care Unit area with the unit supervisor (employee #44) and the infection control assistant (employee #43) on 3/11/14 at 9:30 am, located on floor number three of the facility the following was observed:

a. The Intensive Unit Care provided evidence that it does not have housekeeping area the personnel was observed on 3/11/14 at 9:30 am cleaning the area when the housekeeping personnel cleaned the area deposit the dirty water and cleaned the mops outside of the unit area.

b. The area have four open units ( #2, #3, #4 and #5) and one (#1) private room with door used in occasions to dialyze patients or placed patients with isolation needs. Pealing pain was observed at the back of the patient bed on unit #5.

c. The biohazard ours garbage lacks of identification label on unit #1 and #5.

d. The therapy equipment used for patient's on units #2 and #3 lacks of identification label.

e. Two tubes of blue cap 2.7 ml. with expired date on September 2013, one tube of rose cap 6.0 ml. with expired date on December of 2013, one bag of Saline Solution .9% 500 ml. with expired date on February of 2014, two bags of 500 ml of Dextrose 5% with expired date on January 2014 were observed on the emergency cart used by the personnel in emergencies. Dust and rust were observed on the emergency cart located on patient unit #1.

f. The thermometer located on the material storage was fixed with adhesive tape on the shelve of the cabinet. Bags of Saline Solution .9% 50 ml. and 100 ml. and bags of Dextrose 5% 100 ml. were observed on shelves without a plastic cover protection.

g. Two water jar's without lid contain water used per nurses personnel to administer oral medications to patients of the intensive care unit were observed on both side of the washstand over a piece of hand paper on nurses station. The hand paper was observed humid and slash water was observed around the washstand.

h. One vial of Metoclopramide Injection 10 mgs. (5 mgs/ml ) single dose expired date on July 1/2014 and one vial of Magnesium Sulfate opened without identification label lacks of date, hour and signature when opening were observed on patient unit #4.

i. The emergency cart used by the personnel in emergencies case located on the main entrance of the Intensive Care Unit was observed open because the lock is broken, with a lot of dust, rust and stains were observed in the exterior and interior of the emergency car. Two bags of D/W 5% 500 ml. expired date on January of 2014 was identified on the interior of the car. According to policies of the facility the emergency cars was reviewed every day on each nurse shift and then signed the log.

3. During the observational tour of the Medicine Department located on 6th floor with the facility's infection control nurse assistant (employee #43) on 3/11/14 at 10:40 am the following was observed:

a. A patient family of room #618 was observed with mask in front of the nurse station and elevators.

b. One bag of N/SS .9% without plastic cover protection and the biohazard trash disposal was observed without identification label on the intravenous room area.

c. The room of clean linens was observed with open wood cabinet with shelves, the shelves were observed on deteriorate condition, black stains and pealing pain were observed on the shelves. These shelves are use by the nurse personnel to place clean linens. One straw basket use to placed syringes was observed on one of the deteriorate wood shelve. The lamp located on the ceiling did not have a plastic protector cover and the bulb was exposed. This area was observed on deteriorated condition mush dust was seen.

d. The door of the utility room did not closed because the lock has problem, it was found with its door unlocked and accessible to non authorized persons. The area is properly maintained and constructed to limit infection control risks and possible cross contamination and failed to ensure that personnel assigned to this area are protected from environmental hazards in this work area.

e. The walls and floor of the medication room was observed with much dust and dirty. This area has cabinets with stainless still material all of the surfaces have stains, dust and rust. One open jug of Isopropyl Alcohol 50 % of 16 ounce and one jug of Barium Sulfate Suspension (2.1%) was observed on the interior of the washstand, the area was observed dirty dusty and rust.

f. The biohazard ours can lacks of identification label on patient room #617 A.

g. During the observational tour of the Medicine Department on 3/11/14 at 11:00 am a non identified room only indicated the number 628 was observed on the corridor, on left side was observed a bathroom and on right side was observed the housekeeping room. On the interior of this room was observed with one car used by a register nurse designated to provide skin local care to hospitalized patients with ulcers or wounds, one car to takes the laboratory blood samples, one electrocardiogram machine, one canalization car, one scale, a glucometer machine was observed over the medication car and a portable fountain for personnel use. The nurse supervisor (employee #4) was interview at 11:05 am and she stated: ''This room was used on past by the physician for examination room on now is used for medication area. Two medications cars placed on this room because did not have space on nurse area''. The two medications cars were observed open and the medication kardex was maintain on the top of the car, dirty and black sticky spots related to adhesive tape used by nurses was observed on different areas of the medication cars.

h. Two bottles of BD Bactec Standard Anaerobic/F without the protector cap, one open Uretheral Catheterization tray #14, one open bottle of Betadine Surgical Scrub of 16 ounces with expiration date was on February of 2013, exposes gauzes, papers and syringes were observed over the blood samples car. The blood samples car did not have a trash can only have a plastic bag to deposit the garbage.

i. It was found with its front door unlocked and accessible to non authorized persons, the lock was found broken and did not protect this area to prevent unauthorized access. The area was observed disorganized, heavy dust was detected on the walls and floor.

j. The main door of the Utility room was maintain without security lock, the door was found broken and did not protect this area to prevent unauthorized access. Four bags of Saline Solution .9% were observed on the utility room area.

k. On 3/11/14 at 11:30 am a register nurse of medicine ward put two unsterile gloves over the nurse counter then she takes the gloves and put it on her hands and enters the medication room. The nurse did not washing her hands with soap and water and put the contaminated gloves not according to infection control measures.

4. During the observational tour of the Surgery Department located on 5th floor with the facility's infection control nurse assistant (employee #43) on 3/12/14 at 1:35 pm the following was observed:

a. The room designated to place the ice maker machine lacks of liquid soap and dispenser to perform the hand washing.

b. Urine and water was observed on the patient bathroom #506.

c. A patient personnel bag was observed directly on the floor on patient room #506 A.

d. A regular trash disposal of patient room #512 used for contact isolation did not have lid.

e. During the observational tour of the Surgery Department on 3/12/14 at 1:40 pm it was observed a register nurse (employee #45) enter at room number 525 a medication car, on this room as observed a metal cabinet with material used to provide local, care the car was maintain with security lock. A car used to provide local care was observed without security lock. Four bags of Saline Solution .9% 100 ml without plastic cover was observed over the car.
The nurse was interview and she stated: ''This room was used before to provide local care to patients with ulcers or wounds. Now it is use to placed the mediation cars.''
However this room lacks of identification label only indicated the number 525, on left side has a bathroom and on right side is the housekeeping room. This room was maintained unlocked because the lock was broken. On the interior of this room as observed, an emergency car used by a register nurse designated to place venopunction materials. Two commercial plastic trays were observed over the car and on the interior of the tray various blood tubes and two urine collector glass.
An electrocardiogram machine and one scale were placed on this room. The medication car was observed with dust and rust. Medication Flomax Tamsulosin 0.4 mgs. lot. DV5401 was detected on the medication patient tray the car was maintained without security lock. This medication car was observed in poor condition they have a wood panel to cover the deteriorate areas and the wood was paint with commercial paint.
On the right side of the room a deteriorate treatment table was observed with heavy dust, black sticky spots related to dressing tape used to covered the broken areas. Central Vein Tray, Thoracenthesis tray, Foley tray and others medical surgical materials expose were observed on the lower shelve of the treatment table. The regular trash can did not have the lid.
On the left side of the room a deteriorated wood cabinet was observed with colostomy material, foot printer, eye pads, vaginal speculum, sterile strip and others materials. A deteriorate curtain was observed on windows.
The nurse coordinator (employee #46) was interview at 1:50 pm and she stated: ''This room was used on the past by the physician for examination, today is used to placed the medication carts others materials placed on this area because did not have sufficient space to placed other equipment and materials''. This area was observed with heavy dust, dirty and disorganized.

Based on medical record reviewed (R.R), policies and procedure, it was found that the facility failed to ensure that discharge planning evaluations are perform for 9 out of 77 records review (R.R #2, #3, #7, #13, #16, #17, #20, #21 and #23).

Findings include:

1. The policies and procedures for discharge planning for patients admitted at the hospital established last revised on May of 2012 states '' The continuity of patient care in the discharge planning, establishes the intervention in all of admitted patients. However if necessary estimate the patient at the moment of admission to identified all special situations that could affected the patient during the hospitalization or during discharge process.

The records reviewed on 3/11/14, 3/12/14 and 3/13/14 at 8:30 a.m through 4:30 p.m. and failed to provide evidence of discharge planning initial intervention.

a. R.R #2 is a 63 years old female admitted to the facility on 12/03/13 with a diagnosis of Post Menopause Complex Ovarian Cyst.

b. R.R #3 is a 70 years old female admitted to the facility on 01/09/14 with a diagnosis of Left Knee Meniscal Tear.

c. R.R #7 is a 10 months 20 days old male admitted to the facility on 2/12/14 with a diagnosis of Fever.

d. R.R #13 is a 79 years old male admitted to the facility on 01/29/14 with a diagnosis of Uncompensated COPD and High Blood Pressure.

e. R.R #16 is a 31 years old female admitted to the facility on 12/07/13 with a diagnosis of Abdominal Pain, Appendicitis.

f. R.R #17 is a 60 years old male admitted to the facility on 12/19/13 with a diagnosis
of Hemorrhoids Trombosed.

g. R.R #20 is a 57 years old male admitted to the facility on 1/18/14 with a diagnosis
of Ureteriolithiasis Hydronephrosis.

h. R.R #21 is a 50 years old female admitted to the facility on 1/18/14 with a diagnosis
of Left Ureteriolithiasis.

i. R.R #23 is a 56 years old male admitted to the facility on 11/21/13 with a diagnosis
of Left Ureteriolithiasis.

Based on record review (RR) performed with the Director of Discharge Planning (employee #14) and two Discharge Planning coordinators (employees # 15 and #16) it was determined that the facility to assure that interdisciplinary personnel participate in the development of a discharge planning in 6 out of 77 records reviewed. (R.R. # 74, #75, # 77, # 57, #40 and
#78).

Findings include:

1. The facility's Initial Evaluation form for discharge planning has a section V named Multidisciplinary Discharge Plan where the Physician, Registered Nurse, Nutritionist, Social Worker and other members who participated during patient care, can establish their discharge plan. This form allows that each professional can see the interventions and discharge planning of others. Also, the policies and procedures reviewed on 03/14/14 at 9:00 am, named "Discharge Planning Process " states on step C Alternatives or Action Plan. "Once all needs are analyzed, a plan of action or correction should be developed considering all possible alternatives". However, in six RR performed on 03/14/14 from 9:00 am thru 11:30 am with employees #14, #15 and #16; the professional personnel are not writing their discharge plan.


a. During RR # 75 performed on 03/14/14 at 9:30 am, it was found that the patient was admitted on 03/11/14 with a primary diagnose of Sacral and Lateral Left Infected Ulcer. The secondary diagnoses are Gastroenteritis and Dehydration. She has a gastric tube (G-tube) an the surgeon ordered on 03/13/14 at 3:11 pm discharge planning for gastrostomy feeding at home with Jevity 1.5 to run at 40 ml/hr 7am-8pm daily. Also, ordered wound home care service. The Nutritionist performed a nutritional reevaluation on 03/13/14, established the discharged planning for nutritional intake in her nutritional evaluation but did not include the same nutritional plan in the initial evaluation form.

b. During RR # 74 performed on 03/14/14 at 9:45 am, it was found that the patient was admitted on 02/25/14 with a primary diagnose of Disphagya, Odinophagya and as secondary diagnoses are: Malnutrition, High Blood Pressure (HBP) and ruled out (R/O) of Transient Ischemic Attack (TIA). He is in respiratory mechanical ventilation. On 03/10/14 at 10 am the physician ordered discharge planning for Hospice service with respiratory mechanical ventilation at home. The discharge planning coordinator talked with the Hospice coordinator and the respiratory therapist of the hospital to coordinate the use of portable respiratory mechanical ventilation that patient needs at home. As part of the discharge planning, all professionals mentioned above established to visit patient's home to determine adequacy on electrical outlets for connecting the portable respiratory mechanical ventilation and to coordinate the medical surgical supplies that patient needs. However, on the initial evaluation form, no evidence was found of the respiratory therapist planning where she establish the respiratory trials that she has to make with the patient during the transition between the respiratory mechanical ventilator and the portable respiratory mechanical ventilator. This respiratory trial is performed 24 hours prior to patient's discharge home.

c. During RR # 77 performed on 03/14/14 at 10:15 am, it was found that patient was admitted on 03/10/14 with a primary diagnose of Cellulitis on Right leg with Stage III ulcer. The physician ordered ulcer care at home. The discharge planning coordinator talked with patient's medical insurance and is waiting for referral. However, the discharge planning coordinator writes her plan and every day issues on her progress notes but did not establish her planning in the initial evaluation form.

d. During RR # 57 performed on 03/14/14 at 10:30 am, it was found that patient was admitted on 03/04/14 with a primary diagnose of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure(CHF). The patient is in respiratory mechanical ventilation. The physician ordered on 03/10/14 discharge planning for portable respiratory mechanical ventilation and Hospice service. The discharge planning coordinator talked with the respiratory therapist of the hospital, with the respiratory therapist of the Hospice service and determines to make a survey at patient's home for adequacy on electrical outlets to connect the portable respiratory mechanical ventilator. Also, they were planning that patient have to do the respiratory trials before going home but those issues were not included in the planning section of the initial evaluation form.

e. During RR # 40 performed on 03/14/14 at 11:00 am, it was found that patient was admitted on 03/10/14 with a primary diagnose of Uncontrolled Congestive Heart Failure (CHF) and Cardiovascular Disease (CVD). As secondary diagnoses are: Diabetes Mellitus (DM), and Coronary Artery Disease (CAD). The physician ordered on 03/13/14 at 3:05 pm discharge planning for medical equipment at home. The discharge planning coordinator made all the arrangements with the medical equipment company and oriented caregiver. However, all the planning made by the coordinator was written on progress notes and did not establish her discharge planning on the initial evaluation form.

f. During RR # 78 performed on 03/14/14 at 1:30 p.m., it was found that patient was admitted on 03/10/14 with a primary diagnose of Stage III Necrotic Ulcer on Right Foot and Stage III Ulcer on Right Hip. The physician ordered on 03/13/14 at 4:00 pm discharge planning for home infusion, ambulance service and for ulcer care at home. The discharge planning coordinator submitted the physician order for the services mentioned above for the patient's medical insurance approval. No evidence was found of a plan documented on the initial evaluation form.

2. As observed, the discharge planning coordinators coordinate the services that patients need and have case discussion with the physicians. The discharge planning coordinators and other professionals that participate in the discharge planning are not establishing an interdisciplinary plan where everyone can see the recommendations of each others. Every professional write their plan in progress notes and is not easy to see the integrated participation of all of them in the evaluation form for discharge planning.

Based on the review of policies/procedures, seven medical records of patient who died in the hospital, it was determined that the facility failed to notify deaths or imminent deaths in a timely manner to the Organ Procurement Organization (OPO) Lifelink for 4 out of 7 records review (R.R #2, #5, #6, and #7).

Findings include:

1. During seven medical records evaluated of patient who have died in the hospital on 3/14/14 at 1:00 pm it was found that the facility failed to notify deaths in a timely manner to the OPO Life Link. (R.R #2, #5, #6, and #7).

a. RR# 2 a 61 year old male patient with multiple trauma who died on 12/19/13 at the emergency room, the medical record was reviewed on 3/14/14 at 1:30 pm. The Life Link referral sheet and the death certificate were not found on the clinical record. The case number was not found on the nurse ' s death note on 12/19/13.

b. RR#5 is an 18 year old male with multiple bullet impacts (brain death) no evidence was found on the nurses ' death note on 8/26/13 at 4:35 am to whom the case was notified and number of the referral to Life Link. The death certificate was not found in the medical record.

c. RR#6 a 61 year old female patient with Cardiac Arrest, Liver cancer, was reviewed on 3/14/14 at 1:30 pm, evidence found on the nurse's death note on 7/16/13 at the 3-11 shift at 4:35 am that the patient died at 10:50 pm, death was notified to the physician and supervisor and patient was sent to the morgue. However, the patient died on 7/17/13. No evidence of who notified the case to Life Link, no evidence of the person who nurse spoke to at Life Link, no evidence of the date, hour of death and case number, and the record had discrepancy on the date and hour of death as evidence on the nurses notes. Also the nurses not revealed that the patient was transfer to the morgue at 10:48 pm.

During interview with the director of nursing (DON) employee # 1 on 4/14/14 at 1:50 pm, the surveyor discussed the case due to the inaccuracy of date and hour of death and she stated " The nurse wrote the wrong date of death on her note, it should have said 7/17/13. I have to check that record " .

The physician ' s death note on 7/17/23 at 11:00 pm was reviewed on 4/14/14 at 1:00 pm and revealed that the patient died from metastatic cancer complications but no hour of death was written on the medical record.

d. RR# 7 a 73 year old male patient with Hepatic Renal Failure who died on 7/19/13 at 5:32 am. The record was reviewed on 3/14/14 at 1:30 pm. The nurses ' death note was not found on the medical record. No evidence of the death referral to Life Link. No evidence if the death was notified on a timely manner, no evidence of who it was notified to, date and hour of the notification. No evidence of the referral case number. The facility failed to notify Life Link of the death of this patient on a timely manner. The facility failed to write a nurses dead note with relevant information of the patient's death. The death certificate was not found in the clinical record.

Based on observations made of the surgical department and review of policies/procedures with the Operating Room Supervisor (employee #21), it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice and patients' care.

Findings include:

Observations made of the surgical department on 3/11/14 from 9:15 am till 3:00 pm provided the following evidence:

1. No delineation was observed on 3/11/14 at 9:20 am for employees to access sterile and non-sterile areas. No signs were provided at all entrances to the restricted areas that clearly indicate the surgical attire required.

2. It is required by local law to comply with the guidelines for Design and Construction of Hospital and Health Care Facilities. These guidelines on table 7.2 (ventilation requirements for areas affecting patient care in hospitals and outpatient facilities) requires that the relative humidity must be kept between 30-60 % and temperature of 68-73ºF in the operating suites, the following relative humidity were measured on 3/11/14: in suite #1 the temperature registered 62ºF and Humidity registered 63% at 9:55 am , in suite #2 the temperature registered 66ºF and Humidity 61% at 10:05 am, in suite #3 the temperature registered 65ºF at 10:30 am, in suite #7 the temperature registered 63.9ºF at 11:15 am.

a. During the review of record of temperature and relative humidity of facility operation room, on 3/11/14 at 2:00 pm provide evidence that the relative humidity of suite #1 through 7 was out of range 30-60 % and no evidence was provided of the corrective action performed to corrected as follow:

a.i. On Suite #1 in the month of January 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 2014 the relative Humidity on the 3 shift was between 61-79% and no evidence was provided of the corrective action.

a. ii. On Suite #2 in the month of January 1, 2, 3, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 2014 the relative Humidity on the 3 shift was between 61-69% and no evidence was provided of the corrective action.

a. iii. On Suite #3 in the month of January 3, 8, 10, 11, 14, 15, 16, 22, 23, 24, 29, 2014 the relative Humidity was between 78-99% and the temperature was between 77-79ºF, no evidence was provided of the corrective action.

a. iv. On Suite #6 in the month of January 2, 5, 10, 14, 15, 16, 17, 27, 28, 2014 the relative Humidity on the 3 shift was between 61-85% and no evidence was provided of the corrective action.

a. v. On Recovery Room in the month of January 1, 2, 3, 4, 8, 10, 11, 12, 13, 14, 15, 16, 17, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2014 the relative Humidity on the 3 shift was between 61-69% and no evidence was provided of the corrective action.
a. vi On Suite #1 in the month of February 1, 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2014 the relative Humidity on the 3 shift was between 61-68% and no evidence was provided of the corrective action.

a. vii. On Suite #2 in the month of February 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 2014 the relative Humidity on the 3 shift was between 61-69% and no evidence was provided of the corrective action.

a. viii. On Suite #3 in the month of February 4, 18, 2014 the relative Humidity was between 64-79%, no evidence was provided of the corrective action.

a. ix. On Suite #5 in the month of February 1, 2,3, 4, 5, 6, 7, 8, 9, 10, 11, 20, 21, 22, 23, 24, 25, 26, 27, 28, 2014 the relative Humidity on the 3 shift was between 61-72% and no evidence was provided of the corrective action.

a. x. On Suite #6 in the month of February 2, 4, 5, 6, 7, 11, 12, 13, 14, 17, 19, 20, 22, 23, 24, 25, 26, 28, 2014 the relative Humidity on the 3 shift was between 61-69% and no evidence was provided of the corrective action.

a. xi. On Recovery Room in the month of February 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 8, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 2014 the relative Humidity on the 3 shift was between 62-69% and no evidence was provided of the corrective action.

a. xii. On Suite #1 in the month of March 1, 2, 2014 the relative Humidity on the 3 shift was between 61-66% and no evidence was provided of the corrective action.

a. xiii. On Suite #2 in the month of March 1, 2, 2014 the relative Humidity on the 3 shift was between 62-64% and no evidence was provided of the corrective action.

a. xiv. On Suite #5 in the month of March 1, 2, 2014 the relative Humidity on the 3 shift was between 62-63% and no evidence was provided of the corrective action.

a. xv. On Suite #6 in the month of March 1, 2, 2014 the relative Humidity on the 3 shift was between 61% and no evidence was provided of the corrective action.

3. No evidence was found on 3/11/14 at 2:40 pm of the daily and weekly terminal cleaning for the operating suites.

4. The housekeeping maintenance room was observed on 3/11/14 at 11:30 am with seven mops and 2 pails, the two pails were without identification labels.

5. Cidex OPA trays were found on the Equipment Room near Suite #5 Manufacturers' recommendations suggests that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media. However the six container of Cidex OPA was place outside of the exhaust hood.

6. Mechanisms were not developed to ensure that infection control practices are followed as reviewed on 3/11/14 from 9:15 am till 3:00 pm to properly maintain a sanitary environment as evidenced by the following:

a. In Recovery Room the following was observed on 3/11/14 at 9:55 am:

a. i. None sterile gauze was place in a plastic tray expose to the environment.

a. ii. Infant Sodium Bicarbonate 4.2% expired on 3/1/14 available for patient used in the recovery room Crash Cart.

b. In operating suite #1 through #7 the anesthetist chair it was observed with a tapestry with cloth.

c. In operating suite #1 the chair in vinyl was observed broken, that made difficult for disinfection.

d. No evidence was found of the temperature and relative humidity of the Sterile Material Room, #1, #2, #3.

e. Infant Sodium Bicarbonate 4.2% expired on 3/1/14 and 4 vial of Vasopressin 20 unit/ml expired on 2/14, available for patient used in the Crash Cart #3.

f. In the Sterile Material Room (Storage #2) it was found 3 Paracentesis Kit expired on 2/14.

g The Central Supply area was visit on 3/12/14 at 10:00 am and was found that the facility performed the spores culture daily, however the Cartons result, the facility personnel mark both result (+ and -) in the autoclave test for Spores mark (+ and -) in the control area. These types of mark on the spore carton Test result do not clearly verify the result of the test.

h. 2 out of 4 walls in the central supply area are on Gibson board not easy to clean.

i. In the central supply area was observed a wood table with Formica in the top area and was observed with broken Formica. The table had the 4 leg in wood with crack paint.

7. No evidence was found on 3/11/14 at 2:40 pm of the daily and weekly terminal cleaning for the Central Supply.

Based on medical records reviewed (R.R.) with the operation room supervisor (employee #21), it was determined that the facility failed to ensure that the medical history and physical examination (H&P) is documented by a physician for each patient no more than 30 days before or 24 hours after admission or registration and updated prior to surgery or procedure requiring anesthesia services when the H&P was performed within 30 days before admission or registration for 6 out of 77 medical record reviewed ( R.R#41, #44, #45, #46, #47 and #48).

Findings include:

1. R.R #41 is a 70 year old male admitted to the facility on 3/3/14 with a diagnosis of Recurrent Right Inguinal Hernia. During the record review performed on 3/12/14 at 10:45 am it was found that the patient entered to the operating room on 3/3/14 to perform a Repair of Recurrent Right Inguinal Hernia and requiring anesthesia services. However the H&P was performed by the patient's physician on 2/10/14, twenty (21) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

2. R.R #44 is an 89 years old male admitted to the facility on 3/10/14 with a diagnosis of Cataract Right eye. During the record review performed on 3/12/14 at 1:35 pm it was found that the patient entered to the operating room on 3/10/14 to perform a Cataract right eye and requiring anesthesia services. However the H&P was performed by the patient's physician on 2/28/14, nine (9) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

3. R.R #45 is a 70 year old male admitted to the facility on 3/3/14 with a diagnosis of Chronic Cholecistitis. During the record review performed on 3/12/14 at 2:00 pm it was found that the patient entered to the operating room on 3/3/14 to perform an Exploratory Laparostomy Cholecystectomy and requiring anesthesia services. However the H&P was performed by the patient's physician on 2/25/14, six (6) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

4. R.R #46 is an 81 year old male admitted to the facility on 3/10/14 with a diagnosis of Conjuntival Mass in Left eye. During the record review performed on 3/12/14 at 2:10 pm it was found that the patient entered to the operating room on 3/10/14 to perform a an Excision of Conjuntival Mass in left eye and requiring anesthesia services. However the H&P was performed by the patient's physician on 2/24/14, fourteen (14) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

5. R.R #47 is a 68 year old male admitted to the facility on 3/11/14 with a diagnosis of Right Knee Total Joint Replacement. During the record review performed on 3/12/14 at 2:25 pm it was found that the patient entered to the operating room on 3/11/14 to perform a Right Knee Total Joint Replacement and requiring anesthesia services. However the H&P was performed by the patient's physician on 1/30/14, forty (40) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

6. R.R #48 is a 76 year old male admitted to the facility on 3/11/14 with a diagnosis of Right Knee Total Joint Replacement. During the record review performed on 3/12/14 at 2:50 pm, it was found that the patient entered to the operating room on 3/11/14 to perform a Right Knee Total Joint Replacement and requiring anesthesia services. However the H&P was performed by the patient's physician on 1/30/14, forty (40) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

Based on the review of medical records and policies/procedures of the operating room with the Operating Room supervisor (employee #21), it was determined that the facility failed to execute complete surgery informed consents that includes the name of the physician who administrated the anesthesia, If patient accept transfusion, Risk of the surgery 6 out of 77 medical records reviewed (R.R. #41, #42, #45, #46, #49 and #50).

Findings include:

1. R.R. #41 is a 70 years old male admitted with diagnosis of Recurrent Right Inguinal Hernia. The consent form for surgery intervention or medical procedure was signed by the patient on 2/6/14, the consent form lacks of the name of the anesthesiologist who administrated the anesthesia. Lacks of the ricks of the surgery procedure. The patient signed the consent form to accepted transfusion however; it did not provide information related to the risks if the patient received transfusion during the surgery intervention and lack of risk of the surgery.

2. R.R. #42 is a 63 years old female admitted with diagnosis of Soft Tissue Tumor Back. The consent form for surgery intervention or medical procedure was signed by the patient on 2/22/14, the consent form lacks of the name of the anesthesiologist who administrated the anesthesia. Lacks of the ricks of the surgery procedure. Lack if patient accept transfusion and did not provide information related to the risks if the patient received or not received transfusion during the surgery intervention.

3. R.R. #45 is a 63 years old male admitted with diagnosis of Cholecystitis. The consent form for surgery intervention or medical procedure was signed by the patient on 2/20/14, the consent form lacks of the name of the anesthesiologist who administrated the anesthesia. The consent lacks of the ricks of the surgery procedure. Lack if patient accept transfusion and did not provide information related to the risks if the patient received or not received transfusion during the surgery intervention.

4. R.R. #46 is an 82 years old male admitted with diagnosis of Left Eye Conjunctival Mass. The consent form for surgery intervention or medical procedure was signed by the patient on 2/24/14, the consent form lacks of the name of the anesthesiologist who administrated the anesthesia. Did not provide information related to the risks if the patient received transfusion during the surgery intervention.

5. R.R. #49 is a 29 years old female admitted with diagnosis of Cholelithiasis. The consent form for surgery intervention or medical procedure was signed by the patient on 3/11/14 the consent form lacks of the name of the anesthesiologist who administrated the anesthesia. The consent lacks of the ricks of the surgery procedure. Did not provide information related to the risks if the patient received transfusion during the surgery intervention.

6. R.R. #50 R.R. #42 is a 63 years old female admitted with diagnosis of Soft Tissue Tumor Back. The consent form for surgery intervention or medical procedure was signed by the patient on 3/10/14 the consent form lacks of the name of the anesthesiologist who administrated the anesthesia. The consent lacks of the ricks of the surgery procedure. Did not provide information related to the risks if the patient received or not received transfusion during the surgery intervention.

Based on the observational tour through the operating rooms (O.R) and review of six nurse anesthetist credential files (C.F.) with the human resource director (employee #26), it was determined that the facility failed to maintain updated credential files for anesthetist nurses (CRNA) related to updated competencies for 5 out of 6 nurse anesthetist credential files (C.F #1, #2, #4, #5 and #6) to ensure appropriate scope of anesthesia services.

Findings include:

1. Anesthetist credential files were reviewed on 3/12/14 from 1:00 pm till 2:00 pm, the following was found:

a. Five out of six anesthetist nursing credential files do no provided evidence of an updated anesthetist competency the last competencies evaluation was performed on 1/22/13. (C.F #1, #2, #4, #5 and #6).

Based on the review of ten medical records to evaluate anesthesia services with the Operating Room supervisor (employee #21), it was determined that the facility failed to ensure that informed consent forms are properly executed for10 out of 10 records reviewed (R.R. #41, #42, #43, #44, #45, #46, #47, #48, #49 and #50).

Findings include:

1. During the review of ten medical records on 3/12/14 from 11:00 am till 3:00 pm the anesthesia consent form did not provide evidence of the name of the physician that administered the anesthesia and the type of anesthesia that was provided to the patients.

a. One out of ten medical records was incomplete for the anesthesia consent form due to the lack of type of anesthesia given to the patient (R.R. #47).

b. Ten out of ten medical records were incomplete for the anesthesia consent due to the lack of the name of the anesthesiologist's that administered the anesthesia (R.R. #41, #42, #43, #44, #45, #46, #47, #48, #49 and #50).

Based on the review of six closed and active clinical records reviewed (R.R), policies/procedures manual and the observational tour with the emergency room (E.R) nursing supervisor (employee # 29) and interview, it was determined that the facility failed to maintain hand washing sinks stations with hot water, to promote privacy during respiratory treatment to patients, to promote that the use of ice and lubricating jelly for pediatric patients are manage in order to prevent cross contamination, lack sign posting in the entrance/admitting area, policies and procedures manual are not available, no emergency call system on the adult waiting area men bathroom, pediatric triage entrance door in bad condition, patient stretchers and floor of isolation rooms had rust, hand dryer located on pediatric waiting room girl and boys bathrooms are full of rust, intravenous and medical surgical storage area had missing ceiling tiles, pediatric bathroom of observation area was used to storage wheelchairs and a metal file box and .9 % saline solution and heparin lock devices are not manage accordingly with accepted infection control standards of practice.

Findings include:

1. The following was identified during the observational tour of the emergency room department nursing supervisor (employee #29) on 3/11/14 from 8:50 am till 11:59 am:

a. Sinks located on adult acute area, shower area and pediatric isolation area does not have available hot water. Facility failed to ensure that hand washing facilities are maintained in good condition.

b. No signs were posted in the entrance and admitting area for notification of the rights of the individuals who entered the E.R.

c. In the adult observation area, there is a room were respiratory treatments are provided to patients. In this area facility had two reclining chairs were they locate the patients while personnel provide respiratory therapy treatment. Curtains to provide privacy for patient while receiving treatment were not observed.

d. In the pediatric triage area it was observed one ice storage bin used to storage ice to be used with pediatric patients who came with fever or to apply on swollen areas. The ice storage bin was located directly on the floor and a plastic cup was located inside directly on the ice. Facility failed to ensure that ices to be use for external use of pediatric patients are stored in a sanitary manner so it is protected against cross contamination.

e. Lubricating jelly was observed located inside a 30 ml plastic medication cup. Nursing supervisor (employee #29) stated that nursing personnel use this lubricating jelly with the rectal thermometer on pediatric patients, who came to the emergency department. Facility failed to ensure that single use of lubricating jelly was performed in pediatric patients who nursing personnel took rectal temperature.

f. Policies and procedures manual are not available for review on 3/11/14 accordingly with information provided by the Nursing supervisor (employee #29). She indicates that " Hospital San Lucas " located on Ponce Puerto Rico was using their manual for reference.

g. Emergency call system on the adult waiting area men bathroom was not in good working condition.

h. Pediatric triage entrance wooden door was observed in bad condition.

i. Patient stretcher and floor of the negative pressure isolation room were observed with rust.

j. Patient stretcher located on the pediatric isolation room was observed with rust.

k. Electric hand dryer located on pediatric girls and boy ' s waiting room bathrooms are full of rust.

l. Intravenous and medical surgical storage area had missing ceiling tiles. Facility failed to have environment in good condition.

m. Pediatric bathroom of observation area was used to storage wheelchairs and a metal file box. Facility failed to maintain patient bathrooms free of unnecessary equipment and furniture.

n. Two 50 milliliters .9 % saline solution bags was observed located on the observation adult area were personnel manage blood samples and intravenous solutions items and equipment are located. Bags of intravenous solutions are used as a common source of supply for more than one patient. One of the bags indicates on the label that this saline solution is used to flush heparin lock patient devices. The other bag indicates on the label that this saline solution must be used to dilute intravenous medication. Facility failed to maintain strict adherence to safe injection practices during patient care.

Based on the review of the State Law License regulations and the review of physical therapy services credential files (C.F.), it was determined that the facility failed to updated personnel credential files for lack of, cardio pulmonary Resuscitation certificates (CPR), Hepatitis B vaccine and Influenza Vaccine for six (6) out of six (6) credential files, ( Physical Therapy C. F . #1, #2, #3, #4, #5 and #6).

Findings include:

a. Five (5) out of six (6) physical therapist did not maintain updated the cardio pulmonary Resuscitation certificates (CPR) ( CF's #1, #2, #4, #5 and #6).

b. One (1) out of six (6) physical therapist did not provide evidence of Hepatitis Vaccine (CF #1).

c. Three (3) out of six (6) physical therapist credential files did not have evidence of their Influenza vaccine or responsibility exoneration according to the Health Department Administrative Order # 244 of October 10, 2008 (CF's #1, #2 and #3).

Based on the review of policies and procedures and observations with the supervisor of the Respiratory Therapy Department (employee #23), it was determined that the facility failed to ensure that services are provided in accordance with acceptable standards of practice related to respiratory equipment not labeled with the date and hour when started on the equipment, for 6 out of 6 patients rooms visited (patient's rooms #5506A, #601 A, #610 B, #611, #701 B and #706 A).

Findings include:

1. During the observational tour with the Respiratory Therapy Department Supervisor (employee #23) on 3/14/14 from 10:30 am till 2:15 pm in six out of six patient's rooms provided evidence that the patient's respiratory equipment were found in plastic bags on the patient's night tables. However, as observed the respiratory equipment in plastic bags do not have the labeled with the date and hour when the equipment was started to use. (Patient ' s room ' s #5506A, #601 A, #610 B, #611, #701 B and #706 A).

Based on the review of seventeen respiratory therapists credential files (C.F) with the Human Resource Director (employee #26), it was determined that the facility failed to ensure that 5 out of 17 respiratory therapists personnel meet the qualification specified and consistent with State laws related to updated, license, police antecedent penalty, annual influenza vaccine and annual competency evaluation of (C.F #2, #3, #5, #13 and #16).

Findings include:

1. One out of seventeen respiratory therapists credential files reviewed on 3/14/14 at 12:20 pm provide evidence of the provisional license was expired on 12/17/13 not accordance to the state Law # 24 from June 4, 1987 that Regulates the Respiratory Care Practice in PR. (C.F #2).

2. Four out of seventeen respiratory therapists credential files reviewed on 3/14/14 at 12:20 pm did not provide evidence of the updated police penalty antecedent (C.F.s #2, #3, #13 and #16)

3. One out of seventeen respiratory therapists credential files reviewed on 3/14/14 at 12:20 pm did not have evidence of their Influenza vaccine or responsibility exoneration according to the Health Department Administrative Order # 244 of October 10, 2008. (C.F. #3)

4. One out of seventeen respiratory therapists credential files reviewed on 3/14/14 at 12:20 pm did not have evidence of their annual competencies evaluation. (C.F. #5).

Based on the review of six medical records, policies/procedures, it was determined that the facility failed to ensure that the organization of respiratory therapy services is appropriate to the scope and complexity of the services provided for 4 out of 6 clinical records reviewed (RR #51, #52, #53, #54, #55 and #56.).

Findings include:

1. Six medical records were reviewed with Respiratory Therapy Supervisor (employee #23) on 3/14/14 from 9:50 am till 2:00 pm provided evidence that respiratory therapists did not administer respiratory therapy treatment in accordance with the physician 's order six out six (RR #51, #52, #53, #54, #55 and #56). Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis.

a. R.R #51 is an 11 years old male admitted on 3/13/14 with a diagnosis of Bronchial Asthma. The record review was performed on 3/14/14 at 9:50 am provided evidence that the physician ordered in the Emergency room on 3/13/14 at 7:10 am Proventyl 0.5 milliliter (ml)/3 ml Normal Saline Solution (NSS) every 30 minute per 3. On 3/13/14 at 10:10 am the physician ordered Admit patient to pediatric Ward with Free Flow Nebulizer (FFN) Proventyl 0.5 ml/3 ml NSS every 2 hour per 2 then every 4 hour, Pulmicort 0.5 ml without frequency and Ventury Mask at 30%. Evidence was provided that the fist treatment of Proventyl was provided at 7:30 am, 8:00 am and 8:30 am. However the next treat with Proventyl ordered at 10:10 am was provide by the respiratory Therapy on 3/13/14 at 3:39 pm, 7 hour later, the next respiratory therapy was provided at 6:30 pm (every 3 hour), then at 11:20 pm (5 hour later.

a. i. No evidence was found related to the communication between the physician and the respiratory therapist.
a. ii. No evidence was found related to the communication between the nurse and the therapist.
a. iii. No evidence was found that the physician was notified that the respiratory therapy was not given to the patient since 3:39 pm.
a. iv. The patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

b. R.R #52 is a 2 years old male admitted on 3/13/14 with a diagnosis of Upper Respiratory Tract Infection and Pneumonia. The record review was performed on 3/14/14 at 10:50 am provided evidence that the physician ordered in the Emergency room on 3/13/14 at 9:55 am Vaponphrine 0.25 ml/3 ml NSS every 30 minute per 2. On 3/13/14 at 1:00 pm the registered nurse sign the physician ordered for Vaponephrine 0.25 ml/3 ml NSS every 1 hour per 3 and writes notified. On 3/13/14 at 12:45 pm the Physician ordered admit patient to pediatric Ward with FFN Vaponephrine 0.25 ml/3 ml NSS every 4 hour and Pulmicort0.25 ml every 12 hour and Pulse Oxymeter every 8 hour. The treatment was started by the respiratory therapist at 10:10 am, then at 10:50 am. The next treatment was administrated on 3/13/14 at 3:28 pm, 2.5 hour more later, then every 4 hour.
b. i. No evidence was found related to the communication between the physician and the respiratory therapist.
b. ii. No evidence was found that the physician was notified that the respiratory therapy was not given to the patient since 3:28 pm.
b. iii. The patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

c. R.R #53 is a 67 years old female admitted on 3/10/14 with a diagnosis of Lower Respiratory Tract Infection. The record review was performed on 3/14/14 at 11:15 am provided evidence that the physician ordered on 3/10/14 at 10:30 am Admit patient to medicine ward with FFN Albuterol 0.083% + Atrovent 0.02% every hour and FFN Nebusal 6% every 12 hour.

The nurse signs the order on 3/10/14 at 12:30 pm 2 hour later. On 3/10/14 at 5L: 20 pm the physician ordered Nasal Cannula (N/C) 3 Litter (L)/ minute and FFN Albuterol 0.25/Atrovent 2.5 every 4 hour with chest tapping. The physician did not write if milliliter (ml) or milligram (mg). On 3/13/14 at 9:00 pm the physician ordered FFN Albuterol 0.25/Atrovent 2.5 mg every 4 hour and Insentive Spirometry every 1 hour per 5 minute.

On 3/13/14 the respiratory therapist wrote on the progress note the label for reminding the physician the respiratory therapy evaluation. Evidence was provided that the first treatment of Albuterol was provided at 1:29 pm; 3 hour after the physician ordered and 1 hour after the registered nurse sign the order. The next treatment was provided at 3:40 pm, every 2 hour not as prescribed every 4 hour. On 3/12/14 the respiratory therapist provide the patient treatment at 11:00 am then at 3:45 pm, 45 minute later. On 3/12/14 the respiratory therapist provide the patient treatment with Nebusal at 9:00 am and no evidence was found of the subsequence therapy with this medication. No evidence was found that the physician ordered discontinue, no evidence was found that the respiratory therapist communicate with the physician to reevaluate this order. On 3/13/14 the respiratory therapist provide Albuterol/ atrovent treat treatment at 11:10 am and the next dose was provided at 11:15 pm. 12 hour later.

c i. No evidence was found related to the communication between the physician and the respiratory therapist.
c. ii. No evidence was found related to the communication between the nurse and the therapist.
c. iii. No evidence was found that the physician was notified that the respiratory therapy was not given to the patient since 1:29 pm.
c. iv. The patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

d. R.R #54 is an 83 years old male admitted on 2/25/14 with a diagnosis of Respiratory Failure on Mechanic Ventilator, Tracheostomy and Gastrostomy. The record review was performed on 3/14/14 at 1:15 pm provided evidence that the physician ordered on 3/6/14 at 3:45 pm FFN Xopenex 1.25 ml/3 ml + Atrovent 2.5 ml every 4 hour. On 3/7/14 at 2:00 pm the physician post operative ordered FFN Xopenex 1.25 ml/3 ml + Atrovent 2.5 ml every 4 hour. On 3/10/14 at 10:00 am the physician ordered Transfer to medicine Ward with FFN Xopenex 1.25 ml/3 ml + Atrovent 2.5 ml every 4 hour.

Evidence was provided that on 3/7/14 the respiratory therapist provided the Xopenex and Atrovent treatment at 3:46 am, then at 11:10 am, 7 hour 25 minute later than ordered.
On 3/7/14 the respiratory therapist provided the Xopenex and Atrovent treatment at 6:54 pm then on 3/8/14 at 12:00 am, 5 hour15 minute later than ordered, then at 7:55 am, 7 hour 40 minute later than ordered, then at 11:00 am, 3 hours later than ordered, then at 4:30 pm, 5 hour 30 minutes later than ordered.

On 3/9/14 the respiratory therapist provided the Xopenex and Atrovent treatment at 3:35 pm then at 6:40 pm 3 hour later, the at 11:55 pm, 5 hour 30 minutes later, then on 3/10/14 at 3:10 am, 3 hour later, then at 8:00 am , 5 hour later not every 4 hour as ordered.

On 3/12/14 the respiratory therapist provided the Xopenex and Atrovent treatment at 3:16 am, then at 8:30 am, 5 hour later, then at 10:30 am 2 hours later not accordance to physician order.

d i. No evidence was found related to the communication between the physician and the respiratory therapist to notify the treatment delay and omission of treatment.
d. ii. The patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.
d. iii. The physician failed to write a complete physician order related to the unit dose of the Xopenex, failed to identify the amount and type of diluents and failed to identify the duration of treatment.

e . R.R #55 is an 80 years old male admitted on 3/7/14 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The record review was performed on 3/14/14 at 1:35 pm provided evidence that the physician ordered on 3/7/14 at 4:45 pm Albuterol 0.25/Atrovent 2.5 every 4 hour. On 3/10/14 at 11:30 am the physician ordered O2 by nasal Cannula at 2 litter and Albuterol 0.25/ Atrovent 2.5 every 30 minute per 3. On 3/9/14 Albuterol 0.25/Atrovent 2.5 every 4 hour alternate with Albuterol 0.25/ Pulmicort 0.5 every 12 hour. On 3/11/14 at 9:00 am Albuterol 0.25/Atrovent 2.5 every 4 hour alternate with Albuterol 0.25/Pulmicort 0.5 every 12 hour.

However the physician failed to write a complete physician order related to the unit dose of the Albuterol, Atrovent and Pulmicort, failed to identify the amount and type of diluents and failed to identify the duration of treatment. The physician failed to document the prescribed order in a legible letter.

f. R.R #56 is a 65 years old male admitted on 3/12/14 with a diagnosis of Acute Cholecistitis. The record review was performed on 3/14/14 at 1:50 pm provided evidence that the physician ordered on 3/12 at 5:30 pm Atrovent 2.5/3NSS every 6 hour. The physician failed to write a complete physician order related to the unit dose of the Atrovent and failed to identify the unit of diluents and failed to identify the duration of treatment. The physician failed to document the prescribed order in a legible letter.