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Based on a recertification survey, the review of hospital licenses and certifications, it was determined that the facility failed to ensure that it is in compliance with Federal and State laws related to correct labeling of propane tanks and endorsement according to regulations of the Public Service Commission, and expired State License.

Findings include:

a. During the review of the facility's licenses/certifications on 9/23/16 at 11:45 am, it was identified that their permission for the 3 electric generators issued by the Environmental Quality Board are expired since 2012. The facility submitted as evidence a permit application for the construction or operation of emission sources in Puerto Rico dated 24 September 2015. However was not submitted any tracking management to acquire permits for the three generators.

b. Endorsement and certification of the gas line to the kitchen issued by the Public Service Commission according to the regulations for the liquefied petroleum gas, natural gas and other hazardous products conducted by pipes was not provide by the facility. The facility provide a Job order from Santa Juanita Gas Service , Inc. ; indicating that the lines running from the tanks to the kitchen does not have gas leaks.

c. During the touring performed on 9/21/2016 at 9:10 am it was observed that two propane gas without the correct labeling of propane gas tanks and endorsement according to regulations of the Public Service Commission.

Based on the review of hospital licenses, it was determined that the facility failed to ensure that they have an updated Sanitary Environmental license which meets with approved standards as established by State Law #117 from 12/1/04.

Findings include:

During the review of facility licenses on 9/23/16 at 11:30 am, it was identified that the facility failed to have an updated Sanitary Environment license; it expired on 6/7/16. The facility provided evidence that they paid and solicited an inspection on 06/27/16; however the agency has not visited the facility for inspection.

Based on a recertification survey, the review of medical records, policies and procedures, documents, observations, tests and interviews from 9/20/16 through 9/23/16 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: 42 CFR 482.13 Condition of Participation: Patient ' s Rights, 42 CFR 482.23 Condition of Participation: Nursing Services, 42 CFR 482.24 Condition of Participation Medical Record Services, 42 CFR 482.28 Condition of Participation Food and Dietetic Services, 42 CFR 482.41 Condition of Participation Physical Environment and 42 CFR 482.42 Condition of Participation Infection Control which makes this condition 42 CFR 482.12 Governing Body Not Met.

Based on a recertification survey, interview and review of the facility' s institutional plan documents performed on 09/22/16 at 9:35 a.m., it was determined that the facility failed to ensure that the institutional plan provides for capital expenditures for at least a three year period including the operating budget year.

Findings include:

The facility's institutional plan was reviewed on 09/22/16 at 9:35 a.m. and provided evidence of the annual operating budget. However, no evidence was provided of a plan for capital expenditures for at least a 3-year period which includes anticipated income and expenses.
During interview with the Administrator (employee #30) performed on 09/22/16 at 8:45 a.m., stated: " I do my budget up to 2017, projecting one year ahead. "

Based on a recertification survey, review of admission package, review of policy and procedure of restraint Protocol, policy and procedure of Did Not Resuscitation (DNR) Protocol, observation tour of the medical record areas, it was determined that the facility failed to ensure that patient right was protected and promoted, which make this condition Not Met (Cross reference TAG #A117, TAG #A118, TAG #A132, TAG #A147, TAG #A166, TAG #A167 and TAG #214).

Based on medical record reviewed, it was determined that the facility failed to provide Medicare recipients "An Important Message from Medicare" (IM) two days before discharge to execute their rights to appeal facility ' s discharge, failed to sign, provide the two forms, or provide the second form and inform patients of the IM requirements for 2 out of 30 records reviewed (RR) (RR. #37 and #55).
Findings include:

1. R.R. #37 is a 38 years old female who is admitted on 8/11/16 with a diagnostic of Asthma. The record was review on 9/20/16 at 3:42 pm. The patient was discharge home on 8/16/16 for a length of stay (LOS) of 5 days. The Important Message from Medicare was provided upon admission however the two days prior discharge Important Message from Medicare was not provide. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

2. RR #55 is an 87 years old female who was admitted on 1/28/2016 with a diagnosis of Left Distal Radius Fracture. The record was reviewed on 9/21/16 at 2:42 pm. The patient was discharge home on 2/01/16 for a LOS of 4 days. The Important Message from Medicare was provided upon admission however the two days prior discharge Important Message from Medicare was not provide. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

Based on a recertification survey, the review of documents and the admission packet with the admission manager (employee #26), it was determined that the facility failed to ensure that patient's rights are promoted regarding complete disclosure in the admission packet related to whom they have to contact to file a grievance.

Findings include:

1. Review of the admission packet provided to the patient at the admission process on 9/20/16 at 9:00 am, it was identified that updated information of the phone number and address for lodging a grievance with the State agency and the Medicare hot line was not included.
2. During the initial tour performed on 9/20/16 at 10:00 am it was observed an notification posting in the rooms door, notified the patient right and the phone number to be contact. However, no evidence was found related to the updated telephone number of a representative in the State agency as Assistant Secretary for Regulation and Accreditation of Health Facilities (SARAFS) State Law 101 Division and Medicare Division.

Based on five records reviewed (R.R) with Do Not Resuscitate (DNR) consent with the admission manager (employee #26), it was determined that the facility failed to ensure that patients or their representatives formulate advance directives and comply with these directives related to written DNR or Do Not Intubate orders at the time that the patient signs the consent for DNR or DNI for 5out of 5 records reviewed (R.R #6, #7, #8, #9 and #14).

Findings include:

The facility failed to inform patients or their representatives that they have the right to formulate advance directives and comply with these directives related to DNR and DNI order requests as reviewed on 9/20/16 from 10:00 am till 4:45 pm. and 9/23/16 from 8:00 till 1:00 pm

1. During the review of the facility policy and procedure related to Do Not resuscitate on 9/20/16 at 10:00am provide evidence of the following:

a. The facility did not contemplate in their policy the patient choice to Do Not Intubate (DNI).

b. According to the DNR policy step #1: the Registered Nurse (RN) is the responsible personnel to take the physician order to DNR. Step #2: to verify that patient consent for DNR was sign by the physician and the patient or relative. Step #3: the RN is responsible to provide patient and relative support. Step #5: the DNR order be re-evaluate every 24 hour by the primary physician and documented the outcome in the physician progress note. Include that if the physician order was not properly documented in the eventuality of cardiorespiratory arrest, the nursing personnel initiate the resuscitation measure in all cases.

2. During the R.R performed on 9/20/16 from 10:00 am till 4:45 pm. and 9/23/16 from 8:00 till 1:00 pm it was found the following:

a.R.R #6 is a 64 years old male who was admitted on 8/29/16 with a diagnosis Acute Renal Failure. According to the record review on 9/20/16 at 10:10 am performed with fifth floor supervisor (employee #34), the patient's representative signs the DNI consent on 8/31/16 at 3:50 pm. No evidence was found of the physician order for patient DNI. No evidence was found of the justification, orientation and re-evaluation of the patient related to the DNR on the physician's progress notes.

The RN nurses note performed on 8/31/16 at 12:00 am the nurse documented that patient was with DNR protocol. No evidence was found related to RN provide patient and relative support accordance to DNR policy and procedure. No evidence was found that the nurse assessed the DNR policy and procedure. No evidence was found of the re-evaluation of the DNI order according with the patient's clinical condition. In the event that an emergency arises it is not clear what will happen with the patient since the patient or his relative signed the DNI consent, but there is no physician's order for the DNI and the RN identified in the patient record and in the patient treatment kardex that patient was in DNI protocol.

b. R.R #7 is a 73 years old female who was admitted on 9/14/16 with a diagnosis Bilateral Bronchopneumonia (BKP), Chronic Obstructive Pulmonary Disease (COPD) and Sacral Ulcer. According to the record review on 9/20/16 at 11:45 am performed with fifth floor supervisor (employee #34), the patient's representative signs the DNR consent on 9/14/16 at 3:44 pm. No evidence was found of the physician order for patient DNR. No evidence was found of the justification, orientation and re-evaluation of the patient related to the DNR on the physician's progress notes. The RN nurses note performed on 9/15/16 at 3:00 pm the nurse documented that patient was with DNR No evidence was found that the nurse assessed the DNR policy and procedure.

No evidence was found of the re-evaluation of the DNR order according with the patient's clinical condition. In the event that an emergency arises it is not clear what will happen with the patient since the patient or his relative signed the DNR consent, but there is no physician's order for the DNR and the RN identified in the patient record and in the patient treatment kardex that patient was in DNR. No evidence was found that the RN provides patient or relative support accordance to DNR policy and procedure.

c. R.R #8 is an 84 years old male who was admitted on 9/17/16 with a diagnosis Congestive Heart Failure (CHF). According to the record review on 9/20/16 at 1:25 pm performed with fourth floor coordinator (employee #35), the patient's representative signs the DNR consent on 9/19/16 at 8:35 pm. No evidence was found of the physician order for patient DNR. No evidence was found of the justification, orientation and re-evaluation of the patient related to the DNR on the physician's progress notes. No evidence was found that the nurse assessed the DNR policy and procedure. No evidence was found of the re-evaluation of the DNR order according with the patient's clinical condition. In the event that an emergency arises it is not clear what will happen with the patient since the patient or his relative signed the DNR consent, but there is no physician's order for the DNR and the RN identified in the patient record and in the patient treatment kardex that patient was in DNR. No evidence was found that the RN provides patient or relative support accordance to DNR policy and procedure. The certification for advance directives performed on 9/17/16 at 7:00 pm (19:00) lack if patient have advance directives or not and lack of patient or relative signature.

d. R.R #9 is an 84 years old male who was admitted on 9/17/16 with a diagnosis Bronchopneumonia (BKP). According to the record review on 9/20/16 at 1:45 pm performed with fourth floor coordinator (employee #35), the patient's representative signs the DNR consent on 9/17/16 at 3:00 pm. The physician put the DNR order on 9/17/16 at 3:00 pm. However, no evidence was found of the justification, orientation and re-evaluation of the patient related to the DNR on the physician's progress notes. No evidence was found that the nurse assessed the DNR policy and procedure. No evidence was found of the re-evaluation of the DNR order according with the patient's clinical condition. No evidence was found that the RN provides patient or relative support accordance to DNR policy and procedure.

e. R.R #14 (close record) is a 37 years old male who was admitted on 7/31/16 with a diagnosis Chronic Liver disease. According to the record review on 9/21/16 at 3:15 pm, the patient death on 8/6/16 at 7:55 pm, The respiratory care note performed on 8/9/16 at 7:55 pm the respiratory therapist documented that patient be declared death by the physician and the patient has an DNR. The RN progress note performed on 8/6/16 at 3:00 pm documented that patient was entubated in mechanic ventilator, at 4:50 pm blood glucose (Dxt) was 45 milligram per deciliter (mg/dl), Dextrose full drip administrated, at 5:24 pm Dxt 88 mg/dl. At 5:40 pm 2 ampoule of Sodium bicarbonate be administrated IV push. At 7:00 pm Vital sign Blood Pressure (BP 46/21 millimeter of mercury (mm/Hg), Pulse 40 beet per minute (BPM) and temperature 35.1°C. At 7:55 pm. Patient death, the physician certificates the death. At the moment of patient death the wife and other family was in the patient rooms. However, no evidence was found related to the DNR consent, DNR physician order, a physician orientation and justification for the DNR. The facility personnel failed to follow and comply with the facility DNR policy and procedure.
3. The facility failed to follow and meet with the DNR identification policy and procedure step #8 that indicate that the RN documented in the daily reassessment nurses note all patient with DNR for five of five R.R (R.R #6, #7, #8, #9 and #14).

During interview with Risk management manager (employee #27) on 920/16 at 3:46 pm state that the DNI consent sheet was in develop and was in the process that the legal division of the corporation approve, was performed in English and in Spanish. The DNR process is as follow: the physician oriented the patient or their family and explain that the DNR is non heroic measure, if accept, the patient or the family sign the concern, the physician write the DNR order, the RN documented in the different shift the nurses note patient in DNR. If patient revokes the DNR, the physician documented in the progress note that the patient revoke the DNR consent. In a daily revision I evaluate if the DNR protocol was completed. If some documents is missing, I indicate to the nursing personnel and discuses with the supervisor the finding, the next day I review if completed " .

Base on a recertification survey, observation tour in the emergency room on 9/21/16 with the emergency room supervisor (employee # 5), infection control officer (employee #6) and the director of nursing DON (employee # 13) and to the alternate storage area of the Medical Record Department on 9/22/2016 at 11:45 a.m. with the Office Clerk (Employee #30), it was found that the facility fails to provide confidentiality to all patients records.
Findings include:
1. On 9/21/2016 at 2:04 pm it was observed the emergency room register nurse (employee # 33) documenting in a medical record inside the screening room however two patients were seating inside the room in two treatment chairs and the computer screen was positioned were the patients can read the medical record.
2. On 9/21/2016 at 2:06 pm inside the triage room # 2 it was found an unattended computer with a patient medical record open for a 22 years old female patient with a diagnostic of abdominal pain (patient # 80). The triage room was with the door open and with no employees inside.
3. The facility fails to provide confidentiality to all patient records.


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4. A mechanism to ensure that facility promote the right of each patient of confidentiality of their medical record information were not followed, not performed. The following was identified on 9/22/2016 at 11:45 a.m. in an observational tour to the alternate storage area of the Medical Record Department with the Office Clerk (Employee #30):

a. Door and windows are made of steel and crystal which permits the sight of the files from the outside. Two files were open, causing that unauthorized personnel or other individuals could access the files information. It was observed that a big fan was turned on which caused that the files were opened.
b. Facility failed to safeguard the contents of the medical record, from unauthorized disclosure.

Based on a recertification survey, observational tour, records reviewed (R.R) and review of policies and procedure with the nurse supervisor (employee #35 and #36), it was determine that the facility failed to promote the patient's right to be free of restraints and failed to continually assess and monitor for 4 out of 9 patients (R.R. #10, #11, #12 and #67).

Findings include:

1. R.R. #10 is a 64 years old female who was admitted on 9/19/16 with a diagnosis of Bronchopneumonia (BKP) and mechanic ventilation. According to the record review performed on 9/20/16 at 2:00 pm wit nurse supervisor (employee #35), it was found that on 9/20/16 at 7:00 am the physician performed a telephonic order to start restraint protocol on both hands for 24 hour. However the physician orders lack of physician signature. The Patient restraint sheet lack of the date that be documented, the reason to be restrain was due to avoid patient hurt and avoid interruption of treatment. The type of restraint was soft in both arm, the restraint order be performed on 9/20/16 at 7:00 am till 9/21/16 at 8:00 am (25 hour) the sheet indicate restrain no more than 24 hour.

The registered nurse (RN) lacks to document the sign and symptom or patient behavior previous to restraint, the alternative measure previous to restraint. The nursing assessment and preventive round provided and the time provided, Change in patient behavior, started to assess patient t 8:00 am. The RN lacks to sign the patient restraint sheet. The nurse progress note performed on 9/20/16 at 10:00 am the nurse documented that patient was in restraint protocol. No evidence was found related to patient behavior to be restrained. No evidence was found related to physician evaluation previous to restraint. No evidence was found related to less restrict measure to be performed previous to restraint the patient.

The facility ' s policy and procedure related to restraint reviewed on 9/20/16 at 1:30 pm in the items #1 says that the physician or the professional nurse that identified patient at risk to harm themselves or other patient initiate the restraint process after taken other less restricted alternative or option.

Item #2 indicate that a verbal order for restraint be counter sign by the physician no more that 6 hour after initiate the restrain. Item #5 indicates that nursing personnel maintain constant observation to patient in restraint during continues round every 15 minute to identified patient care needs. Item #6 the professional nurse (RN) documented every 4 hour the observation and intervention performed to the patient in the nursing progress note.

The facility failed to meet their restraint policy and procedure. The RN failed to activate the restraint plan of care.

a- No evidence was found that the physician counter sign the restrain verbal order no more that 6 hour.

b. No evidence was found related to the physician's restriction evaluation ordered on 9/20/16 at 7:00 am.

c. No evidence was found related to the less restricted measure taken before restraint the patient.

d. No evidence was found related to patient or their relative orientation related to the restraint.

e. No evidence was found related to restraint consent be sign by patient or relative.

f. No evidence was found related to RN documentation the constant observation and intervention to the patient in the nursing progress note.

g. No evidence was found related to restraint plan of care be activated by the RN.

2. R.R. #11 is a 44 years old male who was admitted on 8/2/16 with a diagnosis of Anasarca, Diabetes Mellitus and High Blood Pressure (HBP). According to the record review performed on 9/20/16 at 2:15 pm with nurse supervisor (employee #35), it was found that on 9/8/16 at 9:00 am the physician performed an telephonic order to renew restrained. However the physician ordered was incomplete due to lack of area and hour to be restraint and lack of physician signature. The Patient restrain sheet the RN documented that the physician order for restraint was on 9/8/16 at 8:00 am when it was at 9:00 am, the RN lack documented the date, lack to document the alternated measure previous to restraint.

The patient restraint protocol sign and dated by the RN was on 9/8/16 at 8:00 am and lack of area to be restraint and physician date, hour and signature. On 9/15/16 at 8:00 pm a physician telephonic order for Restraint protocol soft per 2 was placed. The patient restraint sheet lack of dated, reason to restrain, description of sign and symptom to restrain, type of restraint areas of restrain, the order of restraint, alternate measure previous to restrain. The patient restraint protocol was left in blank, only provide the date.

The patient consent to restrain was left in blank, only provide relative signature. No evidence was found related to physician order for restrain on 9/16/16. The RN documented in the patient restraint sheet the order was performed on 9/16/16 at 8:00 am. The 11-7 shift lack to document the time frame to be assess and to performed the nursing round and the assessment, if any change in patient behavior and was documented at 12:00 am and 2:00 am.

The restraint protocol lack of the physician signature patient consent to restraint was left in blank only provide relative signature. Do not indicate if accept or not and date and hour. On 9/19/16 at 5:45 pm the physician telephonic order ordered Restraint per 24 hour. The order lacks of type of restraint and area to be restrain and the date and hour and countersign of the physician.

The Restriction sheet performed on 9/19/16 the RN documented that the order be placed on 9/19/16 at 9:20 am, the sheet lack of description of sign and symptom to restraint, type of restraint areas of restrain, the order of restraint, alternate measure previous to restraint. The 7-3, 3-11 and 11-7 shift lack to document the time frame to be assess and to performed the nursing round and the assessment, if any change in patient behavior.

On 9/20/16 at 8:00 am the physician telephonic order renews soft restraint per 2 extremities. The order lacks of the date and hour and countersign of the physician. The Restriction sheet lack of the dated to be performed, the RN documented that the order be placed on 9/20/16 at 8:00 am, the sheet lack of description of sign and symptom to restraint, type of restraint areas of restrain, the order of restraint, alternate measure previous to restraint. The 7-3 shift lack to documented the time frame to be assess and to performed the nursing round and the assessment, if any change in patient behavior.

The facility policy and procedure related to restrain reviewed on 9/20/16 at 1:30 pm in the items #1 that the physician or the professional nurse that identified patient at risk to harm themselves or other patient initiate the restraint process after be taken other less restricted alternative or option. Item #2 indicates that a verbal order for restrain be counter sign by the physician no more that 6 hour after initiate the restraint. Item #5 indicates that nursing personnel maintain constant observation to patient in restraint during continues round every 15 minute to identified patient care needs. Item #6 the professional nurse (RN) documented every 4 hour the observation and intervention performed to the patient in the nursing progress note.

The facility failed to meet their restraint policy and procedure. The RN failed to activate the restraint plan of care.

a. No evidence was found related to physician evaluation previous to restraint.

b. No evidence was found related to less restricted measure to be performed previous to restraint the patient.

c- No evidence was found that the physician counter sign the restraint verbal order no more that 6 hour that be placed.

d. No evidence was found related to RN documentation the constant observation and intervention to the patient in the nursing progress note.

e. No evidence was found related to restraint plan of care be activated by the RN.

3. R.R. #12 is a 36 years old male who was admitted on 9/16/16 with a diagnosis of chronic Schizophrenia and Body Aspiration. According to the record review performed on 9/20/16 at 3:15 pm with nurse supervisor (employee #36), it was found that on 9/16/16 at 4:00 pm the physician ordered soft restrained per 4. However the physician orders lack of time to be restraint. No evidence was found related to restraint patient sheet; no evidence was found related to restrained protocol. The "RN documented in the nurses note flowsheet performed on 9/16/116 at 11-7 shift that patient was restraint. On 9/17/16 at 4:00 pm the physician telephonic orders soft restraint per 4. The telephonic order lacks of dated, hour and countersign of the physician. The RN nurses ' progress note from 7-3, 3-11 and 11-7 shift the RN document no restraint. No evidence was found related to restraint patient sheet; no evidence was found related to restrained protocol. On 9/18/16 at 7-3, 3-11 and 11-7 shift the RN documented that patient was in restraint; however no evidence was found of the physician order, the restraint protocol and the restraint patient sheet. On 9/19/16 at 7:00 am the physician telephonic order soft restraint superior extremity. The telephonic order lacks of dated, hour and countersign of the physician. The RN documented the restraint patient sheet, however left in blank if any change occurs in the 7-3 shift. Lack of documentation in 3-11 and 11-7 shift of time of assessment and round performed if any change occurs. The restraint protocol lacks of physician date, hour and signature. On 9/20/16 at 7:30 am the physician telephonic orders soft restraint superior extremity. The telephonic orders lack of dated, hour and countersign of the physician. The RN documented the restraint patient sheet, however left in blank the time of assessment and round performed if any change occurs and the signature of nurse in the 7-3 shift.

a- No evidence was found that the physician counter sign the restraint verbal order no more that 6 hour.

b. No evidence was found related to the physician's restriction evaluation ordered on 9/16/16 at 4:00 pm.

c. No evidence was found related to the less restricted measure taken before restraint the patient.

d. No evidence was found related to RN documentation the constant observation and intervention to the patient in the nursing progress note.

e. No evidence was found related to restraint plan of care be activated by the RN.


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4. RR #67 was reviewed on 9/20/16 patient with 84 years old male who was admitted on 9/9/16 due to a diagnosis of Severe Anemia. The record was reviewed and it was found the following:

a. The nurse initial admission was performed on 9/13/16 at 6:00 a. m. five days later post admission according of the medication register administration the patient was admitted on 9/9/16 with diagnosis of Respiratory Failure at room #428- A. The nurse initial admission performed on 9/13/16 revealed that the patient was received at Emergency Room per Symptomatic Anemia, Hypotension, weakness and respiratory difficulty. The nurse initial admission lacks information related to health history, allergy history, patient habits, system revision, cardiovascular system, elimination pattern, psychosocial pattern, neurological system, nutritional assessment, pain management, educational needs, discharge planning, nursing diagnosis and other important information, all of this space was maintain in blank. The nurse note provide evidence that the patient has a B/P on 130/54 and during performed the skin assessment revealed that the patient has gray and dry skin, poor turgor, hematoma, abrasion and cellulites on left hand. The nurse note revealed that the patient was stable but not oriented nor capable to respond to questions. She maintain I.V. fluids 0.9 % Normal Saline at 100 ml. per hour on right forearm. The space to write if the patient was received with or accompanied per a relative on the initial admission the nurse wrote ' ' not applicable " . No evidence of nurse admission note on shift 7:00 a. m. till 3:00 p. m. on 9/13/16.

On 9/10/16 at 8:30 (not specified if a. m. or p. m.) a nurse note performed by the License practical nurse (LPN) provide evidence that the patient was maintain alone no family present and the B/P was taken and has 90/30 and she notified the register nurse (employee #42), patients is alert with side rails up. No evidence when the register nurse notified the physician related to the hypotension.

On 9/15/16 at 12:20 a. m. a nurse note reveled that call the physician (employee #38) because the patient presented oxygen saturation on 32%, she put a ventury mask at 50 % and blood gases was taken according with the physician orders. At 5:00 a. m. (4 hours 40 minutes later) a nurse note reveled the result of the ABG's and he ordered intubate the patient and notified the other physician (employee #43), at 5:08 a. m. the nurse documented '' Versed 5 mgs. administered according with ''verbal physician order'' per employee #43 and then procedure to intubate the patient with tube #7.0 at 5:11 a. m., a chest plate was taken and report the result at physician employee #43 and he ordered retired the endotraqueal tube one centimeter realized per respiratory therapy personnel however did not provide evidence of the name of the respiratory therapist. The nurse note revealed that the patient was restrain per both superior extremities at 5:15 a. m. preventive to avoid that the patient interrupt the treatment. The patient record did not provide evidence of restraint orders by the physician and no activated the restraint protocol according of the hospital policies and procedures, no evidence of nursing assessment.

No evidence of progress notes estimated phase on 9/15/16 shift 3:00 p. m. to 11:00 p. m. and 11:00 p. m. to 6:00 a. m.

On observation / intervention and patient response note on shift 7:00 a. m. to 3:00 p.m. at 8:00 a. m. revealed that the patient was received on mechanical ventilation and continue with soft restrain on both superior extremities, the nurse revealed that the patient was observed with laceration on forearm and edema, B/P 98/57 and pulse 105/min. however no evidence when the nurse notified the physician related to the hypotension. On 9/15/16 at 10:00 a. m. a nurse note reveled that taken and execute a physician order's with intensive protocol however the patient was maintain on second floor Medicine room 216 A. The nurse note provides evidence that during performed the patient bath was observed edema on left superior extremity, abdomen, vaginal area and face area. However, no evidence when the nurse notified the physician related to the patient changes. On 9/15/16 at 10:00 a. m. physician order of restriction was placed '' Restrain both arms'' not according with the restraint protocol orders.

At 10:30 p. m. the B/P was 114/54, temperature on 36.0 grades, no evidence of Destrostix and urine output was on 40 ml. At 11:00 p.m. the patient has a B/P on 129/55, urine output 50 ml. no evidence of destrostix every one hour according with protocol, and continue with soft restraint of both superior extremities. At 1:30 a.m the nurse note revealed that the patient has a thermal blanket.

On 9/15/16 at 5:08 a. m. a physician (employee #43) verbal order to restrain the patient per both arms with soft restriction for prevention however no evidence was found related to the physician's restriction evaluation. On 9/20/16 during reviewed the patient record no evidence of the physician signature the restriction order.

The facility failed to meet their restraint policy and procedure. The RN failed to activate the restraint plan of care.

a- No evidence was found that the physician counter sign the restrain verbal order no more that 6 hour.

b. No evidence was found related to the physician's restriction evaluation ordered on 9/15/16 at 5:08 a. m.

c. No evidence was found related to the less restricted measure taken before restraint the patient.

d. No evidence was found related to patient or their relative orientation related to the restraint.

e. No evidence was found related to restraint consent be sign by patient or relative.

f. No evidence was found related to RN documentation the constant observation and intervention to the patient in the nursing progress note.

g. No evidence was found related to restraint plan of care be activated by the RN.

Based on the observational tour, records reviewed (R.R) and review of policies and procedure with the nurse supervisor (employee #35 and #36), it was determine that the facility failed to promote the patient's right to be free of restraints and implemented in accordance with safe and appropriate restraint techniques failed to continually assess and monitor 3 out of 8 patients (R.R. #10, #11, #12).

Findings include:

1.R.R. #10 is a 64 years old female who was admitted on 9/19/16 with a diagnosis of Bronchopneumonia (BKP) and mechanic ventilation. According to the record review performed on 9/20/16 at 2:00 pm wit nurse supervisor (employee #35), it was found that on 9/20/16 at 7:00 am the physician performed an telephonic order to start restraint protocol on both hands for 24 hour. However the physician orders lack of physician signature. The Patient restraint sheet lack of the date that be documented, the reason to be restraint was due to avoid patient hurt and avoid interruption of treatment. The type of restraint was soft in both arm, the restraint order be performed on 9/20/16 at 7:00 am till 9/21/16 at 8:00 am (25 hour) the sheet indicate restraint no more than 24 hour. The RN lacks to document the sign and symptom or patient behavior previous to restraint, the alternative measure previous to restraint.

The nursing assessment and preventive round provided and the time provided, Change in patient behavior. Started to assess patient t 8:00 am. The RN lacks to sign the patient restraint sheet. The nurse progress note performed on 9/20/16 at 10:00 am the nurse documented that patient was in restraint protocol. No evidence was found related to patient behavior to be restrained. No evidence was found related to physician evaluation previous to restraint. No evidence was found related to less restrict measure to be performed previous to restraint the patient.

The facility ' s policy and procedure related to restrain reviewed on 9/20/16 at 1:30 pm in the items #1 says that the physician or the professional nurse that identified patient at risk to harm themselves or other patient initiate the restraint process after be taken other less restricted alternative or option. Item #2 indicates that that a verbal order for restrain be counter sign by the physician no more that 6 hour after is initiated the restraint. Item #5 indicates that nursing personnel maintain constant observation to patient in restraint during continues round every 15 minute to identified patient care needs. Item #6 the professional nurse (RN) documented every 4 hour the observation and intervention performed to the patient in the nursing progress note.

The facility failed to meet their restraint policy and procedure. The RN failed to activate the restraint plan of care.

a- No evidence was found that the physician counter sign the restrain verbal order no more that 6 hour.

b. No evidence was found related to the physician's restriction evaluation ordered on 9/20/16 at 7:00 am.

c. No evidence was found related to the less restricted measure taken before restraint the patient.

d. No evidence was found related to patient or their relative orientation related to the restraint.

e. No evidence was found related to restraint consent be sign be patient or relative.

f. No evidence was found related to RN documentation the constant observation and intervention to the patient in the nursing progress note.

g. No evidence was found related to restraint plan of care be activated by the RN.


2. R.R. #11 is a 44 years old male who was admitted on 8/2/16 with a diagnosis of Anasarca, Diabetes Mellitus and High Blood Pressure (HBP). According to the record review performed on 9/20/16 at 2:15 pm with nurse supervisor (employee #35), it was found that on 9/8/16 at 9:00 am the physician performed an telephonic order to renew restrained. However the physician ordered was incomplete due to lack of area and hour to be restraint and lack of physician signature. The Patient restrain sheet the RN documented that the physician order for restraint was on 9/8/16 at 8:00 am when it was at 9:00 am, the RN lack documented the date, lack to document the alternated measure previous to restraint.

The patient restraint protocol sign and dated by the RN was on 9/8/16 at 8:00 am and lack of area to be restraint and physician date, hour and signature. On 9/15/16 at 8:00 pm a physician telephonic order for Restraint protocol soft per 2 was placed. The patient restraint sheet lack of Dated, Reason to restrain, description of sign and symptom to restrain, type of restraint areas of restraint, the order of restraint, alternate measure previous to restraint. The patient restraint protocol was left in blank, only provide the date.

The patient consent to restrain was left in blank, only provide relative signature. No evidence was found related to physician order for restraint on 9/16/16. The RN documented in the patient restraint sheet the order was performed on 9/16/16 at 8:00 am. The 11-7 shift lacks to document the time frame to be assessed and to performed the nursing round and the assessment, if any change in patient behavior and was documented at 12:00 am and 2:00 am. The restraint protocol lack of the physician signature patient consent to restraint was left in blank only provide relative signature.

No indicate if accept or not and date and hour. On 9/19/16 at 5:45 pm the physician telephonic order ordered Restraint per 24 hour. The order lacks of type of restraint and area to be restraint and the date and hour and countersign of the physician. The Restriction sheet performed on 9/19/16 the RN documented that the order be placed on 9/19/16 at 9:20 am, the sheet lack of description of sign and symptom to restraint, type of restraint areas of restraint, the order of restraint, and alternate measure previous to restraint. The 7-3, 3-11 and 11-7 shift lack to document the time frame to be assess and to performed the nursing round and the assessment, if any change in patient behavior.

On 9/20/16 at 8:00 am the physician telephonic orders renew soft restraint per 2 extremity. The order lacks of the date and hour and countersign of the physician. The Restriction sheet lack of the dated to be performed, the RN documented that the order be placed on 9/20/16 at 8:00 am, the sheet lack of description of sign and symptom to restraint, type of restraint areas of restraint, the order of restraint, and alternate measure previous to restraint. The 7-3 shift lack to document the time frame to be assessed and to perform the nursing round and the assessment, if any change in patient behavior.

The facility ' s policy and procedure related to restrain reviewed on 9/20/16 at 1:30 pm in the items #1 says that the physician or the professional nurse that identified patient at risk to harm themselves or other patient initiate the restraint process after be taken other less restricted alternative or option. Item #2 indicates that a verbal order for restraint be counter sign by the physician no more that 6 hour after be initiate the restrain. Item #5 indicates that nursing personnel maintain constant observation to patient in restraint during continues round every 15 minute to identified patient care needs. Item #6 the professional nurse (RN) documented every 4 hour the observation and intervention performed to the patient in the nursing progress note. The facility failed to meet their restraint policy and procedure. The RN failed to activate the restraint plan of care.

a. No evidence was found related to physician evaluation previous to restraint.

b. No evidence was found related to less restricted measure to be performed previous to restraint the patient.

c- No evidence was found that the physician counter sign the restraint verbal order no more that 6 hour that be placed.

d. No evidence was found related to RN documentation the constant observation and intervention to the patient in the nursing progress note.

e. No evidence was found related to restraint plan of care be activated by the RN.

3. R.R. #12 is a 36 years old male who was admitted on 9/16/16 with a diagnosis of chronic Schizophrenia and Body Aspiration. According to the record review performed on 9/20/16 at 3:15 pm with nurse supervisor (employee #36), it was found that on 9/16/16 at 4:00 pm the physician ordered soft restraint per 4. However the physician orders lack of time to be restraint. No evidence was found related to restraint patient sheet; no evidence was found related to restraint protocol. The RN document in the nurses note flowsheet performed on 9/16/116 at 11-7 shift that patient was restraint. On 9/17/16 at 4:00 pm the physician telephonic orders soft restraint per 4. The telephonic order lacks of dated, hour and countersign of the physician. The RN nurse ' s progress note from 7-3, 3-11 and 11-7 shift the RN document no restraint.

No evidence was found related to restraint patient sheet; no evidence was found related to restraint protocol. On 9/18/16 at 7-3, 3-11 and 11-7 shift the RN documented that patient was in restraint; however no evidence was found of the physician order, the restraint protocol and the restraint patient sheet. On 9/19/16 at 7:00 am the physician telephonic order soft restraint superior extremity. The telephonic order lacks of dated, hour and countersign of the physician.

The RN documented the restraint patient sheet, however left in blank if any change occurs in the 7-3 shift. Lack of documentation in 3-11 and 11-7 shift of time of assessment and round performed if any change occurs. The restraint protocol lacks of physician date, hour and signature. On 9/20/16 at 7:30 am the physician telephonic orders soft restraint superior extremity. The telephonic order lacks of dated, hour and countersign of the physician.

The RN documented the restraint patient sheet, however left in blank the time of assessment and round performed if any change occurs and the signature of nurse in the 7-3 shift.

4. Facility policy and procedure related to restraint reviewed on 9/20/16 at 1:30 pm in the items #1 says that the physician or the professional nurse that identified patient at risk to harm themselves or other patient initiate the restraint process after be taken other less restricted alternative or option. Item #2 indicates that a verbal order for restraint be counter sign by the physician no more that 6 hour after be initiate the restraint. Item #5 indicates that nursing personnel maintain constant observation to patient in restraint during continues round every 15 minute to identified patient care needs. Item #6 the professional nurse (RN) documented every 4 hour the observation and intervention performed to the patient in the nursing progress note.

a- No evidence was found that the physician counter sign the restraint verbal order no more that 6 hour.

b. No evidence was found related to the physician's restriction evaluation ordered on 9/16/16 at 4:00 pm.

c. No evidence was found related to the less restricted measure taken before restraint the patient.

d. No evidence was found related to RN documentation the constant observation and intervention to the patient in the nursing progress note.

e. No evidence was found related to restraint plan of care be activated by the RN.

The facility ' s policy and procedure related to restraint reviewed on 9/20/16 at 1:30 pm in the items #1 says that the physician or the professional nurse that identified patient at risk to harm themselves or other patient initiate the restraint process after be taken other less restricted alternative or option. Item #2 indicates that a verbal order for restraint be counter sign by the physician no more that 6 hour after be initiate the restraint. Item #5 indicates that nursing personnel maintain constant observation to patient in restraint during continues round every 15 minute to identified patient care needs. Item #6 the professional nurse (RN) documented every 4 hour the observation and intervention performed to the patient in the nursing progress note.

f. The facility failed to follow the restraint policy and procedure.

Based on a recertification survey, record reviewed (RR) and interview with the associate Director (employee #16), it was determined that the facility failed to report death that occurs while a patient is in restraints and death that occurs within 24 hours after a patient has been removed from restraints for 5 out of 8 records reviewed ( R.R #13, #14, #15, #16 and #17)

Findings include:

1. During the review of eight medical records with restraint on 9/20/16 from 9:30 am till 4:30 pm, on 9/21/16 from 3:15 pm till 4:00 pm, on 9/23/16 from 8:30 am till 11:00 it was found the following:

a. Five out of eight record reviews provide evidence that the patient death during patient is with soft restraint R.R #13, #14, #15, #16 and #17. No evidence was found related to CMS death report of patient restraint.

b. The facility failed to ensure to maintain an internal log for recording information on each death that occur within patient was restrain or within 24 hour of the patient being removed from restraint.

During interview with the associate nursing director (employee #16) on 9/23/16 at 3:30 pm state that the facility did not report to CMS patient death during restraint or during 24 hour after been removed restraint and did not has an log book to registered the event.

Based on a recertification survey, observation tour, procedure observation, record review, review of policy and procedure, review of nursing plan of care, review of nursing credential file with the nurse director (employee #13) and Nurse Director Associate (employee #16), it was determined that the facility failed to ensure that nursing services was provided in accordance with nursing standard of practice, that made this condition NOT MET. (Cross Reference TAG #A394, TAG #A396, TAG #A405, TAG #A449 and TAG #A749).

Based on a recertification survey, administrative documents review and interviews with the Nurse Director DON (employee #13) and the Associated Nurse Director (employee #16) on 09/21/16 through 09/23/16, it was determined that the facility failed to ensure that the patient needs are meet by ongoing assessments of patient's needs and provide nursing staff to meet those needs.

Findings include:

The Associated Nurse Director (employee #16) was interview on 9/21/16 at 7:50 a. m. and she stated: '' I have the position of associated nurse director since April of 2016. I was the Supervisor of the Medicine Department on July 2016 I started as the Associate Director as the position was vacant the Nursing Director (employee #13) offered me the positions of associate director and I accepted it. I assist the director at the clinical areas, unless she is not present or I ' m assigned other administrative functions. In my duties is to receive the shifts change, verify the census, check the staffing, absences ect and based on the information decisions are made on a daily basis. I perform rounds with the director and the 7:00 am to 3:00 pm supervisor. One day a week departments are visit and are evaluated, work programs are verify and any other situation that occurs during the day, clinical and administrative situations and are worked depending on the situation. ''

1. During the initial round on Medicine fifth floor for nursing services evaluation on 9/20/16 at 9:00 a. m. with the associated nurse (employee #16) and the nurse supervisor (employee # 30) the review of the patient's assignment and requested the patient classification she stated: '' I did not performed the patient classification at this time.'' The census of the ward was maintained on 31 patients. However, at 11:45 a.m. the nurse supervisor had not done the patients ' classification.

2. On 9/20/16 at 10:00 a. m. during reviewed the patient record #57 a 75 years old female who was admitted on 9/19/16 due to a diagnose of Hyponatremia was found the following:

a. The nurse initial assessment performed on 9/19/16 at 6:00 p. m. lacks information related who accompanied the patient on the admission, patient relative, the hour when the patient was admitted and disposition of the patient personnel objects. The section designated to '' Sistema Hematopoyetico " , " Patron de percepcion y concepto propio " , Psichosocial Pattern, " Efectos de la Enfermedad " , " Patron de Valores y Creencias " , " Criterios prevencion caidas " , if during the hospitalization the patient was possible candidate for service of nutritionist, social worker, physical therapy or religious services, Level of Motivation for Learning, Educational Needs and Nursing Diagnosis was maintain in blank.

The nurse signed the document however the license number was illegible. The patient and family education plan on the space for '' Clave de Evaluacion '' was maintain in blank. The form designated to '' Education to patient y/o family for Infection Control Program, Intergumentary System Assessment and the form for Orientation related to the personnel belongings not performed by the nurse.

b. The nursing treatment kardex provide evidence that the patient was admitted on 9/18/16 with diagnosis of '' Hyponatremia '' The kardex indicated a diabetic diet ADA diet with two snacks daily but did specified the hours when the patient received the snacks. Indicated a '' Destrostix but did not indicated how many times a day was to be performed the Destrostix. Did not performed the patient '' clasification or cathegorization.'' On the daily activities only wrote '' Bed rest '' however did not indicated how the patient received the bath and other information related to daily activities. Lacks of the nursing diagnosis and was not sign by the nurse who admitted the patient. The kardex reveled that on 9/19/16 was pending '' EKG '' On 9/20/16 at 9:00 a. m. the patient record was selected per the surveyor to reviewed and provide evidence that the EKG was not perfomed at this time.

c. The Diabetic Register for blood glucose test lacks of the identification label. Only provide evidence of a Destrostix performed by a register nurse (employee #32) on 9/20/16 at 6:00 a. m. However the number of the Destrostix result and the nurse signature was not legible.

d. The medication register administration kardex performed on 9/18/16 lacks of the patient weight and the allergy history. The kardex provide evidence that on 9/19/16 the patient received Normal Saline at 100 ml. / hour. The patient record was reviewed on 9/20/16 at 9:00 a. m. and provide evidence that the nephrology consult requested on 9/19/16 at 1:00 p. m. was answer on 9/19/16 at 11:38 p. m. and ordered decrease I.V. fluids to 50 ml. / hr. the order was taken by a register nurse (employee #32) on 9/20/16 at 2:10 a. m. two hours and 40 minutes later however, no evidence on the kardex of this I.V. changes ordered per the nephrologists.

The patient was visit during the surveyor round accompanied with Associated Nursing Director (employee #16) and the Nurse Supervisor (employee #30) on 9/20/16 at 10:00 a. m. and was observed that the patient maintain the same I.V. line until the admission, did not have a regulator or I.V. pump and the label located on the I.V. bag of Normal Saline 1000 ml. indicated 100 ml. per hour, however the patient did not received the I.V fluids according of the nephrologists order.

e. A consultation report request on 9/19/16 at 1:00 p. m. did not provide evidence of the date when request the consult, at what service, the name of consultant. No evidence of who notified the consult and to whom, date and hour. The reason to request the consult was illegible. The consultant answer the consult on 9/19/16 at 11:38 p. m. however lacks of consultant signature and license number.

f. The nurse note performed by the nurse on 9/19/16 at 3:00 p. m. lacks of the nurse license number.

g. The form designated for '' Notification HIPPA Law " lacks of identification label and the name and signature of the authorized institution personnel.

h. The important massage of Medicare related to the patient rights lacks of the date when the patient signed the document.

i. The authorization for medical treatment lacks of patient name, hour and other information solicited on the document only provide the patient signature.

3. On 9/20/16 on shift 7:00 a. m. till 3:00 p. m. the patient #57 on Medicine Ward B fight floor was visit at 10:00 a. m. with the Nurse Supervisor (employee #30) and the Associated Nurse Director (employee #16).

During performed the patient visit it was observed that she did not stay on her bed and stay at the bathroom. The patient referred that she call the nurse long time but the nurses never came and she went to the bathroom to wash her mouth. The patient was assisted to the bed with the nurse personnel (employee #16 and employee #30). The patient was observed with tremors because she referred to much cold and the nursing personnel covered with her blanket.

The patient was observed with IV line on her left superior extremity, did not have a IV fluids regulator or IV pump machine, a yellow label indicated I.V. solution 1000 ml. of Normal Saline at 0.9 % 100 ml. / hr. and lacks the hour when initiated the solution and the angio catheter only read '' September 19.''

The patient room floor was observed dirty and small pieces of papers were observed around the bed room area.

The patient was interview and referred did not received nurse assistant for long time and did not received her medications during this day, she referred she use medication '' Metformin 500 mgs but before she take her breakfast and then the Metformin. However she referred at this time (10:10 a. m.) she did not received the mediations for diabetes and blood pressure.

At 10:25 a. m. a register nurse (employee #31) enters the patient room with a blue gloves and a canalization tray, she put a tray directly on the top of the patient bed then she closed the I.V. line and removed the angio catheter, however did not removed her gloves and did not used hand sanitizer before removed the angio catheter, when removed the angio catheter discard on the sharp container discard the I.V. solution then discard her gloves but did not wash her hands, then she goes to the exit room door go to the medication cart management the medication kardex but never wash her hands or used hand sanitizer.

At 10:30 a. m. the nurse enters the patient room with gloves I.V. Saline Solution and a label indicated 100 ml./hr. she put the I.V. bag solution and a label directly on the patient bed, then enters her hand on the canalization tray and takes a alcohol swap cleaning at the patient area on right superior extremity then put the used alcohol directly on the patient bed, take a angio catheter, with the same gloves touch the patient area canalized and fixed.

The associated nurse director (employee #16) goes out of the patient room and went again with a yellow label indicated Saline Solution 50 ml. / hr. and then put the label directly at the patient bed. The I.V. stand was maintain at the left side of the patient bed and the nurse moved the I.V. stand at right side and then removed the plastic cover of the I.V. line and put at the I.V. solution.

The nurse supervisor (employee #30) goes out of the patient room and went again with a ''heparin saline flush and a regulator '' provide at the nurse the heparin saline flush and put the regulator directly on the patient bed, the nurse flushing the heparin lock but did not disinfected the septum, then put the regulator at the I.V. line and put the solution at the patient, removed her gloves and discard, takes the canalization tray, goes out of the patient room, then put the tray over the medication cart located on the corridor discard the empty '' heparin saline flush vial '' take the canalization tray goes to the nurse station and put the tray on the medical surgical material area.

The R.N #31 failed to follow agency's policies and procedures related to the patient canalization. Did not clean her hands according with appropriate standards of infection control, which pose risk of cross contamination.

The R.N #31 failed to follow agency's policies and procedures related to hand washing and failure to adequately set up the materials that she was going to use according with appropriate standards of infection control.

4. According of the Administrative Nurse Manual on the designated area of ' ' Work Assignment '' (Asignacion de Trabajo) reviewed on 9/22/16 at 3:00 p.m. the facility utilized the plan of care as base to elaborated the assignment and they have a patient categorization, specials activities of patient, specials assignments for nurses and patients distribution for each nurse. The assignment was performed with a nurse supervisor for the three shifts 7:00 a. m. till 3:00 p. m., 3:00 p.m. till 11:00 p. m. and 11:00 p. m. till 7:00 a. m. during seven days of the week. The responsibility of the assignment is performed by the nurse supervisor of each department or the professional designated of the unit and the supervisor is the responsible before and after the shift to evaluate if all of the personnel performed and complied of the assignment.

5. On 9/23/16 at 2:40 p. m. the skin care nurse (employee #18) was interviewed related to her functions and he stated: '' I worked at this facility for 7 years on medicine floor until April 2016. I am s Associate Degree Nurse ADN. The position was available and I pass the interview process. I work rotary shifts and work one alternate weekend. When I am free the ward staff provides the ulcer treatment to the patients and general skin care. I do not do surgical wound cleaning. When I am not here I leave all the necessary supply and the staff on the shifts does the treatment. If the surgeon provides specification for treatment it is follow as per physician orders. I have no training or certification as skin care nurse. I took a course of skin care of 12 hours of continue education. Related to my Job description when a case is referred to me for skin care I interview the patient and proceeded to evaluated all the patient's and performed the care. I do not have an office assigned for skin care the supply is located at the general supervisors ' office. "
The nurse director (employee #13) was interviewed on 9/23/16 at 3:00 p. m. and she stated that: '' The nurse (employee #18) was assigned because the her performance was being evaluated. Actually we have pending a skin care program but it is not structure, it is pending.
During the credentials file evaluation of the skin nurse it did not provide evidence of a Specialist Skin Care Nurse, it only provide evidence of a '' Certificate of Completion educational activity for 12.0 contact hours.
According to the Associated Nurse, he responds directly to the Nursing Service Director. No evidence of indicators to evaluate and supervise the procedures performed by the skin care nurse. The nurse evaluation was by R.N. Associated Nurse with medicine ward signed per the employee on 1/28/16. Duties and functions lacks of administrator signature. The change from Medicine Department to Nursing Department was performed on 4/18/16 and was approved on 4/19/16.

6. RR #67 was reviewed on 9/20/16 patient with 84 years old male who was admitted on 9/9/16 due to a diagnosis of Severe Anemia. The record was reviewed and it was found the following:

a. The nurse initial admission was performed on 9/13/16 at 6:00 a. m. five days later post admission according of the medication register administration the patient was admitted on 9/9/16 with diagnosis of Respiratory Failure. The nurse initial admission performed on 9/13/16 revealed that the patient was received at Emergency Room per Symptomatic Anemia, Hypotension, weakness and respiratory difficulty. The nurse initial admission lacks information related to health history, allergy history, patient habits, system revision, cardiovascular system, elimination pattern, psychosocial pattern, neurological system, nutritional assessment, pain management, educational needs, discharge planning, nursing diagnosis and other important information, all of this space was maintain in blank. The nurse note provide evidence that the patient has a B/P on 130/54 and during performed the skin assessment revealed that the patient has gray and dry skin, poor turgor, hematoma, abrasion and cellulites on left hand. No evidence on the patient record when the patient was evaluated per the nurse skin care.

Based on a recertification survey, the review of forty six nursing credential files (C.F's) included the contracted services of the anesthesia department (CF's 32 till 44), it was determined that the facility failed to ensure that twelve (12) personnel are licensed in accordance with state and local laws related to Influenza Vaccine , Penalty Antecedent, Professional College, Annual Evaluation, Health Certificates, Duties/ Functions and Competences for 13 out 46 C.Fs (C.Fs #14, #29, #31, #32, #33, #34, #35, #36, #37, #38, #39, #41 and #42 ).

Findings include:

1. Forty four nursing credential files were reviewed with assistant of the Human Recourse Director (employee #19) on 9/21/16 at 11:15 a. m. through 2:30 p.m. and provided evidence of the following:

a. Six out of forty six nursing credential files did not have evidence of influenza vaccine (C.F #31, #34, #35, #36, #41 and #42).

b. One out of forty six nursing credential files did not have evidence of influenza vaccine updated the last administration was on 12/4/14 (C.F #14).

c. Two out of forty six nursing credentials files did not have evidence of their professional association (C.F #33 and #42).

d. One out of forty six nursing credential files did not have evidence of the Hepatitis Vaccine Immunization (C.F #31).

e. Seven out of forty six credentials files did not have evidence of the negative criminal record " " antecedents penales " (C.F #29, #32, #34, #35, #39, #41 and #42).

f. One out of forty six credential files did not have evidence of the Health Certificate (C.F #31).
g. One out of forty six credential files the Health Certificate expired on 9/23/16 (C.F #37).
h. One out of forty six credential files did not have evidence of annual evaluation (C.F #33).
i. Two out of forty six credential files have job description but one did not have a date and the employee signed (C.F #37) and one lacks of the date when signed (C.F #42) .
j. One out of forty six credential files have competencies but one the date when the employee signed (C.F #38).

Based on a recertification survey eighty records was reviewed and it was determined that the facility failed to developed, implemented and keep current patient plan of care for twenty records reviewed (RR) 8 for restrain and others 12 records the facility failed to developed, implemented and keep current patient plan of care for restraint for eight (8) out of 8 record reviewed (R.R #10, #11, #12, #13, #14, #15, #16, #17) and for the others 12 out of 20 records failed to develop nursing care plans (RR#57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #80).

Findings include:

1. Eight out of eight record reviewed provide evidence that patient were restraint, however no evidence was found that the nurses personnel developed implemented and maintain a current plan o care for restraint patient. (R.R #10, #11, #12, #13, #14, #15, #16 and #17).


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2. Twelve out of eighty record reviewed did not provide evidence that the nurses personnel developed, implemented and maintain a current plan o care for patient. (R.R #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #80).

Based on a recertification survey, review of five record reviewed (R.R) with the respiratory therapist supervisor (employee #29) it was determined that the facility failed to ensure that drugs and biological must be ordered ,prepared and administered in accordance with accepted standards of practice for 3out of 5 record review (R.R #23 #24 and #25).

Findings include:

1. Five medical records were reviewed on 9/23/16 from 2:00 pm till 4:30 pm of patients who received respiratory therapy and provided evidence that respiratory therapy physician order was not in accordance to the standards of practice (date and time of the order, drug name, dose, frequency, and route, duration). Records reviewed provided evidence that patients ' physician order was incomplete due to lack of the dose unit and the route of administration for three out of five record review (R.R #23 #24 and #25).

a. R.R #23 is an 87 years old female who was admitted on 9/20/16 with a diagnosis of Bronchitis Asthmatic. The record review was performed on 9/23/16 at 2:30 pm, with the respiratory therapist supervisor (employee # 29) and provided evidence that on 9/20/16 at 3:00 pm the physician ordered Albuterol 0.83 / Atrovent 0.2 every 4 hour and Pulmicort 0.5 every 12 hr. The physician lack to ordered treatment accordance to the standard of practice due to lack of the dose unit and the route of administration. The RN failed to take and execute a physician order not in accordance to the standard of practice that physician orders for the administration of drugs and biological must include the dose unit and the route of administration.

b. R.R #24 is a 55 years old male who was admitted on 9/19/16 with a diagnosis of Descompensed Congestive Obstructive Pulmonary Disease (COPD). The record review was performed on 9/23/16 at 2:50 pm, with the respiratory therapist supervisor (employee # 29) and provided evidence that on 9/19/16 at 8:45 am the physician ordered Albuterol 0.83 plus (+) Atrovent 0.2 every 4 hour and Pulmicort 0.5 every 12 hr. The physician ordered Albuterol 0.83 (+) Atrovent 0.2 every 6 hour and Pulmicort 0.5 every 12 hr. The physician lack to ordered treatment accordance to the standard of practice due to lack of the dose unit and the route of administration. The RN failed to take and execute a physician order not accordance to the standard of practice that physician orders for the administration of drugs and biological must include the dose unit and the route of administration.

c. R.R #5 is a 77 years old male who was admitted on 9/19/16 with a diagnosis of Left White Lung. The record review was performed on 9/23/16 at 3:15 pm, with the respiratory therapist supervisor (employee # 29) and provided evidence that on 9/19/16 at 5:30 pm the physician ordered Atrovent 0.2 every 4 hour and Pulmicort 0.5 mg every 12 hr. The physician lack to ordered treatment accordance to the standard of practice due to lack of the dose unit and the route of administration. The RN failed to take and execute a physician order not in accordance to the standard of practice that physician orders for the administration of drugs and biological must include the dose unit and the route of administration.

Based on recertification survey, observational tour of the medical records department on 9/21/2015 at 2:00 p.m. with the Medical Record Director (employee #22) through the central file area, alternate storage area, and review of the policies and procedure's manual and interviews it was determined that the facility failed to maintain active and inactive medical records on a safety and secure storage room, to complete records within 30 days following discharge, to have mechanism to ensure that facility medical record department perform an accurate process to monitor and notify for the prompt completion of medical records, to provide Medicare recipients "An Important Message from Medicare" (IM) two days before discharge, to ensure that telephone orders are countersigned by the physician within the first twenty-four hours after the order was given, to provide confidentiality to all patients records and document pertinent treatment orders and important information related to patient health condition. (Cross reference Tags A-0117, A-0147, A-0438, A-0454, A-0458 and A-0468) All of which makes this condition "Not Met"

Based on a recertification survey, interviews and observations during the tour of the Medical Record Department on 9/21/16 from 9:05 a.m. to 2:20 p.m. with the Medical Record Administrator (Employee #22), it was determined that the facility failed to ensure that active and inactive medical records are filed under proper safety conditions, to complete records within 30 days following discharge and a to have mechanism to ensure that facility medical record department perform an accurate process to monitor and notify for the prompt completion of medical records.

Findings include:

1. On 9/21/2016 at 9:05 a.m. Office Clerk (Employee #30) arrives to a building outside the hospital structure. In that building are located the hospital inactive medical records. The building is divided for multiples areas. In those areas are located the boxes of Doctors ' Center Hospital Bayamon inactive record, Nuclear medicine inactive records, X rays department inactive records, Doctors ' Center Hospital San Juan inactive records and Doctors ' Center Hospital Manatí inactive records. The building has an estimated over a thousand boxes of inactive medical records of different areas and hospitals.
On the area of Doctors ' Center Hospital Bayamon inactive record are boxes of records on wood pallets and file shelves. The area was dirty, not organized, electric cables uncover, wet floors, rusty water pipes, emergency exit door even though the door had a lock the door did not sealed leaving a big space for pest to go in to the record area one iguana, one gypsum board wall with a black and humid spot on the lower right corner, broken boxes by moisture, clinical records exposed, two ceiling damaged lights, a box filled with garbage (two plastic bottles with a yellow liquid (urine like), wooden shelves, high temperature, humidity on the ceiling tiles and there were missing ceiling acoustic tiles. (Exhibits #1-#13)
2. On 9/21/2015 at 2:00 p.m. the surveyor and Medical Record Director (Employee #22) performed a tour through the medical records department that is in a building next to the Hospital. It was observed that one shelve was made with wood. The shelves were over filled and not properly filed, making them not accessible. The files on the top of the shelves touched the ceiling.
On all the hallways there were medical records on the floor and on the steps of a ladder. It was observed a black plastic bag on a shelve, the paint of one wall behind the shelve was fragmented, chipped and dusty, the roof had a big black spot above medical record shelves, rusty shelves, no smoke detector was observed, two dead roaches and the temperature was low. (Exhibits #14-#33)
During interview with Medical Record Director (employee #22) performed on 09/21/16 at 2:20 p.m., stated: " The medical record area is over filled, the file boxes cannot be place in order. I asked to the facility employee in charge of the building next to ours for a space to temporarily place the medical records until we can identify which record are going to be inactivated and move to Manati. This additional area has been in use for a month now, and we estimate to use it for two more month. Then we will have space to bring the files back into our department area. "
3. On 9/22/2016 at 11:45 a.m. a tour with the Office Clerk (Employee #30) was perform at the building next to the Medical Record Department. The door ' s lock is not functioning has a chain with a lock instead. The door and windows are made of steel and crystal which permits the sight of the files from the outside. The medical records were on wood pallets and on the floor. Some files were open, caused by a fan. One hallway connects to another big room that is used by another department of the Hospital to do maintenance work and as storage, which could cause that not authorize personnel have access to the medical records. It was observed that an electrical extension cord was loose on the floor and connected to a power outlet and a big brown and orange spot on the roof. (Exhibits #34-#59)
4. On 9/22/2016 at 3:10 p.m. was observed that Medical Record Department staff was installing black plastic bags on the door and windows of the building. The employees carried more wooden pallets inside the building.
During interview with Medical Record Director (employee #22) performed on 09/23/16 at 3:17 p.m., stated: " We are working to get the shelves for that area, administration gave us authorization. I have part of my staff working with the visibility of the door and windows, and we found some wood pallets to take the medical records off the floor. "
5. Facility failed to ensure that all active and inactive medical records are filed and maintain under proper safety conditions.
6. A mechanism to ensure that facility ' s medical record department performs an accurate process to monitor and notify for the prompt completion of medical records were not followed. These findings were identified during interview to the Medical Record Administrator (Employee #22) in the active medical records department on 9/20/16 at 8:35 am till 10:30 am:

a. Medical Record Administrator (Employee #22) stated on interview on 9/20/16 at 9:00 am her department do not prepares a report that include the exact number of incomplete and delinquent files. She also stated that her staff participate on a training last Friday, with the purpose of be capacitated to identify and tabulate incomplete and delinquent files. She stated that she told her employees to prepare the report with the information to be provided before surveys ends.

7. The incomplete medical record report received on 9/21/16 at 1:49 pm revealed that there are 474 incomplete records by the medical staff up until August of 2016. There is an average of 647 monthly discharges; however the exact amount of days that medical records were incomplete could not be determined accordingly with the information included in the report.

8. The incomplete medical record statistic report did not provide evidence of incomplete or delinquent files by nursing staff or other disciplines as determined on interview to the Medical Record Administrator (Employee #22) on 9/20/16 from 8:35 am till 10:30 am:

The Medical Record Administrator (Employee #22) stated on interview on 9/20/16 at 9:30 am that facility only include in the incomplete medical records quantification cases incomplete by medical staff.
9. R.R #32 is an 83 years old female, admitted on 5/19/16 with a diagnose of Acute Abdominal Pain Biliary Obstruction, and secondary diagnose of Diabetes Mellitus. During the record review on 9/20/16 at 1:00 pm the following was found:
a. The patient glucose blood levels were 358 milligrams per deciliter (mg/dl) on 5/25/16 at 11:00 am, 404 mg/dl on 5/25/16 at 4:00 pm, 389 mg/dl on 5/26/16 at 1:00 pm, 371 mg/dl on 5/26/16 at 4:00 pm, 349 mg/dl on 6/1/16 at 11:00 am, 393 mg/dl on 6/3/16 at4:00 pm, 348 mg/dl on 6/3/16 at 9:00 pm, 419 mg/dl on 6/5/16 at 11:00 am, 488 mg/dl on 6/5/16 at 4:00 pm, 400 mg/dl on 6/5/16 at 9:00 pm, 342 mg/dl on 6/6/16 at 9:00 pm, 400 mg/dl on 6/7/16 at 6:00 am, 500 mg/dl on 6/7/16 at 4:00 pm, 455 mg/dl on 6/7/16 at 9:00 pm, 349 mg/dl on 6/8/16 at 6:00 am, 400 mg/dl on 6/8/16 at 4:00 pm, and 315 mg/dl on 6/8/16 at 9:00 pm.
b. The patient ' s glucose blood level worksheet give evidence that the nursing staff performs the glucose blood level assessment to patient and when level were altered they performed an intervention however there is no evidence in this document of the re-evaluation or the cause of why it was not re-evaluated the patient glucose blood levels after the intervention according to nursing standard of practices and policy of the "Registro Diabetico Glucosa en Sangre" of the facility, that states in the bottom of the document the following: " Notify the physician immediately and document the action in the medical file of the patient. Re-evaluate altered levels: subcutaneous- in 2 hours, intravenous- in 1 hour " .
10. R.R #45 is a 63 years old male, admitted on 1/21/16 with a diagnose of Neck Abscess. During the record review on 9/21/16 at 10:40 am the following was found:
a. The patient glucose blood levels were 386mg/dl on 1/24/16 at 11:00 am, 360 mg/dl on 1/24/16 at 9:00 pm, 500 mg/dl on 1/25/16 at 6:00 am, 391 mg/dl on 1/26/16 at 9:00 pm, 355 mg/dl on 1/27/16 at 6:00 am, and 363 mg/dl on 1/27/16 at 9:00 pm. The nursing staff performed an intervention however there is no evidence in this document of the re-evaluation or the cause of why it was not re-evaluated the patient glucose blood levels after the intervention according to nursing standard of practices and policy of the "Registro Diabetico Glucosa en Sangre" of the facility, that states in the bottom of the document the following: " Notify the physician immediately and document the action in the medical file of the patient. Re-evaluate altered levels: subcutaneous- in 2 hours, intravenous- in 1 hour " .
b. The nurse activated the pain assessment on the plan of care, which establishes that the nurse will evaluate the location, intensity, and frequency of the pain every 4 hours and when necessary (PRN). However there is no evidence on the " Registro de Signos Vitales " of the pain assessment or the cause of why it was not re-evaluated for pain on 1/24/16 at 4:00 pm, 1/24/16 at 6:00 pm, 1/24/16 at 8:00 pm, 1/26/16 at 4:00 pm, 1/26/16 at 7:00 pm, 1/27/16 at 4:00 pm, 1/30/16 at 4:00 pm, 1/30/16 at 6:00 pm, and 12/1/16 at 4:00 pm.
11. R.R #50 is a 64 years old male, admitted on 12/13/12 with a diagnose of Acute Bronquitis. During the record review on 9/21/16 at 1:10 pm the following was found, the patient glucose blood levels were 425 mg/dl on 12/13/12 at 1:20 pm, 387 mg/dl on 12/14/12 at 6:00 am, 370 mg/dl on 12/14/12 at 11:00 am, 385 mg/dl on 12/14/12 at 6:00 pm, 397 mg/dl on 12/14/12 at 9:00 pm, 354 mg/dl on 12/15/12 at 6:00 am, 441 mg/dl on 12/15/12 at 4:00 pm, 478 mg/dl on 12/15/12 at 9:00 pm, 367 mg/dl on 12/16/12 at 4:00 pm, 500 mg/dl on 12/16/12 at 9:00 pm, 320 mg/dl on 12/17/12 at 6:00 am, and 308 mg/dl on 1/27/12 at 11:00 am. The nursing staff performed an intervention however there is no evidence in this document of the re-evaluation or the cause of why it was not re-evaluated the patient glucose blood levels after the intervention according to nursing standard of practices and policy of the "Registro Diabetico Glucosa en Sangre" of the facility, that states in the bottom of the document the following: " Notify the physician immediately and document the action in the medical file of the patient. Re-evaluate altered levels: subcutaneous- in 2 hours, intravenous- in 1 hour " .
12. R.R #56 is a 25 years old female, admitted on 4/15/16 with Cesarean Delivery (40 weeks). During the record review on 9/21/16 at 3:18 pm the following was found, the patient glucose blood levels were 70 mg/dl on 4/15/16 at 10:30 am. The nurse writes in the "Registro Diabetico Glucosa en Sangre" of the patient: " notify physician " . Then the nurse performed an intervention which consisted on administrating D5W/0.45 normal saline solution (NSS) at rate 100 milliliters (ML) , however there is no evidence in this document of the re-evaluation or the cause of why it was not re-evaluated the patient glucose blood levels after the intervention according to nursing standard of practices and policy of the "Registro Diabetico Glucosa en Sangre" of the facility, that states in the bottom of the document the following: " Notify the physician immediately and document the action in the medical file of the patient. Re-evaluate altered levels: subcutaneous- in 2 hours, intravenous- in 1 hour " .

Based on a recertification survey, 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 to consults, nurses notes, physician progress notes, physician's orders included telephone order's, vital signs and physician discharge summary evaluation and other information and documents in the patient medical record that are not accessible for 13 out of 80 records reviewed (R.R #10, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #80 ).

Findings include:

During ten active clinical records reviewed (R.R #57 through #67 and #80) reviewed during the survey performed from 09/20/16 from 09/23/16 from 8:00 am till 4:30 p. m. did not contain complete information and documentation related to consults, nurses notes, physician progress notes, physician's orders included telephone order's, vital signs and physician discharge summary evaluation and other information and documents in the patient medical record that are not accessible.

1. RR #57 was reviewed on 9/20/16 at 9:00 a. m. patient with 75 years old female who was admitted on 9/19/16 due to a diagnose of Hyponatremia. The record was reviewed and was found the following:

a. The nurse initial assessment performed on 9/19/16 at 6:00 p. m. lacks information related who accompanied the patient on the admission, patient relative, the hour when the patient was admitted and disposition of the patient personnel objects. The section designated to '' Sistema Hematopoyetico " , " Patron de percepcion y concepto propio " , Psichosocial Pattern, " Efectos de la Enfermedad " , " Patron de Valores y Creencias " , " Criterios prevencion caidas " , if during the hospitalization the patient was possible candidate for service of nutricionist, social worker, physical therapy or religious services, Level of Motivation for Learning, Educational Needs and Nursing Diagnosis was maintain in blank.

The nurse signed the document however the license number was illegible. The patient and family education plan on the space for '' Clave de Evaluacion '' was maintain in blank. The form designated to '' Education to patient y/o family for InfectionControl Program, Intergumentary System Assessment and the form for Orientation related to the personnel belongings not performed by the nurse.

b. The nursing treatment kardex provide evidence that the patient was admitted on 9/18/16 with diagnosis of '' Hyponatremia '' The kardex indicated a diabetic diet ADA diet with two snacks daily but did specified the hours when the patient received the snacks. Indicated a '' Destrostix but did not indicated how many times a day was to be performed the Destrostix. Did not performed the patient '' clasification or cathegorization.'' On the daily activities only wrote '' Bed rest '' however did not indicated how the patient received the bath and other information related to daily activities. Lacks of the nursing diagnosis and was not sign by the nurse who admitted the patient. The kardex reveled that on 9/19/16 was pending '' EKG '' On 9/20/16 at 9:00 a. m. the patient record was selected per the surveyor to reviewed and provide evidence that the EKG was not realized at this time.

c. The Diabetic Register for blood glucose test lacks of the identification label. Only provide evidence of a Destrostix performed by a register nurse (employee #32) on 9/20/16 at 6:00 a. m. However the number of the Destrostix result and the nurse signature was not legible.

d. The medication register administration kardex performed on 9/18/16 lacks of the patient weight and the allergy history. The kardex provide evidence that on 9/19/16 the patient received Normal Saline at 100 ml. / hour. The patient record was reviewed on 9/20/16 at 9:00 a. m. and provide evidence that the nephrology consult requested on 9/19/16 at 1:00 p. m. was answer on 9/19/16 at 11:38 p. m. and ordered decrease I.V. fluids to 50 ml. / hr. the order was taken by a register nurse (employee #32) on 9/20/16 at 2:10 a. m. two hours and 40 minutes later however, no evidence on the kardex of this I.V. changes ordered per the nephrologists.

The patient was visit during the surveyor round accompanied with Associated Nursing Director (employee #16) and the Nurse Supervisor (employee #30) on 9/20/16 at 10:00 a. m. and was observed that the patient maintain the same I.V. line until the admission, did not have a regulator or I.V. pump and the label located on the I.V. bag of Normal Saline 1000 ml. indicated 100 ml. per hour, however the patient did not received the I.V fluids according of the nephrologists order.

e. A consultation report request on 9/19/16 at 1:00 p. m. did not provide evidence of the date when request the consult, at what service, the name of consultant. No evidence of who notified the consult and to whom, date and hour. The reason to request the consult was illegible. The consultant answer the consult on 9/19/16 at 11:38 p. m. however lacks of consultant signature and license number.

f. The nurse note performed by the nurse on 9/19/16 at 3:00 p. m. lacks of the nurse license number.

g. The form designated for '' Notification HIPPA Law " lacks of identification label and the name and signature of the authorized institution personnel.

h. The important massage of Medicare related to the patient rights lacks of the date when the patient signed the document.

i. The authorization for medical treatment lacks of patient name, hour and other information solicited on the document only provide the patient signature.

2. RR #58 was reviewed on 9/20/16 at 11:40 a. m. patient with 79 years old male who was admitted on 9/18/16 due to a diagnose of Pyelonefritis. The record was reviewed and it was found the following:

a. The physician History and Physical Examination was maintained in blank.

b. A consultation report request on September 18, 2016 at 8:00 a. m. lacks of the name of consultant. No evidence of who notified the consult and to whom, date and hour. The consultant answer the consult lacks of the consultant license number.

c. The physician admission note performed on 9/18/16 at 2:00 p. m. lacks information related to the signs and symptoms. The area designated to identified if the patient has '' Special / Psychosocial / Cultural / Religion Needs and the area designated for '' Education to patient / relatives planned regarding and Discharge Planning '' was maintain in blank.

d. The physician order for 9/17/16 at 7:20 p.m for '' Ventury Mask at 35 % not taken per the register nurse.

e. The patient was admitted on 9/18/16 with diagnoses of Pyelonefritis the record was reviewed on 9/20/16 and provided evidence that the '' Interdisciplinary Care Plan '' was placed on the patient record and only has the initial diagnosis however was maintain in blank.

f. The Physician Assessment of the Emergency Room was performed on 9/17/16 at 6:15 p.m. and lacks of the patient weight, chief complaint, provisional diagnosis, patient disposition and the condition of the patient at the moment when goes out of the emergency room. The document was signed per the physician however lacks of the physician license number.

g. The patient was admitted at the fifth floor department on 9/18/16 the form used per the Emergency Room Department for the change of patients shift " entrega de pacientes " did not have the hour when the patient arrive at the floor.

h. The Authorization of Medical Surgical treatment consent form was signed by the patient daughter on 9/17/16 but did not have identification label and lacks of the patient name and record number.

i. The nursing treatment kardex performed by the nurse but lacks of the date, the patient classification/(cathegorization, the daily activities, the allergies history, nursing diagnosis and the signature of the nurse who admitted the patient.

3. RR #59 was reviewed on 9/20/16 at 3:40 p. m. patient with 49 years old female who was admitted on 9/18/16 due to a diagnose of Hidronefrosis and Ureterolitiasis.

a. The '' Clinic Evaluation of Emergency Room performed by the physician lacks of identification label. The designated area to write Chief Compliant " Queja principal " , provisional diagnosis, the hour, vital signs (temperature, respiration and pulse), patient weight, condition of patient when go out of the emergency room and disposition was maintain in blank and lacks of the physician license number. The documentation and the physician signature was illegible.

b. The nurse initial assessment performed on 9/18/16 at 8:45 p. m. lacks information related
the name of the physician to notified the admission, the service and the hour and the area designated to documented the nurse intervention and evaluation was maintain in blank.

c. The initial social worker interview performed on 9/20/16 did not provide evidence of patient and family orientation, did not mark on the space if the patient was referred or not referred to social worker services.

d. The form designated to '' Entrega Admision a Departamentos Clinicos Emergency Room '' provide evidence that the patient has a B/P ON 137/94 the nurse note performed by the register nurse (employee #33) revealed that the patient was alert, oriented, not referred pain, has angio #22 on left arm and received Rocephin 1 gm., pending urine culture but did not provide evidence of a blood pressure re-assessment before transferring the patient to other department.

e. The nursing treatment kardex did not provide evidence of the date when the patient was admitted. The designated area to write the patient daily activities, nursing diagnosis, classification or categorization was maintained in blank and lacks of the nurses ' signature. The Kardex revealed that the physician ordered Urine Culture, Blood Culture every 20 minutes per two times, EKG, Chest X Ray and KUB on 9/18/16 but the kardex did not provide evidence if it pending or realized. The admission orders written by the physician on 9/18/16 at 4:25 p. m. revealed that the orders not taken by the nurse, lacks of nurse signature, date and hour.

f. A consultation report answer per the Urology on 9/19/16 at 8:00 a. m. lacks of the consultant license number, and the documentation was illegible. No evidence of who notified the consult and to whom, date and hour. The consultant answer the consult lacks of the consultant license number.

g. A consultation report request on 9/18/16 at 7:00 a. m. lacks of the name of the consultant. No evidence of who notified the consult and to whom, date and hour. The consultant answer the consult on 9/18/16 at 4:25 p. m. and the documentation was illegible.

h. A consultation report request to Internal Medicine notified on 9/19/16 at 12:09 p. m. however the consult did not provide evidence of the reason to solicit the consult and the consult never answer.

i. The admission note performed per the physician on 9/18/16 at 4:00 p. m. did not have the reason for admission and signs and symptoms. The information written by the physician and the physician signature was illegible and lacks of the license number.

j. The pre -anesthesia assessment was performed on 9/19/16 however no evidence of the post-anesthesia assessment related to anesthesia complications within the first 24 to 48 hours post -op, lacks of the anesthesiologist post assessment, signature, date and pour.

k. The anesthesia consent performed on 9/19/16 the area designated to written the type of anesthesia was illegible.

l. The form designated to ''Contaje Corto '' the signature of the register nurse was illegible and lacks of the license number.

m. The consent form for Blood Transfusions and or derivate taken on 9/19/16 at 2:00 p. m. did not have the name of the physician authorized per the patient when in emergency case was the responsible for the patient condition.

n. The consent form for '' Operation or Diagnostic Procedures '' taken on 6/19/16 at 8:00 a. m. the name of the surgeon, the anesthesiologist and other information was illegible.

o. The patient record was reviewed on 9/20/16 at 3:40 p. m. and reveled that when the patient was transferring to other hospital on 9/17/16 and the B/P was on 179/96. On Emergency Room on 9/18/16 at 12:00 m.n. has 180/110. The patient was transfer of the emergency room to ward on 9/18/16 at 8:16 p. m. and has a B/P on 137/94. The record provides evidence that on 9/17/16 at 9:10 p. m. on Emergency Room the physician ordered Vasotec 2.5 mgs. I.V. and then took a B/P in one hour, the order was taken by the register nurse (employee #34) on 9/18/16 at 12:50 a. m. however no evidence on the patient record if the patient received the '' Vasotec '' according of the physician order.

p. The patient record revealed that the patient was maintain a higher B/P before the surgery intervention, the daily ''vital signs'' check form provided evidence that on 9/18/16 at 8:45 p. m. has 164/96. On 9/19/16 at 12:00 m.n. has 120/80. On 9/19/16 at 8:00 a. m. has 140/90. The patient was transfer to operating room on 9/19/16 at 4:00 p. m. and no evidence of vital signs before the patient transfer to operating room department.

q. The anesthesia record reveled on 9/19/16 at 3:30 p. m. condition on close performed per the anesthesiologist that the patient has a B/P on 176/77.

r. The '' Recovery Room '' nurse note provided evidence that the patient was received at recovery room on 9/19/16 at 5:45 p. m. and transfer to ward at 9:10 p. m. and revealed that the patient has a B/P on 155/95. The nurse note performed by the register nurse of the ward (the signature and the license number was illegible) on 9/19/16 at 9:30 p. m. provide evidence that the patient arrival to ward department room #315 B and has a B/P on 164/90 the next B/P was taken on 9/20/16 at 12:00 m.n. 2 hours and 30 minutes later and the B/P was on 132/86. The next B/P was taken on 9/20/16 at 8:00 a. m. eight hours later and revealed that the patient has a B/P on 156/90.

s. The facility nurse personnel failed to perform a re-assessment all of the times when the patient present high blood pressure, the nurse never notified the blood pressure changes at the patient physician. The patient kardex medication was reviewed and did not revel if the patient received medication for blood pressure.

t. The pre-operative check for surgical procedure performed on 9/18/16 on shift 7:00 a. m. to 3:00 p. m. lacks of the nurse signature on the space designated to revised by and the space designated to re-check was maintain in blank.

u. The nurse note performed on 9/18/16 at 2:00 a. m. by the register nurse (employee #35) only revealed that the patient was maintain N.P.O. to operating room and at 6:00 a. m. patient not refer pain.

v. No evidence of nurse note on 9/19/16 on shift 7:00 a. m. to 3:00 p. m. The nurse note performed on shift 3:00 p. m. to 11:00 p. m. at 9:30 p. m. by the register nurse (the signature not legible) only revealed that the patient was receiving from the operating room alert and oriented and not refer pain. On shift 11:00 p. m. to 7:00 a. m. at 1:00 a. m. the register nurse (employee #36) only wrote patient in stable condition at this moment not refer pain.

4. RR #60 was reviewed on 9/23/16 at 11:15 a. m. patient with 52 years old male who was admitted due to a diagnose of Phymosis Chordee and secondary diagnosis of Diabetes Mellitus and was found the following:

a. A consultation report request on May 16, 2016 at 7:00 a. m lacks of the date and hour. The consultant answering the consult on 5/16/57 at 3:28 p. m. was signed by the consultant however lacks of the physician license number.

b. The form designated for '' Notification HIPPA Law " lacks of the date when the patient signed the document and the name and signature of the authorized institution personnel.

5. RR #61 was reviewed on 9/23/16 at 1:15 p. m. patient with 46 years old female who was admitted on 9/19/16 due to a diagnose of Nodular Thyroid with Calcification and secondary diagnoses of Hypertension and Hypothyroidism. The record was reviewed and was found the following:

a. A consultation report request on 8/30/16 at 11:04 (did not specified if a. m. or p. m.) and did not provide evidence of what service requested and the name of consultant. On the area designated to mark if only a consultation, consult and follow up or please feel free to order was maintain in blank. No evidence of who notified the consult and to whom, date and hour. No evidence of the reason to requested the consult, the date and the hour. The consultant answer the consult on 9/14/16 at 3:31 (did not specified if a. m. or p. m.) a. m. however lacks of consultant license number.

b. The ''Operation Report performed on 9/19/16 at 2:40 p. m. the space to written '' instrument count verifier '' was maintain in blank.

c. The '' Recovery Room '' form performed on 9/19/16 the nurse signature and the license number of the '' received note at 6:40 p. m. was illegible.

d. The pre-operative check form performed on 9/19/16 did not provide evidence of the name of person who performed the re-check and lacks of the date.

e. The '' Admission Request '' performed on 9/19/16 did not identified type of admission. The physician order performed on 9/19/16 lacks of the hour when the physician written the order.

f. The '' Register of Medication Administration " pages 2, 3, 4 and 5 lacks of identification label. The first page lacks of the patient weight and the patient allergy history.

g. The patient vital signs register provide evidence that the patient has on 9/19/16 at 6:40 p. m. a B/P on 150/88 six hours later on 9/20/16 at 12:00 m. n. B/P on 140/84 eight hours later on 9/20/16 at 8:00 a. m. a B/P on 144/86. No evidence on the patient record when the nurse performed a blood pressure re-assessment and no evidence if the physician was notified per the register nurse related to the patient blood pressure changes.

h. The initial nurse assessment performed on 9/19/16 at 6:40 p. m. provided evidence that the patient weight was 264 pounds and the BP was 150/88 and the nurse diagnosis was '' Alteration on the Endocrine System, however no evidence of recommended that the physician ordered a nutritional evaluation. The Interdisciplinary Plan of Care was initiated per the register nurse and no evidence of nutritional intervention.

i. The form designated to '' Intergumentary System '' performed per the register nurse lacks of the date and the nurse license number and the nurse signature was illegible.

j. The form designated to '' Manejo de Riesgo Educacion Paciente y/o Familia was mintain in blank.

k. The nurse note performed on 9/19/16 on shift 11:00 p. m. to 7:00 a. m. included nurse signature was illegible. The additional note related to observations/interventions and patient answers not legible.

l. A nurse note performed on 9/19/16 at 6:30 did not indicated if the note was written at a. m. or p. m. The note reveled that was written when the patient return from the operating room and described a patient on pain scale level " 8" and the person who wrote the note specified
'' Se le notifica a la graduada todo lo antes mensionado. '' It was notified to the registered nurse everything mention above. The signature of the person who wrote the note was illegible and lacks of the license number. However, no evidence of nurse intervention related to the patient pain and no evidence of re-assessment of the patient blood pressure.

m. The patient was discharge to home on 9/20/16 at 10:20 a. m. and no evidence of a nutritional referral, on the nursing discharge instructions only wrote if oriented , how to clean the wound, however did not indicated with what.

n. The form designated for '' Notification HIPPA Law " lacks of the date and the name of hospital representative personnel.

o. The '' Treatment Nursing Kardex '' was performed on 9/19/16 and lacks of the signature of the nurse was admitted the patient.

6. RR #62 was reviewed on 9/23/16 at 1:00 p. m. patient with 32 years old male who was admitted on 9/20/16 due to a diagnose of Gynecomastia and was found the following:

a. The physician short stay record performed on August 22, 2016 at 3:00 p. m. the physical examination lacks of the patient blood pressure and pulse. All of the information written per the physician was illegible and lacks of the physician license number.

b. A physician order was placed on 9/20/16 at 6:00 p. m. for Ancef 1 gram I.V. lacks frequency and not taken by the nurse.

c. A physician verbal order written by the nurse on 9/20/16 at 3:45 p. m. was signed by the nurse on 9/20/16 at 3:45 p. m. to administer '' Morphine 6 mgs. I.V. slowly stat '' the record was reviewed on 9/23/16 at 1:00 p. m. and provide the order did not read back lacks of the physician signature, date and hour.

d. The form designated for '' Notification HIPPA Law " was maintained in blank.

e. The Ambulatory Surgery Patient Orientation performed by the nurse on 9/20/16 did not signed by the nurse and lacks of the date.

f. The anesthesia consent form was performed on 9/20/16 and lacks of the hour.

7. RR #63 was reviewed on 9/23/16 at 10:40 a. m. patient with 44 years old female who was admitted on 6/15/16 due to a diagnose of Thyroid Mass Status post Trans cervical total Thyroidectomy. The record was reviewed and was found the following:

a. The Recovery Room form performed on 6/15/16 revealed that the patient arrival at 6:45 p. m. and the transferred to room on 6/16/16 at 10:30 a. m. the patient was evaluated by the anesthesiologist on 6/15/16 and lacks of the hour and the license number. No evidence of the nurse note when received the patient on the floor.

b. A consultation report request and did not provide evidence of the date when request the consult, at what service, the name of consultant. On the area designated to mark if only a consultation, consult and follow up or please feel free to order was maintain in blank. No evidence of who notified the consult and to whom, date and hour. No evidence of the reason to requested the consult, the date and the hour. The consultant answer the consult on 6/10/16 at 11:00 a. m. however lacks of consultant signature, license number and identification label.

c. A consultation report request on June 7, 16 at 10:42 (did not specified if a. m. or p. m.) did not provide evidence at what service and the name of consultant. On the area designated to mark if only a consultation, consult and follow up or please feel free to order was maintain in blank. No evidence of who notified the consult and to whom, date and hour. The consultant did not answer the consult.

d. The physician admission order's placed on 6/15/16 lacks of the hour when the physician ordered.

e. The form designated for '' Notification HIPPA Law " lacks of the date when the patient signed the document and the name and signature of the authorized institution personnel.

f. The post - operative follow up call not performed on the first twenty four hours when the patient discharge to home not according of the facility policies and procedures.

8. RR #64 was reviewed on 9/23/16 at 11:55 a. m. case of 50 years old female who was admitted on 9/20/16 due to a diagnose of Left Elbow lateral Epiconditis and was found the following:

a. The '' History and Physical Examination '' was performed by the physician on 9/12/16 at 9:00 a. m. and the gynecologic and social history was maintained in blank and lacks of the physician license number.

b. The Recovery Room assessment performed on 9/20/16 revealed that the patient arrival at recover room at 8:45 a. m. and then transferred to room on 9/20/16 at 10:55 a. m. the pain assessment was performed and two classification was performed at the same time cero pain and classified on four scale of pain, however no evidence of intervention related to pain management. The nurse note was performed at 8:45 a. m. and revealed that the patient discharge to home without complications and never referred pain.

c. A physician verbal order to administered ' ' Ancef 2 gms. for intraoperative use was written by the nurse, the record was reviewed on 9/23/16 at 11:55 a. m. and lacks of the date and the hour when the nurse received the verbal order.

d. A consultation report request lacks of identification label, name of the consultant only written '' I M '', on the area designated to mark if only a consultation, consult and follow up or please feel free to order was maintain in blank. No evidence of who notified the consult and to whom, date and hour. The consultant answers the consult on 9/15/16 at 11:00 a. m however lacks of the license number.

e. The post - operative follow up call was performed on 9/21/16 at 8:00 a. m. on the first twenty four hours when the patient discharge to home the patient did not answer and no evidence of a second call.

f. The form designated for '' Cotejo Pre-operatorio '' revealed that the '' pre-operative cotejo'' was performed on shift 7:00 a. m. till 3:00 p. m. but the '' pre-operative cotejo'' not performed according of the pre- operative form.

g. The form designated to identified the area of the procedure before enter at the operating room suite performed on 9/20/16 the space for '' time out, verification of the procedure area and third time out '' lacks of the signature and the physician license number, the spaces was maintain in blank.

h. The form designated to realize the '' Contaje Corto'' was performed on 9/20/16 however lacks of the hours when reviewed and did not signed by the register nurse.

i. The form designated to '' Admission Request '' lacks of the admission date, type of admission and did not mark if the patient required discharge planning.

j. The form designated for '' Notification HIPPA Law " lacks of the date when the patient signed the document and the name and signature of the authorized institution personnel.

9. RR #65 was reviewed on 9/23/16 at 11:35 a. m. patient with 67 years old male who was admitted on 8/29/16 due to a diagnose of Incisional Hernia without obstruction or gangrene. The record was reviewed and was found the following:

a. The Pre-operative check list performed on 8/29/16 did not have the patient name and lacks of the hour when the anesthesiologist signed the document.

b. A consultation report request on 8/20/16 at 2:00 p. m. lacks of identification label, the solicited service, on the area designated to mark if only a consultation, consult and follow up or please feel free to order was maintain in blank. No evidence of who notified the consult and to whom, date and hour. The consultant answer the consult however lacks of the license number, the date and the hour when answering the consult.

c. The form designated to '' Admission Request '' the area designated for admitting criteria, discharge planning required and allergy history was maintain in blank. The admission orders lacks of the date and the hour when the physician ordered the admission.

d. The '' Blood Transfusion Consent '' was signed by the patient authorized the physician and/ or the hospital personnel to administer blood or components in emergency case did not have the patient name, record number, the name of the authorized physician, the date and the hour when the patient signed the consent and the signature of the physician who takes the authorization, the date and hour.

e. The form designated for '' Notification HIPPA Law " lacks of the date when the patient signed the document and the name and signature of the authorized institution personnel.

10. RR #66 was reviewed on 9/22/16 at 2:30 p.m. patient with 69 years old male who was admitted on 9/19/16 due to a diagnose of Bladder Tumor. The record was reviewed and it was found the following:

a. The physician short stay record performed on August 26, 2016 at 1:00 p. m. on the physical examination all of the information written by the physician on the physical examination was illegible and lacks of the physician license number.

b. The post-anesthesia assessment related to the anesthesia complications within 24 to 48 hours post up was maintain in blank and lacks of anesthesiologist signature, date and hour.

c. The space designated to mark if the patient received airway on the recovery room assessment was maintained in blank. No evidence of pain assessment, no evaluation for discharge by the anesthesiologist. The area designated to the nurse documented the patient condition lacks of information the space was maintain in blank.

d. A consultation report request on August 20, 16 at 1:00 p. m. lacks of the name of consultant. On the area designated to mark if only a consultation, consult and follow up or please feel free to order was maintain in blank. No evidence of who notified the consult and to whom, date and hour. The consultant answers the consult however lacks of the hour went answering and lacks of the consultant license number.

e. The post - operative follow up call was performed on 9/20/16 at 9:20 a. m. and provided evidence that the patient did not answer however no evidence of a second call. The document was signed by the nurse and lacks of the nurse license number.

f. The form designated for '' Cotejo Pre-operatorio '' lacks of the signature of the person who reviewed the information and the date, the name of the person who performed a second revision and the date re-revision. Lacks of the date when performed the pre-operative check.

g. The form used on the operating room department for '' Contaje Corto '' provide evidence that when ended the procedure and performed the instruments and other materials used during the surgery there is absence of '' sponge holder on the tray. ''

h. The information of the consent form taken on 8/26/16 at 1:00 p. m. was illegible.

i. The consent form for blood transfusion and derivates lacks information related to the patient name, record number, the name of the physician, the date and the hour when the patient signed the consent. The consent lacks of signature of the physician who takes the consent, the date and the hour.

j. The form designated for '' Notification HIPPA Law " lacks of the date when the patient signed the document and the name and signature of the authorized institution personnel.

k. The nurse initial assessment performed on 9/18/16 at 8:00 p. m. on the section designated to ''if during the hospitalization the patient was possible candidate for service of nutritionist, social worker, physical therapy or religious services '' was maintain in blank.

11. RR #67 was reviewed on 9/20/16 patient with 84 years old male who was admitted on 9/9/16 due to a diagnosis of Severe Anemia. The record was reviewed and it was found the following:

a. The nurse initial admission was performed on 9/13/16 at 6:00 a. m. five days later post admission according of the medication register administration the patient was admitted on 9/9/16 with diagnosis of Respiratory Failure at room #428- A. The nurse initial admission performed on 9/13/16 revealed that the patient was received at Emergency Room per Symptomatic Anemia, Hypotension, weakness and respiratory difficulty. The nurse initial admission lacks information related to health history, allergy history, patient habits, system revision, cardiovascular system, elimination pattern, psychosocial pattern, neurological system, nutritional assessment, pain management, educational needs, discharge planning, nursing diagnosis and other important information, all of this space was maintain in blank. The nurse note provide evidence that the patient has a B/P on 130/54 and during performed the skin assessment revealed that the patient has gray and dry skin, poor turgor, hematoma, abrasion and cellulites on left hand. The nurse note revealed that the patient was stable but not oriented nor capable to respond to questions. She maintain I.V. fluids 0.9 % Normal Saline at 100 ml. per hour on right forearm. The space to write if the patient was received with or accompanied per a relative on the initial admission the nurse wrote ' ' not applicable " . No evidence of nurse admission note on shift 7:00 a. m. till 3:00 p. m. on 9/13/16.

The nurse progress note for 9/9/16 was maintain in blank and only provide evidence that on 9/9/16 at 6:15 p. m. the patient was canalized on left arm with angio #20 heparin lock and take a laboratory samples. However the nurse (employee #41) signed the note but was illegible.

On 9/10/16 at 8:30

Based on a recertification survey, thirty closed records reviewed (R.R) with the Medical Record Administrator (Employee #22) during survey process from 9/20 thru 9/23/2016, it was determined that the facility failed to ensure that clinical records have documentation related to nurse's notes without signature, documentation of the date and time, lack of treatment Kardex, counter sign of telephonic physician order, activate plan of care, progress note justification and orientation of the physician for restraint, nursing assessment during restraint and complete discharge summary for 7 out of 80 records reviewed (R.R #10, #11, #12, #28, #31, #32, and #39).
Findings include:

A. Thirty medical records were reviewed from 9/20 thru 9/23/2016 with the Medical Record Administrator (Employee #22) and the following was found:

1. R.R #28 did not have the nurse's signature on 3 nurse ' s notes on 7/31/16 at 1:00 am, 7/31/16 at 1:40 am, and on 6/14/16 at 8:30 pm.

2. R.R. #31 the kardex of medication was not found on 9/20/16 at 11:28 am.

3. R.R #32 is a 83 years old female, admitted on 5/19/16 with a diagnose of Acute Abdominal Pain Biliary Obstruction, and secondary diagnose of Diabetes Mellitus. During the record review on 9/20/16 at 1:00 pm the following was found:
a. There is evidence of an incomplete daily nurse's flow/treatment sheet that does not have evidence of the date, and the Registered Nurse (RN) of the 7:00 am shift did not sign the note. The RN did not sign the 7:00 am nurse ' s note from 5/23/16. Four progress notes from the physician were found not timed on 5/19/16, 5/20/16, 5/23/16, and 5/26/16. The discharge summary form was not filled and there was no evidence of a final progress note that included condition at discharge, discharge instructions and follow-up care required provided when requested by the surveyor on 9/20/2016 at 1:40 pm.

b. There is evidence that part of the nursing staff uses a combination of roman numerals and Arabic numerals to write the date, while the other nursing staff uses only Arabic numerals. There is no mechanism to ensure that all nursing personnel write the date uniformly and in a consistent manner.
During interview with Medical Record Director (employee #22) performed on 09/23/16 at 3:20 p.m., stated: " Some of the nursing staff uses the roman numerals to identify the month in the documentation of the date. "
c. There are four pages of the "Registro Diabetico Glucosa en Sangre" Blood Glucose Registry Log on the patient file. The first page starts on V/14/16 (5/14/16) then it follows with V/25/16 (5/25/16). There is no evidence or explanation of what occurred in that interval of time. This page continues from V/25/16 (5/25/16) to VI/1/16 (6/1/16), however in the second page the glucose levels starts on V/25/16 (5/25/16) to V/30/16 (5/30/16). There is evidence that the nursing staff used two different pages of Blood Glucose Registry Log to measure the patient glucose blood levels on the same dates.
d. During the review of the policies and procedures on the documentation of the medical record performed on 9/23/16 at 3:00pm there is no evidence of how document the date.
e. No evidence was found on the facility ' s nomenclature registry of the uses of the roman numerals on the clinical record documentation.
4. During RR #39 the discharge summary form was not filled and there was no evidence of a final progress note that included condition at discharge, discharge instructions and follow-up care required provided when requested by the surveyor on 9/20/16 at 4:07 pm.

5. R.R #43 the RN of the 7:00 am shift did not sign the note on 04/22/16.


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6. R.R. #10 is a 64 years old female who was admitted on 9/19/16 with a diagnosis of Bronchopneumonia (BKP) and mechanic ventilation. According to the record review performed on 9/20/16 at 2:00 pm wit nurse supervisor (employee #35), it was found that on 9/20/16 at 7:00 am the physician performed an telephonic order to start restraint protocol on both hands for 24 hour. However the physician orders lack of physician signature. The Patient restraint sheet lack of the date documented, the reason to be restrained was due to avoid patient hurt and avoid interruption of treatment. The type of restraint was soft in both arm, the restraint order be performed on 9/20/16 at 7:00 am till 9/21/16 at 8:00 am (25 hour) the sheet indicate restrain no more than 24 hour. The registred nurse (RN) lacks to document the sign and symptom or patient behavior previous to restraint, the alternative measure previous to restraint. The nursing assessment and preventive round provided and the time provided, Change in patient behavior and started to assess patient t 8:00 am. The RN lacks to sign the patient restraint sheet.

The nurse progress note performed on 9/20/16 at 10:00 am the nurse documented that patient was in restraint protocol. No evidence was found related to patient behavior to be restrained. No evidence was found related to physician evaluation previous to restraint. No evidence was found related to less restrict measure to be performed previous to restraint the patient.

The facility ' s policy and procedure related to restraint reviewed on 9/20/16 at 1:30 pm in the items #1 that the physician or the professional nurse that identified patient at risk to harm themselves or other patient initiate the restraint process after be taken other less restricted alternative or option. Item #2 indicates that a verbal order for restraint be counter sign by the physician no more that 6 hour after be initiate the restraint. Item #5 indicates that nursing personnel maintain constant observation to patient in restraint during continues round every 15 minute to identified patient care needs. Item #6 the professional nurse (RN) documented every 4 hour the observation and intervention performed to the patient in the nursing progress note.

The facility failed to meet their restraint policy and procedure. The RN failed to activate the restraint plan of care.

a- No evidence was found that the physician counter sign the restraint verbal order no more that 6 hour.

b. No evidence was found related to the physician's restriction evaluation ordered on 9/20/16 at 7:00 am.

c. No evidence was found related to the less restricted measure taken before restrain the patient.

d. No evidence was found related to patient or their relative orientation related to the restraint.

e. No evidence was found related to restraint consent be sign by patient or relative.

f. No evidence was found related to RN documentation the constant observation and intervention to the patient in the nursing progress note.

g. No evidence was found related to restraint plan of care be activated by the RN.

7. R.R. #11 is a 44 years old male who was admitted on 8/2/16 with a diagnosis of Anasarca, Diabetes Mellitus and High Blood Pressure (HBP). According to the record review performed on 9/20/16 at 2:15 pm with nurse supervisor (employee #35), it was found that on 9/8/16 at 9:00 am the physician performed a telephonic order to renew restrained. However the physician order was incomplete due to lack of area and hour to be restraint and lack of physician signature.

The Patient restrain sheet the RN documented that the physician order for restraint was on 9/8/16 at 8:00 am when was at 9:00 am the RN lacks to document the date, lack to document the alternated measure previous to restraint. The patient restraint protocol sign and dated by the RN was on 9/8/16 at 8:00 am and lack of area to be restraint and physician date, hour and sigh.

On 9/15/16 at 8:00 pm a physician telephonic order for Restraint protocol soft per 2 was placed. The patient restraint sheet lack of Dated, Reason to restrain, description of sign and symptom to restrain, type of restraint, areas of restraint, the order of restraint, alternate measure previous to restraint. The patient restraint protocol was left in blank, only provide the date.

The patient consent to restraint was left in blank, only provide relative signature. No evidence was found related to physician order for restraint on 9/16/16. The RN documented in the patient restraint sheet the order was performed on 9/16/16 at 8:00 am. The 11-7 shift lack to documented the time frame to be assess and to performed the nursing round and the assessment, if any change in patient behavior and was documented at 12:00 am and 2:00 am.

The restrain protocol lack of the physician signature patient consent to restraint was left in blank only provide relative signature. No indicate if accept or not and date and hour. On 9/19/16 at 5:45 pm the physician telephonic order ordered Restraint per 24 hour. The order lacks of type of restrain and area to be restraint and the date and hour and countersign of the physician.

The Restriction sheet performed on 9/19/16 the RN documented that the order be placed on 9/19/16 at 9:20 am, the sheet lack of description of sign and symptom to restraint, type of restraint areas of restraint, the order of restraint, alternate measure previous to restrain.

The 7-3, 3-11 and 11-7 shift lack to document the time frame to be assess and to performed the nursing round and the assessment, if any change in patient behavior. On 9/20/16 at 8:00 am the physician telephonic order renews soft restraint per 2 extremities. The order lacks of the date and hour and countersign of the physician.

The Restriction sheet lack of the dated to be performed, the RN documented that the order be placed on 9/20/16 at 8:00 am, the sheet lack of description of sign and symptom to restraint, type of restraint areas of restraint, the order of restraint, alternate measure previous to restrain. The 7-3 shift lack to documented the time frame to be assess and to performed the nursing round and the assessment, if any change in patient behavior.

The facility policy and procedure related to restraint reviewed on 9/20/16 at 1:30 pm reads in the items #1 that the physician or the professional nurse that identified patient at risk to harm themselves or other patient initiate the restraint process after be taken other less restricted alternative or option. Item #2 indicates that a verbal order for restraint be counter sign by the physician no more that 6 hour after be initiate the restrain. Item #5 indicates that nursing personnel maintain constant observation to patient in restraint during continues round every 15 minute to identified patient care needs. Item #6 the professional nurse (RN) documented every 4 hour the observation and intervention performed to the patient in the nursing progress note.

The facility failed to meet their restraint policy and procedure. The RN failed to activate the restraint plan of care.

a. No evidence was found related to physician evaluation previous to restraint.

b. No evidence was found related to less restricted measure to be performed previous to restraint the patient.

c- No evidence was found that the physician counter sign the restraint verbal order no more that 6 hour that be placed.

d. No evidence was found related to RN documentation the constant observation and intervention to the patient in the nursing progress note.

e. No evidence was found related to restraint plan of care be activated by the RN.

8. R.R. #12 is a 36 years old male who was admitted on 9/16/16 with a diagnosis of chronic Schizophrenia and Body Aspiration. According to the record review performed on 9/20/16 at 3:15 pm with nurse supervisor (employee #36), it was found that on 9/16/16 at 4:00 pm the physician ordered soft restrained per 4. However the physician orders lack of time to be restraint.

No evidence was found related to restraint patient sheet; no evidence was found related to restraint protocol. The "RN documented in the nurses note flowsheet performed on 9/16/116 at 11-7 shift that patient was restraint. On 9/17/16 at 4:00 pm the physician telephonic orders soft restraint per 4. The telephonic order lacks of dated, hour and countersign of the physician.

The RN nurse ' s progress note from 7-3, 3-11 and 11-7 shift the RN document no restraint. No evidence was found related to restraint patient sheet; no evidence was found related to restraint protocol. On 9/18/16 at 7-3, 3-11 and 11-7 shift the RN documented that patient was in restraint; however no evidence was found of the physician order, the restraint protocol and the restraint patient sheet.

On 9/19/16 at 7:00 am the physician telephonic orders soft restraint superior extremities. The telephonic order lacks of dated, hour and countersign of the physician. The RN documented the restraint patient sheet, however left in blank if any change occurs in the 7-3 shift. Lack of documentation in 3-11 and 11-7 shift of time of assessment and round performed if any change occurs. The restraint protocol lacks of physician date, hour and signature.

On 9/20/16 at 7:30 am the physician telephonic orders soft restraint superior extremities. The telephonic order lacks of dated, hour and countersign of the physician. The RN documented the restraint patient sheet, however left in blank the time of assessment and round performed if any changes occur and the signature of nurse in the 7-3 shift.

The facility policy and procedure related to restraint reviewed on 9/20/16 at 1:30 pm in the items #1 that the physician or the professional nurse that identified patient at risk to harm themselves or other patient initiate the restraint process after be taken other less restricted alternative or option. Item #2 indicates that a verbal order for restraint be counter sign by the physician no more that 6 hour after be initiate the restraint. Item #5 indicates that nursing personnel maintain constant observation to patient in restraint during continues round every 15 minute to identified patient care needs. Item #6 the professional nurse (RN) documented every 4 hour the observation and intervention performed to the patient in the nursing progress note.

a- No evidence was found that the physician counter sign the restrain verbal order no more that 6 hour.

b. No evidence was found related to the physician's restriction evaluation ordered on 9/16/16 at 4:00 pm.

c. No evidence was found related to the less restricted measure taken before restraint the patient.

d. No evidence was found related to RN documentation the constant observation and intervention to the patient in the nursing progress note.

e. No evidence was found related to restraint plan of care be activated by the RN.

Based on a recertification survey, the review of policies and procedures and records reviewed (R.R) with the Medical Record Director (Employee #22), 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 for 16 out of 80 records reviewed (R.R #6, #10, #11, #12, #16, #32, #33, #34, #39, #41, #51, #62, #63, #64, #67 and #80).

Findings include:

1. R.R #32 is a 83 years old female, admitted on 5/19/16 with Acute Abdominal Pain Biliary Obstruction. During the record review on 9/20/16 at 1:00 pm the following was found:
a. Telephone order from 5/30/16 at 6:50 pm. This telephone orders for medications and treatments were not countersigned by the physician.

2. R.R #33 is a 76 years old male, admitted on 3/1/16 with Unilateral Inguinal Hernia. During the record review on 9/20/16 at 2:00 am the following was found:

a. Telephone order from 3/3/16 at 7:45 pm. This telephone orders for medications and treatments were not countersigned by the physician.
b. Telephone order from 3/7/16 at 11:00 am. This telephone orders for medications and treatments were not countersigned by the physician.

c. Telephone order from 3/8/16 at 2:25 pm. This telephone orders for medications and treatments were not countersigned by the physician.

d. Telephone order from 3/12/16 at 5:00 pm. This telephone orders for medications and treatments were not countersigned by the physician.

e. Telephone order from 3/12/16 at 7:00 pm. This telephone orders for medications and treatments were not countersigned by the physician.

3. R.R #34 is a 69 years old male, admitted on 1/06/16 with Congestive Heart Failure (CHF). During the record review on 9/20/16 at 2:30 pm the following was found:

a. Telephone order from 1/10/16 at 8:40 pm, 1/11/16 at 12:45 pm,1/11/16 at 12:oo pm1/12/16 at 12:20 pm, 1/12/16 at 8:00 pm, 1/19/16 at 8 am, 1/19/16 at 5:15 pm, 1/19/16 at 5:25 pm, 1/21/16 8:00 am,1/21/16 at 9:00 am,1/23/16 at 8:00 am,1/23/16 at 4:00 pm, 1/24/16 at 1:00 pm, 1/24/16 at 1:01 pm, 1/25/16 at 2:45 pm, 1/26/16 8:30 pm, 1/26/16 at 8:00pm, 1/29/16 at 8:00 am, 1/29/16 at 12:30 pm . These telephone orders for medication and treatment were not countersigned by the physician.
4. R.R #39 is a 62 years old female, admitted on 2/19/16 with Hydronephrosis with Renal and Urethral Calculus Obstruction. During the record review on 9/20/16 at 4:07 pm the following was found:

a. Telephone order from 2/20/16 at 1:40 pm. This telephone order for medication and treatment were not countersigned by the physician.
b. Telephone order from 2/20/16 at 5:50 pm. This telephone order for medication and treatment were not countersigned by the physician.
c. Telephone order from 2/22/16 at 11:30 am. This telephone order for medication and treatment were not countersigned by the physician.
5. R.R #41 is a 79 years old female, admitted on 2/08/16 with Hypertensive Heart and Chronic Kidney Disease. During the record review on 9/20/16 at 4:30 pm the following was found:

a. Telephone order from 9/02/16 at 10:00 am. This telephone order for medication and treatment were not countersigned by the physician.

6. R.R #51 is a 17 years old female, admitted on 10/25/12 with Mandibular Osteotomy and Mandibular Retrusion. During the record review on 9/21/16 at 1:25 pm the following was found:

a. Telephone order from 10/25/12 at 12:30 pm. This telephone order for medication and treatment were not countersigned by the physician.


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7. R.R #6 is a 64 years old male who was admitted on 8/29/16 with a diagnosis Acute Renal Failure. According to the record review on 9/20/16 at 10:10 am performed with fifth floor supervisor (employee #34), it was found the following:

a. Seven telephone order from 9/14/16 at 10:20 am, from 9/14/16 at 10:47 am, from 9/17/16 at 2:00 pm, from 9/17/16 at 2:00 pm at 10:00 am. This telephone order for medication and treatment were not countersigned by the physician.

8. R.R. #10 is a 64 years old female who was admitted on 9/19/16 with a diagnosis of Bronchopneumonia (BKP) and mechanic ventilation. According to the record review performed on 9/20/16 at 2:00 pm with nurse supervisor (employee #35), it was found the following:

a. Telephone order from 9/20/16 at 7:00 am. This telephone order for treatment were not countersigned by the physician

9. R.R. #11 is a 44 years old male who was admitted on 8/2/16 with a diagnosis of Anasarca, Diabetes Mellitus and High Blood Pressure (HBP). According to the record review performed on 9/20/16 at 2:15 pm with nurse supervisor (employee #35), it was found the following:

a. Telephone order from 9/13/16 at 8:00 am. This telephone order for treatment were not countersigned by the physician

b. Telephone order from 9/15/16 at 8:00 pm. This telephone order for treatment was not countersigned by the physician.

c. Telephone order from 9/18/16 at 9:00 am. This telephone order for treatment was not countersigned by the physician.

d. Telephone order from 9/18/16 at 6:40 pm. This telephone order for medication and treatment were not countersigned by the physician.

e. Telephone order from 9/19/16 at 5:46 pm. This telephone order for medication and treatment were not countersigned by the physician.

f. Telephone order from 9/20/16 at 8:00 am. This telephone order for treatment was not countersigned by the physician.

10. R.R. #12 is a 36 years old male who was admitted on 9/16/16 with a diagnosis of chronic Schizophrenia and Body Aspiration. According to the record review performed on 9/20/16 at 3:15 pm with nurse supervisor (employee #36), it was found the following:

a. Telephone order from 9/17/16 at 4:00 pm. This telephone order for medication and treatment were not countersigned by the physician.

b. Telephone order from 9/18/16 at 7:00 am. This telephone order for treatment was not countersigned by the physician.
c. Telephone order from 9/19/16 at 7:00 am. This telephone order for treatment was not countersigned by the physician.

d. Telephone order from 9/20/16 at 7:30 am. This telephone order for treatment was not countersigned by the physician.

11. R.R #16 (close record) is a 37 years old male who was admitted on 6/17/16 with a diagnosis Acute pancreatitis. According to the record review on 9/23/16 at 9:00 am, it was found the following:

a. Telephone order from 6/17/16 at 4:45 pm. This telephone order for medication and treatment was not countersigned by the physician.

b. Telephone order from 6/18/16 at 2:50 pm. This telephone order for medication and treatment was not countersigned by the physician.

c. Telephone order from 6/18/16 at 6:30 pm. This telephone order for medication and treatment was not countersigned by the physician.

d. Telephone order from 6/18/16 at 8:00 am. This telephone order for treatment was not countersigned by the physician.

e. Telephone order from 6/19/16 at 7:55 pm. This telephone order for medication and treatment was not countersigned by the physician.

f. Telephone order from 6/20/16 at 8:05 pm. This telephone order for medication and treatment was not countersigned by the physician.

g. Telephone order from 6/20/16 at 3:25 pm. This telephone order for medication and treatment was not countersigned by the physician.

h. Telephone order from 6/20/16 at 4:30 pm. This telephone order for treatment was not countersigned by the physician.

i. Telephone order from 6/20/16 at 4:50 pm. This telephone order for medication and treatment was not countersigned by the physician.

j. Telephone order from 6/20/16 at 5:12 pm. This telephone order for medication and treatment was not countersigned by the physician.

k. Telephone order from 6/20/16 at 5:14 pm. This telephone order for medication and treatment was not countersigned by the physician.

l. Telephone order from 6/21/16 at 7:00 am. This telephone order for treatment was not countersigned by the physician.

m. Telephone order from 6/21/16 at 12:21 pm. This telephone order for medication and treatment was not countersigned by the physician.

n. Telephone order from 6/22/16 at 5:00 pm. This telephone order for medication and treatment was not countersigned by the physician.

o. Telephone order from 6/23/16 at 9:23 am. This telephone order for medication and treatment was not countersigned by the physician.

p. Telephone order from 6/24/16 at 10:20 am. This telephone order for treatment was not countersigned by the physician.

q. Telephone order from 6/26/16 at 7:40 am. This telephone order for medication and treatment was not countersigned by the physician.

r. Telephone order from 6/27/16 at 6:10 am. This telephone order for medication and treatment was not countersigned by the physician.

s. Telephone order from 6/27/16 at 11:15 am. This telephone order for medication and treatment was not countersigned by the physician.

t. Telephone order from 6/27/16 at 1:05 pm. This telephone order for medication and treatment was not countersigned by the physician.

u. Telephone order from 6/30/16 at 8:20 am. This telephone order for medication and treatment were not countersigned by the physician.

v. Telephone order from 7/1/16 at 11:50 am. This telephone order for medication and treatment was not countersigned by the physician.

w. Telephone order from 7/1/16 at 12:50 pm. This telephone order for medication and treatment was not countersigned by the physician

x. Telephone order from 7/1/16 at 3:30 pm. This telephone order for treatment was not countersigned by the physician

y. Telephone order from 7/1/16 at 7:50 pm. This telephone order for medication and treatment was not countersigned by the physician

z. Telephone order from 7/4/16 at 7:50 am and 8:00 am. This telephone order for medication and treatment was not countersigned by the physician.

aa. Telephone order from 7/5/16 at 11:10 am. This telephone order for medication and treatment was not countersigned by the physician

bb. Telephone order from 7/5/16 at 11:22 am . This telephone order for medication and treatment was not countersigned by the physician

cc. Telephone order from 7/5/16 at 12:20 pm. This telephone order for medication and treatment was not countersigned by the physician

dd.Telephone order from 7/5/16 at 10:35 pm. This telephone order for medication and treatment was not countersigned by the physician

ee. Telephone order from 7/6/16 at 9:50 am. This telephone order for medication and treatment was not countersigned by the physician

ff. Telephone order from 7/6/16 at 10:00 am. This telephone order for medication and treatment was not countersigned by the physician

gg. Telephone order from 7/6/16 at 2:45 pm. This telephone order for medication and treatment was not countersigned by the physician

hh. Telephone order from 7/6/16 at 10:45 pm. This telephone order for medication and treatment was not countersigned by the physician.

ii. Telephone order from 7/8/16 at 6:00 am. This telephone order for medication and treatment was not countersigned by the physician.

jj. Telephone order from 7/8/16 at 9:45 am. This telephone order for medication and treatment was not countersigned by the physician.

kk. Telephone order from 7/8/16 at 1:43 pm. This telephone order for medication and treatment was not countersigned by the physician.

ll. Telephone order from 7/8/16 at 2:40 pm. This telephone order for medication and treatment was not countersigned by the physician.


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12. RR #62 was reviewed on 9/23/16 at 1:00 p. m. patient with 32 years old male who was admitted on 9/20/16 due to a diagnose of Gynecomastia and was found the following:

a. A physician order was placed on 9/20/16 at 6:00 p. m. for Ancef 1 gram I.V. lacks frequency and not taken by the nurse.

b. A physician verbal order written by the nurse on 9/20/16 at 3:45 p. m. was signed by the nurse on 9/20/16 at 3:45 p. m. to administer '' Morphine 6 mgs. I.V. slowly stat '' the record was reviewed on 9/23/16 at 1:00 p. m. and provides lack order did read back lacks of the physician signature, date and hour.

13. RR #63 was reviewed on 9/23/16 at 10:40 a. m. patient with 44 years old female who was admitted on 6/15/16 due to a diagnose of Thyroid Mass Status post Trans cervical total Thyroidectomy. The record was reviewed and was found the following:

a. The physician admission order's placed on 6/15/16 lacks of the hour when the physician ordered.

14. RR #64 was reviewed on 9/23/16 at 11:55 a. m. case of 50 years old female who was admitted on 9/20/16 due to a diagnose of Left Elbow lateral Epiconditis and was found the following:

a. A physician verbal order to administered ' ' Ancef 2 gms. for intra-operative use was written by the nurse, the record was reviewed on 9/23/16 at 11:55 a. m. and lacks of the date and the hour when the nurse received the verbal order.

15. RR #67 was reviewed on 9/20/16 patient with 84 years old male who was admitted on 9/9/16 due to a diagnosis of Severe Anemia. The record was reviewed and it was found the following:

a. A physician's ordered on 9/8/16 at 11:30 p. m. to '' Transfuse stat and CBC 4 hours post transfusion'' signed per the physician and lacks of the license number, did not specified type of transfusion and per how many hours received the transfusion.

b. The telephone order requested per the physician (employee #38) taken by the register nurse (employee #39) on 9/9/16 at 10:15 p. m. to '' Hold PRBC and FFR '' no read back and not signed per the physician on the first 24 hours according with facility policies and procedures.

c. The physician order written on 9/10/16 at 4:00 p. m. not taken by the register nurse and the order was illegible included the physician signature and lacks of the license number.

d. The physician order written on 9/11/16 was illegible included the hour. On the same paper other orders was written per physician and lacks of the date and the hour when the physician writes the order and lacks of the physician license number.

16. RR #80 was reviewed on 9/22/16 at 3:25 p. m. patient with 51 years old female who was admitted to surgery on 6/30/16 due to a diagnose of Malignant Neoplasm of Thyroid Gland. The record was reviewed and it was found the following:

a. A physician verbal order written on 6/30/16 at 9:10 a. m. was written and signed by the nurse on 6/30/16 at 9:10 a. m. to administer '' Morphine 4 mgs. I.V. slowly stat '' the record was reviewed on 9/22/16 at 3:25 p. m. and lacks of the date, the hour and the physician signature.

Based on a recertification survey, interview, Policies and Procedures (P&Ps) and thirty clinical records review performed on 09/20/16 with the Medical Record Director (Employee #22) it was found that the facility failed to ensure that the physicians complete the documentation of the History and Physical form in a period of 24-48 hours after the admission of the patients, as observed in 9 out of 30 records review (RR #32, #34, #41, #42, #45, #46, #47, #50 and #53 ).

Findings include:

1. During RR #32 review performed on 09/20/16 at 2:30 pm it was found that the physician failed to document the History and Physical form for this patient since the admission was performed on 05/19/16 at 3:34 pm.

2. During RR #34 review performed on 09/20/16 at 2:30 pm it was found that the physician failed to document the History and Physical form for this patient since the admission was performed on 01/6/16 at 12:30 pm.

3. During RR #41 review performed on 09/20/16 at 4:30 pm it was found that the physician failed to document the History and Physical form for this patient since the admission was performed on 2/8/16 at 11:00 am.

4. During RR #42 review performed on 09/20/16 at 4:40 pm it was found that the physician failed to document the History and Physical form for this patient since the admission was performed on 5/17/16 at 7:00 pm.

5. During RR #45 review performed on 09/21/16 at 10:40 am it was found that the physician failed to document the History and Physical form for this patient since the admission was performed on 1/21/16 at 7:29 am.

6. During RR #46 review performed on 09/21/16 at 11:12 pm it was found that the physician failed to document the History and Physical form for this patient since the admission was performed on 2/5/16 at 5:29 pm.

7. During RR #47 review performed on 09/21/16 at 11:24 am it was found that the physician failed to document the History and Physical form for this patient since the admission was performed on 2/17/13.

8. During RR #50 review performed on 09/21/16 at1:10pm it was found that the physician failed to document the History and Physical form for this patient since the admission was performed on 12/13/12.

9. During RR #53 review performed on 09/21/16 at 2:25 pm it was found that the physician failed to document the History and Physical form for this patient since the admission was performed on 5/25/16 at 7:29 am.

During interview with the Medical Record Director (employee #22) performed on 09/20/16 at 1:10 pm he stated: "the physicians have 24-48 hours to complete the History and Physical examination form. "

During interview with the Medical Director (employee #31) performed on 09/23/16 at 2:45 pm he stated: "the physicians have 24 hours to complete the History and Physical examination form. We have been working this concern with the faculty. The faculty by-laws establish that time of period and they have to comply".

10. The facility failed to ensure that physicians comply with the documentation of the History and Physical Form as established on the Medical staff by laws, Admissions- item #6 on page #3 that states: " A complete history and physical examination shall, in all cases, be dictated within 24 hours of admission of the patient " .

Based on a recertification survey, thirty records review (RR), accompanied by the Medical Record Administrator (Employee #22) during survey process from 9/20 thru 9/23/2016 it was found that the facility failed to complete the discharge summaries, as found on 2 out of 30 records reviewed, (RR #32 and #39 ).

Findings include:

1. During RR #32 performed on 9/20/2016 at 1:40 pm, an 83 years old female that was admitted on 5/19/2016 due to Acute Abdominal Pain with Biliary Obstruction. The discharge summary form was not filled and there was no evidence of a final progress note that included condition at discharge, discharge instructions and follow-up care required provided when requested by the inspector.

2. During RR #39 performed on 9/20/16 at 4:07 pm, a 62 years old patient that was admitted on 2/19/16 due to Hydronephrosis with Renal and Urethral Calculus. The discharge summary form was not filled and there was no evidence of a final progress note that included condition at discharge, discharge instructions and follow-up care required provided when requested by the surveyor.

Based on recertification survey, observations, controlled medications count, emergency carts check, medications carts verifications, medications storage check and interviews, it was determined that the facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel on 5 out of 5 patients wards (PWs).(PW #2, #3, #4, #5 and the Emergency Room).

Findings include:

1. On 09/20/16 at 9:10 am a tour was perform with the Pharmacist (Employee # 25) for the verification of proper storage of the drugs and biological

a. On 09/20/16 at 9:10 am on the 3rd floor surgical ward accompany with employee # 25 it was found two medications carts unsecure, the medication refrigerator unlock and the medications cabinet unlock.
b. On 09/20/16 at 9:45 am on the 5th floor medicine ward accompany with employee # 25 it was found medications cabinet unlock.
On interview with the Register Nurse (employee # 14) state that the medications cabinet did not have a key lock but they close the door of the room.
c. On 9/20/16 at 10:04 am on the 5th floor medicine ward accompany with employee # 25 it was found three medications carts unsecured.
d. On 9/20/16 at 10:20 am on the 4th floor ward accompany with employee # 25 it was found three medications carts unsecured and the medications cabinet unlock.
e. On 9/20/16 at 10:35 am on the 2nd floor obstetrics and gynecology ward accompany with employee # 25 it was found two medications carts unsecured and the medications cabinet without a key lock.
f. On 9/20/16 at 10:50 am on the 2nd floor medicine ward accompany with employee # 25 it was found one medications cart unsecured and the medications cabinet unlock.
g. On 9/20/16 at 11:15 am on the Emergency Room accompany with employee # 25 it was found the two medications cabinet unlock.
2. The facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel.

Based on blood bank quality control, manufacturer ' s instructions and blood bank testing personnel interview on September 20, 2016 at 9:48 AM, it was determined that the blood bank failed to follow the manufacturer ' s instructions to activate the blood temperature indicator (Hemotemp II).
The findings include:
1. The blood bank testing personnel use the blood temperature indicator (Hemotemp II) to verify the temperature of blood components sent by the Red Cross Blood Bank and the pack cell returnedto the blood bank before 30 minutes when the blood unit is not transfused.
2. The manufacturer ' s instructions establish that the blood temperature indicator (Hemotemp II) must be activated by warming to 38° C - 42° C.
3. The blood bank procedures manual establishes that the blood temperature indicator must be activated by warming to 37° C by 60 seconds.
4. The blood bank testing personnel confirmed that the blood bank receivedfive pack cell returned before 30 minutes and activated the blood temperature indicator at 37° C on the following days: January 7, 2016 (W201715526009), January 14, 2016 (W2017715508887), February 13, 2016 (W200916348808), June 30, 2016 (W201716639560) and July 4, 2016 (W201716640378).


11584

5. The testing personnel documented the quality control for the Hemotemp II activation at 37°C during the following days:
a.January 8, 15, 22, 29, 2016
b. February 5, 12, 19, 26, 2016
c. March 2, 11, 18, 24, 31, 2016
d. April 8, 15, 22, 29, 2016
e. May 6, 13, 20, 27, 2016
f. June 3, 10, 17, 24, 2016
g. July 1, 8, 15, 22, 29, 2016
h. August 5, 12, 19, 26, 2016
i. September 2, 9, 16, 2016
6. The blood bank testing personnel confirmed on September 20, 2016, that the blood bank failed to activate the blood temperature indicator (Hemotemp II) to range 38° C - 42° C those days.

Based on a recertification survey, observations, review of policies/procedures and interview with the clinical and administrative dietitian, ( employee #1 ) and (employee #7 ) from 09/20/16 through 09/23/16 from 8:30 am until 5:00 pm it was determined that the facility failed to have an organized dietary services who comply with guidelines for acceptable hygiene practices, guidelines for kitchen sanitation, mechanisms to ensure that the nutritional needs of the patients are met in accordance with practitioners' orders and acceptable standards of practice and prevent patient from potential harm related to safe food practices which make this condition not met. (Cross reference to Tag A 619, A 621, A 747 and A 749).

Based a recertification survey, observational tour of the facility's kitchen that prepares the patient's meals, review of menus, policies/procedures and interview with the administrative dietitian (employee #1) on 09/20/16 from 8:30 am till 11:55 am, it was determined that the facility failed to comply with state and federal requirements to promote sanitary environment and procedures and prevent patient from potential harm related to safe food practices and handling those deficient practices has the potential to affect approximately 134 patients and 249 employees.
Findings include:

1. The following was found during the observational tour of the kitchen service with the administrative dietitian (employee #1) on 09/20/16 from 8:30 am till 11:55 am:

a. 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 risk of a health hazard.
b. Steam table trays and cover of the trays were observed curled and in bad condition. These pose personnel at risk of receive burn while serving patient trays with food.
c. Two carts used to storage patient trays were observed with a lot of rust on the shelves.
d. One package with 200 Styrofoam disposable trays was observed located directly on the floor, at the right side of the steam table. These packages of disposable trays were exposed to food production humid and dirty area environment.
e. Hand washing sink located in front of tray line was observed in need of cleaning and maintenance. A sign that include information of the procedure for hand washing were not available in the area. Facility failed to ensure that hand washing facilities are maintained in good condition and include information related with hand washing accepted procedures.

f. In front of the three compartment sink area it was observed a plastic spray bottle with a few quantity of chemical or cleaning solution. These bottles were not labeled with the name of the chemical or cleaning solution and the percent of dilution of the content.

g. In front of the stoves it was observed a built-in metal cabinet used to storage chemicals, plastic garbage bags and a freezer wear insulated jacket; this cabinet had orange-brown coloring on the doors, side panels and edges. This oxidation or rust does not permit complete cleaning, encourage the growth of bacteria.

h. All kitchen area floor and ceiling tiles were observed in need of clean and poor condition. Broken pieces of those tiles do not permit complete cleaning, encourage the growth of bacteria.

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

j. Refrigerator and walk-in freezer floor doors were observed in need of clean.

k. Onions and other vegetables were observed storage directly on the floor of the refrigerator. Other food items are observed storage in cardboard boxes that had humidity and loose pieces.

l. One liter (1000 ml) plastic bottle filled with water was found located on one of the shelves of the walking freezer.

The administrative dietitian (employee #1) stated on interview on 09/20/16 at 9:15 am that she does not know why this bottle filled with water was storage inside the freezer.
m. Tray line steam table station had a broken tire on the front left side. This poses personnel at risk of receive burn while serving patient trays with food.
n. Tray line steam table station is deteriorated with green spots.
o. All stainless steel built in kitchen equipment (preparation tables, carts and islands) are threadbare, deteriorated in old state with green spots.

Administrative dietitian (employee #1) stated on interview on 09/20/16 at 9:25 am that for the three compartment sink they wash with a hot soapy (detergent ) water, rinse with hot clean water and then sanitize items. However they cannot be able to test sanitizer percent to identify if comply with requirements because they did not have available test strips.

p. The facility failed to assure that proper quantity of concentration are use to sanitize items on the three compartment sink.

q. Kitchen entrance doorframe was observed deteriorated in old state, had orange-brown coloring appearance of oxidation. This oxidation or rust does not permit complete cleaning, encourage the growth of bacteria.

r. More than three packages of veal meat were observed defrosting on running water directly on a sink. Veal meats are located directly on the sink area. Facility did not use a tray to locate the veal meat to prevent that has contact with the sink area.

s. An accumulation of dust, dirt, food residues and other debris were found on the kitchen floor, in the stove area where the kettle and fryer are located.

t. The floor under the stoves and oven and in corners was observed with a lot of grime.

u. Tray line assembly area was observed dirty and with appearance of humidity.

v. Employee bathrooms located at the right side of the kitchen ( on the hallway ) were observed with open door all time.

w. Before beginning lunch tray line service, stainless steel trays were observed with ice to be used to cool tuna fish salad.

Administrative dietitian (employee #1) stated on interview on 09/20/16 at 11:40 am that they use ice from one of the patient wards ice dispenser because they did not have ice machine on the kitchen area.

Policies and procedures to manage ice to cool food on the kitchen did not include provisions to ensure infection control precautions during the management of the ice.

x. Dry food storage room were located on the facility basement, the room were observed with unlock door in a hallway with a heavy persons traffic. This promotes that non-authorized personnel access dry food storage area.

y. The dry food storage area was observed with peeling paint on the floor, dust over cardboard boxes with food items, some plastic container with kitchen utensils (serving laddes, spoons etc) and disposable portion cups and trays with lids were observed storage to less than 6 inches from the ceiling tiles. A plastic bag with five packages of 5 pounds each one of ground coffee, two boxes of Oxepa Therapeutic Nutrition, two boxes of Vital 1.5, four boxes of Glucerna enteral nutrition, five packages of 200 Styrofoam disposable trays and two boxes of wax paper to be used in the kitchen were found located directly on the floor inside the dry storage room. Four rolls of towel paper were observed storage without a plastic cover exposed to the environment. Six boxes with paper based patient census information (dated 2015-2016) and a cash register were found located inside the dry storage room.

The facility failed to promote that the dry food storage are use to storage only food and food related items.

z. Humidity inside the dry storage room is 75 %. This range is out of parameters because acceptable parameters must be between 50%-70%.

aa. Food items were stored without any date to indicate when it was received. Cans, boxes, packages and bottles located inside storage room are not organized to promote first in first out system to use food items.
The 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.
bb. A mop and bucket were found located at the side of elevator used to deliver food trays to patient ' s areas.

cc. Housekeeping room located at the entrance of the kitchen area was observed in bad condition, dirty, with stains. Two biohazard containers were observed located on the same housekeeping room.

2. A mechanism to ensure that facility prevent patient from potential harm related to safe food practices and handling were not promoted, not followed. An immediate jeopardy situation was identified on 9/21/16 at 8:33 am due to failure by the facility to prevent patient from potential harm. (Cross Reference to Tags A747 and A749).

Based on a recertification survey, the review of policies/procedures and interview with the clinical and administrative dietitian, ( employee #1 ) and (employee #7 ) it was determined that the facility failed to ensure that food and dietetic services has policies/procedures related to defined time frame to assess and re-assess patients at nutritional risk.

Findings include:

1. Policies and procedures related with nutritional assessment needs of patients were reviewed with the administrative dietitian on 09/20/16 at 1:30 pm. Based on this review and discussion it was determined that mechanisms in order to address the following processes were not formally established. Assessment of patients at nutritional risk is performed based on needs identified by screening after hospitalization at the facility. However, no evidence was found of policies and procedures related to a defined time frame to perform assessments after the screening.

2. Policies and procedures related with nutritional re-assessment needs of patients were reviewed with the administrative dietitian on 09/20/16 at 1:35 pm. Based on this review and discussion it was determined that mechanisms in order to address the following processes were not formally established. Time frame to perform re-assessment of patients at nutritional risk in order to determine if nutritional plan are followed and patients tolerated nutritional plan recommendations were not established.

During interview on 09/20/16 at 10:02 am clinical dietitian (employee #1 ) stated that she gives the first priority to dietitian consults requested by physicians and the second priority to the referrals requested by health care professionals.

3. However she did not re-assess patient ' s compliance with nutritional plan and recommendations on patients identified previously at risk; unless those patients had complications or no tolerance with nutritional plan.

During interview on 09/20/16 at 11:55 am administrative dietitian (employee #1) stated that facility only had one clinical dietitian who works from Monday through Fridays. That facility had an average census of 130-140 patients and it is very difficult to comply with a timeframe for the initial screening assessment and re-assessment based on nutritional risk.

Based on a recertification survey, observation performed on 9/20/16 through 9/23/16 from 8:00 am until 4:00 pm, interview, the review of clinical records and policies/procedures, it was determined that the facility failed to ensure that physical environment, equipment and employees are train and coordinate to maintain a safe and good sanitary environment in the Doctor ' s Center Hospital in Bayamon which makes this condition "Not Met" (cross reference Tags A701, A709, A713, A724, A725 and A726) and also "Not met " with Life Safety Code (Cross reference K0018, K0021, K0046, K0048, K0050, K0051, K0052 K0064, K0072, K0075, K0130 and K0147).

Based on a recertification survey, tests performed on equipment and observations made during the survey for the physical environment with the facility's Physical Plant Director (employee #8), 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.

Findings include:

1. All maintenance closets (emergency room and hospital) were visited from 9/20/16 through 9/23/16 from 8:00 am until 4:00 pm. These closets were found with chemicals to clean the facility and equipment and were all found unlocked and accessible to non-authorized persons.

2. Forty-four patient's sleeping rooms were visited from 9/20/16 through 9/21/16 from 8:00 am until 4:00 pm and the following was determined:

a. Thirteen out of thirteen patient's bathrooms on the third floor were found with the bathroom pull cords wrapped around the grab bars. (Rooms #302 through #314).

b. Sixteen out of sixteen patient ' s bathrooms on the fourth floor were found with the bathroom pull cord wrapped around the grab bars. (Rooms #401 through #416).

c. Eighteen out of twenty patient ' s bathrooms on the fifth floor were found with the bathroom pull cord wrapped around the grab bars. (Rooms #501 through #520).

d. The facility's physical structure director released all pull-cords during the tour; however a plan must be implemented for this deficiency and monitored for compliance

e. Five out of nineteen floor night lights did not work on the fifth floor in patient's rooms
#502, #507 and #508.

f. Five out of nineteen night lights behind patient's beds in rooms #502, #503, #507, #508 and #514 had pull-cords too short to be reached by patients lying in their beds.

g. Five out of thirty night lights behind patient's beds in rooms #404, #410, #411, #412, and #414 (paper tape) had pull-cords too short to be reached by patients lying in their beds.

h. Five out of thirty night lights behind patient's beds in rooms #314 (paper tape), #313,#311, #307, and #302 (without cord) had pull-cords too short to be reached by patients lying in their beds.

i. Five out of forty-nine patient's bathroom did not have one of two grab bars require by ADA install in the toilet and shower area. (Rooms #302, #305, #306, #411 and 520 do not have any in both areas).

j. The shower pull-cord and system in room #414 was installed outside the shower and the cord too short to be reached by patients if laying on the floor.

k. The door latches in Rooms #304, #306, # 407, #504, 506, 507, 513 doors are loose.

l. Room #503 A the bed was observed on 9/20/16 at 9:45 am and was completely straight and fully lowered. The bed was disconnected. When the surveyor performs a test to the bed reveals that the back of the bed start to rise without push any bottom. Patient and caregiver refer on 9/20/16 at 9:46 am that they inform to the nurses about the bed but nobody respond anything about it. Patient refers he has a lot of neck pain.

m. Room #304, #312 and #314 ceiling tile with mold and cross t with rust.

n. Room # 314 B, #405 A,B, #501 A,B, #515 A,B, #517 A, #519 rest panel board broken and repaired with tape.

o. Rooms #308A, #413B, #511A with the front bed board Formica broken.

p. Rooms #302,#307, #308 A,# 310,#312, #402 B, #404, #405, #407, #408 B, #409,#411,#501,#502 A, # 503,# 505 A, #507 A,# 508B, #509 A,#511 B,#514 B and # 515 with rust and scratches on side rails.

q. Rooms #302 and #305 (with broken floor tiles) #310, #403,#404,#405 #409 (broken tiles in front of the closets)#410, #416 (without rubber base), #510 with dirty floor tiles and detaches rubber base.

r. Rooms #305, #307 (water running down the wall on the side b of the room), #310,#401,#402 (with mold), #403,#404, #405,#406, #408, #409, #413 and #505 with peeling off paint.

s. Bathrooms wall and floor from patient ' s rooms # 508 without one tile and #510 with mold.

t. Rooms #302,#304,#305,#306,#307,#308,#309,#310,#312,#314,#415,#503,#504,#505,#506,#507,#508and #509 with broken closet Formica cover.

u. Rooms #308 AB, #403 A, B, #410 A, B, #502 A, #503 A, #507 AB, #508 A, B and #509 A with door night tables broken.

v. Rooms #304 A,B, #306 A,B, #307(broken cover), #402 A, #403B, #405 A,B,#410 A,B, #502A, #503A, #507 A,B, #508 A,B and #509 A with rusty base and damaged tires.

w. Rooms #302B, #305B, #310B,#403 B, #409 A,B, #410 ,B, #412 A,B, #413 B and # 416 B with chair cover broken.

x. Rooms #305 A, #308 A, #401 B and #511 A with broken linen.

3. Operating rooms were visited on 9/22/16 from 1:00 pm 2:00 pm and provided evidence of the following:

a. The hallway floor between of operating suites "A, and C" were found with missing tiles and exposed concrete material and holes which can allow dirt to enter and does not allow for proper cleaning.

b. The door of the autoclave storage was found with tape in the lock not permitting the latch of the door.

c. Missing floor tile in front of the utility room.

d. Operating suite D with peeling off painting.

e. Autoclave packing area with broken tiles and missing tiles.

f. Missing one rubber base in front of the storage autoclave wall.

g. Wooden shelves in the medical surgical supply storage.

h. Push bottom of the operating suite C do not function.

4. 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 (2, 3, 4 and 5).

5. No evidence was found on 9/22/16 at 2:30 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.

6. 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 was on the hand sink area.

12. The diesel tanks used to store and provide diesel to the essential electrical system (EES) was found out with open gate as observed on 9/22/16 at 9:30 am. During the touring it was observed cars parks near the diesel tank.

13. The kitchen was visited on 2/25/15 at 1:40 pm thru 2:40 pm and the following was found:
a). One freezer floor are covered with rust and dirt.

b) The Dry warehouse was visited and cardboard boxes were observed all over the floor unidentified.

c) The Dry warehouse does not have a thermometer to monitor the temperature and relative humidity.

Based on a recertification survey, tests to equipment and observations made during the survey for Life Safety from fire with the facility's Physical Plant Director, 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 9/22/16 from 9:00 am until 4:00 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form ( K0018, K0021, K0046, K0048, K0050, K0051, K0052, K0064, K0072, K0075, K0130 and K0147).

Based on a recertification survey, the review of policies/procedures (P&P) and observations made during the survey for the physical environment with a facility Engineer (employee #8), it was determined that the facility failed to follow established procedures for the storage of biohazard trash related to2 outside metal biohazard storage container that were found with 2 of its doors unlocked.

Findings include:

1. During the tour of the physical structure from 9/20/16 through 9/24/16 from 8:00 am until 4:00 pm, movable plastic garbage dumpsters and large plastic garbage containers were observed with regular and biohazard trash in the hallways on the fifth, third, and second floors located near the elevators.

2. Two large plastic garbage containers were also found within a stairway on the first floor near the sonogram room. These dumpsters and garbage containers were found over filled to the point that the lids could not be closed and its location does not protect it from non authorized access.

Based on a recertification survey, observations made during the survey for the physical environment with a facility Engineer (employee #8) and interview, it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality.

Findings include:

1. No evidence was found on 9/22/16 at 3:00 pm of the preventive maintenance and calibrations of the facility's scales used to weigh patients throughout the hospital.

2. The Medical Record department was visited on 9/23/16 at 9:00 am and the following was found:
a. The door ' s lock is not functioning has a chain with a lock instead.
b. The door and windows are made of steel and crystal which permits the sight of the files from the outside.
c. The medical records were on wood pallets and on the floor. Some files were open, caused by a fan.
d. One hallway connects to another big room that is used by another department of the Hospital to do maintenance work and as storage, which could cause that not authorize personnel have access to the medical records.
e. Two electrical extension cords were loose on the floor and connected to a power outlet.
f. Stains of mold and rust were observed on the ceiling and walls.
g. One fire extinguisher of 5 lbs. and one smoke detector were observed for all the area. The area was dividing in five sub-areas.
3. During the observational tour of the soiled linen storage of the entire hospital on 9/21/16 at 9:30 a.m with a facility Engineer (employee #8), it was observed the lack of the air extractor to provide negative pressure in this room.

4. Dirty laundry is placed in large bins and moved throughout the hospital until it arrives at the basement sorting area as observed on 9/21/16 at 10:30 am. The red plastic bags that the dirty/contaminated laundries are placed in were all found ripped open due to the weight of the dirty linen. Also, these bins did not have covers to protect persons in hallways and elevators from cross contamination.

5. On 9/20/16 at 10:00 am a large portable container filled with regular trash was observed coming out of the escort elevator. The elevator that had the container with trash was also transporting persons to different floor; however this container did not have a cover to protect persons in hallways and the elevator from cross contamination.

6. Maintenance carts were observed from 9/20/16 through 9/22/16 from 8:00 am until 4:00 pm with cleaning chemicals on top and in the middle of the carts and did not have a cabinet on these carts where personnel can lock these cleaning solutions to limit its accessibility to non-authorized persons


Based on a recertification survey, observation, tour performed with the security officer (employee #4) Emergency Room (ER) supervisor (employee #5) and infection control officer (employee #6) on 9/21/16 at 3:30 pm and 9/22/16 at 8:45 am, it was determined that the facility failed to prevent patient from potential harm related to failure to provide care and supervision related to non functioning call system without compensatory measures affecting 26 out of 26 patients in the ER Department needing nursing care. This constitutes an immediate jeopardy.
Findings include:
1. On 9/21/16 at 3:30 am it was observed in the ER department in cubicle #8 a patient in a stretcher at the right side of the cubicle and the nurse call system cable was observed tided in the rails of the left side of the cubicle.
2.14 out of 15 observation cubicles that have capability for 2 patients was observed with only one cable in the nurses call system.
3.Interview with the security officer (employee #4) on 9/21/16 at 3:55 pm related to capacity of the observation cubicle and alternative measure to call if has an emergency situation. The employee #4 stated that " the facility did not have a mitigation plan for the ER department nursing call system. The capacities of the 15 cubicles are for one patient each cubicle.
4. Interview with the ER Supervisor employee #5 on 9/21/16 stated: that all cubicles have one call system cable in the cubicle are prepared for one patient, however in the cubicle place 2 patients to avoid patients leaving in the hallways.
5.On 9/22/16 at 8:45 am on observation tour was performed and observed that 14 out of 15 observation cubicle was with on nurses call system cable and 2 patient in each cubicle
6.Review of the vigilance Administrative Security Surveillance on 9/22/16 at 10:30am provide evidence that on 8/11/16 the security officer (employee #4) documented that in the ER department have in the pediatric area three nurses call for all six patients. In the pediatric isolation has 1 out of 1 nurses call dame. In the Adult cubicle has 12 nurses call for 28 patients. Employee #4 documented that the emergency room lack of 16 nurses call. Some of the cubicles lack of any nurses call cable. Six patients in the hallway without any nurses call system. All nurses call cable of the ER area are wrap in the back portion of the stretcher. There are not answering nurse ' s call and most of the time the ward clerk hand up the call
The administrator (employee# 9) was notified of the immediate jeopardy on 09/22/16 at 11:43 am

The administrator stated she received in 2014 a visit from the Health Department division of Law 101 and the surveyors indicate that facility has to remove the nurse call cord installed in the cubicle and they have to located the patients in the hallways instead putting two patients per cubicle.

Immediate Action:

As a corrective measure the hospital will do the following:

a. On September 22, 2016 3:15 p.m. were installed nurse calls in the emergency room.

b. As an alternate plan, a standard rule for the use of a bell was prepared. This rule covers patient ' s needs that located in the hall of the emergency room.

The immediate jeopardy was lifted on 9/22/2016 at 4:15 pm.

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

Findings include:

1. Emergency staff does not have a key or a special device to open bathroom doors if patients activate the emergency call system and the door is locked from the inside as observed on 9/22/16 at 1:45 pm.

2. The handicapped ramp used to gain access to the main entrance of the hospital was observed on 9/22/16 at 10:02 am and provided evidence that the ramp is observed with exposed concrete aggregate and uneven which can cause the fall of a patient, visitor or employee of the hospital.

3. The Intra Venous (I.V.) storage rooms on the fifth, third, second and emergency room were visited 9/20/16 from 8:00 am until 4:00 pm and provided evidence that these doors are not locked to protect its contents from unauthorized access.

4. On 9/20/16 at 9:00 am a patient was observed in the hallway in front of the X-ray department in a stretcher. The patient was connected to an I.V solution and left in front of a set of seats which reduced the width of this exit passage to less than three feet. The patient was not accompanied by nursing personnel or an escort.

5. The emergency room was visited on 9/22/16 at 1:30 pm and it provided evidence that there are ten observation cubicles. Observation cubicles #1 and #2 contained one patient each (patient's on cardiac monitors) however observation cubicles #3 through #10 all contained two patients each. Within these cubicles there are only one nursing call system each and an oxygen outlet each and no ceiling mounted curtains to separate the patients in these cubicles.

6. In room # 401,405, and #414 the nurses call system does not function. In the bathroom of room #407 the nurse ' s call box besides the toilet was detached from the wall and have all the cable exposed.
7. The triage area in the emergency room was observed on 9/22/16 at 2:45 pm and provided evidence of two chairs was on one side of one of the triage room. It was observed a clear glass door only one curtain with two oxygen regulator. The chairs did not have privacy curtains between them, also were not separated from each other by at least four feet.

Based on a recertification survey,observations made during the survey for the physical environment with a facility Engineer (employee #8), it was determined that the facility failed to ensure that areas supplied by Ultraviolet lights are tested and changed according with manufacturer's recommendations.

Findings include:

1. The facility has Ultraviolet lights in the air handling system of their air conditioning system for various sites of the hospital such as the emergency rooms and operating suites as determined with a facility Engineer (employee #8) on 9/21/16 at 1:50 pm.
However, no evidence was found that the facility is periodically testing these Ultraviolet lights to ensure that they are working properly and at full strength. The facility has these Ultraviolet lights for approximately two years and the manufacturer's recommendations are to test periodically and replace lamp at least once a year.


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2. On 9/23/16 at 9:30 a. m. according of the facility's policies and procedures establish that the relative humidity stay between 30 percent (%) and 60 % and the temperature stay between 68.0 degree Fahrenheit (ºF) and 73.0 ºF. The daily temperature and humidity register log for the Litotricia operating room was reviewed for the year 2015 and 2016 and revealed the following evidence:

a. The daily temperature of the '' Litotricia Operating Room '' for year 2015 reveled that on December 1 and 2 the daily temperature was maintain on 79 ºF

The daily Humidity of the '' Litotricia Operating Room '' for year 2015 reveled that on February 8 to 20, on March 8 to 30, on April 1 to 26, 28, and 30, on May 1 to 31, on June 1 to 30, on July 1 to 31, on August 1 to 19 and on December 1, 2, 22 to 24 and 26 to 28 the humidity exceeded the established parameters.

The facility did not provide evidence of the daily temperature and humidity log of the '' Litotricia Operating Room '' for year 2016.

b. The daily temperature of the '' Pre-op room '' for year 2016 reveled that on January 3 (55ºF), on 1/13 (64ºF), on 1/16 (55ºF), on 1/18 (50ºF), on 1/21 and 1/22 (66ºF), on 1/23(57ºF), on 1/24 (60ºF), on 1/30 and 1/31 (65ºF).

The daily temperature on February 13, 14 and 17 (64ºF), on 2/18 and 2/19 (50ºF), on 2/26 and 2/27 (66ºF).

The daily temperature on March 11 (65ºF), on 3/12 and 3/13 (60ºF), on 3/14 (65ºF), on 3/15, 3/16 and 3/17 (60ºF), on 3/18 (64ºF), on 3/19 (66ºF), on 3/24 (60ºF), 3/26 (74ºF), on 3/27, 3/28 and 3/30 (70ºF).

The daily temperatures on April 15 (64ºF), on 4/16 (66ºF), 4/17 and 4/18 (65ºF), on 4/23 and 4/24 (60ºF).

The daily temperatures on May 6 and 5/8 (78ºF).

The daily temperatures on June 3 (70ºF), on 6/4 and 6/5 (74ºF).

The daily temperatures on July 1 (60ºF).

The daily temperatures on August 29 and 30 (65ºF).

The daily temperatures on September 2 (60ºF), on 9/3, 9/4 and 9/5 (55ºF), on 9/6 and 9/7(56ºF), on 9/8 (57ºF), on 9/9 (59ºF), on 9/11, 9/14, 9/15, 9/16 and 9/18 (65ºF).

c. The daily temperature of the '' Operating Room A '' for year 2016 reveled that on April 4, 5, 6, 7 and 8 was maintain on (60ºF).

No evidence of the daily register humidity log on January 29 of 2016.

d. During reviewed the daily temperature and humidity logs of all of the operating rooms suites provide evidence that the daily temperatures and humidity exceeded the established parameters or was maintain under the established parameters.
The nurse supervisor (employee #20) was interview on 9/23/16 at 9:30 a. m. related of this situation and what is the establish protocol of the department when identified that the temperatures and relative humidity did not stay between 30 % and 60 % and the temperature stay between 68.0 ºF and 73.0 ºF. The nurse supervisor (employee #20) stated: '' I notified by telephone call to the engineer department and performed the intervention. However, when I request the evidence of all interventions with contain the date, the hours, the name of employee who intervenes to resolved the problem and if the employee verified the relative humidity and the temperature post intervention and she referred that she did not have evidence.
The facility did not provided evidence of the corrective actions to resolve the problems related to the relative humidity and temperatures on all of different areas of the Operating Room Department.

Based on a recertification survey, observation of delivery of care, review of medical records, dietary department round, policies and procedures, documents, and interviews from 09/20/16 to 09/23/16 it was identified that the facility failed to prevent patient from potential harm related to failure to practice safe food handling due to failure to prevent the like hood of food borne diseases transmission. The facility fails to follow appropriate standards of infection control accordantly to the 42 CFR 482. 42 which makes this condition, Not Met (Cross reference Tags A0749).

Based on a recertification survey, observation, pest control record reviewed and interviews with the administrative dietitian (employee #1) and dietary department employee (employee #2 and # 3) on 9/21/16 at 8:33 am it was determined that the facility failed to prevent patient from potential harm related to failure to practice safe food handling due to failure to prevent the like hood of food borne diseases transmission. This deficiency practice has the potential to affect approximately 134 patients and 249 employees resulting in immediate jeopardy.
Findings include:
1. During dietary department observational tour with the administrative dietitian (employee #1) and dietary department personnel (employee #2 and #3) it was observed the following:
a. On 9/21/16 at 8:33 am it was observed in the dietary department a life roach walking on the wall near the three compartment sink area and near the clean pots and pans.
b. The dietary department employee #2 was witness of the observation.
c. The dietary department personnel employee #3 stated on 9/21/16 at 8:34 am that pest control treatment was performed every 2 weeks.
d. Review of the pest control log book on 9/21/16 at 8:45 am evidence that the last pest control treatment in the dietary department and dry food storage was performed on 9/8/16.
e. The pest control log book reviewed on 9/21/16 at 8:45 am provided evidence that the facility had roach problems in the kitchen and dry food storage since January 2016.
f. On 9/21/16 at 8:58 am was observed a second life roach walking on the floor near the three compartments sink. (This observation was performed with the administrative dietitian (employee #1)
The administrator was notified of the immediate jeopardy on 09/21/16 at 9:45 am, the administrator notified the survey team that the plan of correction will be as follow:

Immediate Action:

Today 9/21/16 at 10:00 am, the kitchen was fumigated by Serrano Exterminating, pest control company hire by the hospital. They use the following products: Suspend, Delta Dust and Invict Gold Cockroach Gel.

As a corrective measure the hospital will do the following:

a. Serrano Exterminating will perform a weekly fumigation to the kitchen. (Immediate)

b. The findings of each fumigation will be informed to the Administration Office, for monitoring and control. (Immediate)

c. It will be performed a terminal cleaning to the kitchen. As soon as the cleaning is concluded the exterminating company will fumigated with CB-80 and Maxforce Roach Killer. (9/21/16 at night)

d. Plastic boxes will replace cardboard boxes to save dry food. (9/22/2016)

e. The pest control and fumigating company will be giving a lecture to hospital employees about the safety and management of food products provide by external companies. (9/23/2016)

Remarks

1. The storage room adjacent to the Department of Diet shall be conditioned. (9/21/2016)

2. The storage room adjacent to the Department of Diet will be dedicated to give service to the pump system of two air conditioning units. (9/21/2016)

3. In this room, no storage or any other use than for what has been dedicated will not be permitted (9/21/2016)

4. The storage room will remain locked and will be designated only access to engineering staff. (9/21/2016)

5. On September 20, 2016 staff of Maintenance Department will be cleaning the kitchen. They will be supervised by the department supervisor and the supervisor of the department of diets. (9/21/2016)

6. After cleaning, the pest control company will fumigated again the kitchen. (9/22/2016)

7. On Thursday, September 22, 2016 at the end of operations a " foguer " will be installed to complete the fumigation. (9/22/2016)

8. For the next three month the pest control company will be making weekly fumigating service. After completed three month will continued the service monthly. (9/22/2016)

9. In addition, regular cleaning is running a terminal cleaning monthly coordination between the Department and the Department of Maintenance. (9/22/2016).

2. On 9/22/2016 at 8:00 am a observational tour for plans of corrections compliance was perform.

a. The Immediate Jeopardy was lifted on 9/22/2016 at 8:15 am.


Based on a rectification survey, the observations tour with the infection control officer (employee #6), Procedure observations, documents review and interviews, it was determined that the facility failed to promote a sanitary and safe care through its infection control program in the emergency room, medical/surgical ward, Operating Room (OR) and laundry department related to improper infection control procedures and failed to follow infection control standards of practice.

Findings include

1. On 09/20/16 at 9:45 am during the controlled medications count accompany with the Pharmacist (Employee # 25) it was found a Verced 10/50mg multi dose vial (MDV) with expiration date of 4/2018 open with 9 ml available and ready to be use however the Verced did not have the written the date when the vial was open and the initials of the professional who open the vial.

The facility multiples dose vials policies and procedure from 2011 on the 2nd page item number eight state that every time a MDV is open the nursing professional will write his/her initial and the opening date.

2. On 9/20/16 at 3:59 pm while walking from the administration to the facility was observed two full biohazard containers with the biohazard trash bag coming out from the containers with the lids open at the facility basement entrance.

a. CDC Guidelines for Environmental Infection Control in Health-Care Facilities from 2003 on page 113 is written : Medical wastes requiring storage should be kept in labeled, leak-proof, puncture-resistant containers under conditions that minimize or prevent foul odors. The storage area should be well ventilated and be inaccessible to pests. Any facility that generates regulated medical wastes should have a regulated medical waste management plan to ensure health and environmental safety as per federal, state, and local regulations.

b. " La Junta De Calidad Ambiental " is a state regulatory entity and their regulation for biohazard waste from July 15, 2016 on the chapter five regulation 596 letter C number 4 on page 23 state that the biohazard containers have to be close before the removal.

3. During the emergency room observational tour and evaluation from 9/21/16 to 9/22/16 accompany with the physical plant director (employee #8), Emergency room supervisor (employee #5) and the Infection control officer (employee #6) the following was found:

a. On 9/21/16 at 1:10 pm on interview employee #5 state that the room CPR 1 was clean however it was found a sterile water prefilled humidifier with a patient name and dated from the 9/20/16, the linen has a tape fastened on top and the Intra Venous (I.V) fluid bag stand was wrap around with tape.

b. On 9/21/16 at 1:15 pm a commode in adult isolation room inside the shower with stains that appear to be rust.

c. On 9/21/16 at 1:20 pm in the use linen room was observed a red trash bag (biohazard) directly to the floor and the use linen containers with linen coming out the container with the lid open.

d. On 9/21/16 at 1:27 pm in the emergency room pediatric area door 158 is respiratory therapy storage. The storage was with heavy dust on the floors and on the respiratory therapy material.

e. On 9/21/16 at 1:40 pm in the trauma room it was found three packages of linen on top of a plastic box with cast dust all over the packages.

f. On 9/21/16 at 1:55 pm in emergency room cubicle # 8 it was found a full sharp container with the lid locked, no other sharp container was found in the cubicle for the use of the employees.

4. During the procedure observation on 9/23/16 accompany with the Director of Nursing (employee #13) and the Infection control officer (employee #6) the following was found:

a. On 9/23/2016 at 9:40 in the intensive care unit cubicle # 2 during a central line dressing change to Patient # 76 the Register Nurse (employee # 23) change her gloves from non-sterile to sterile without a hand hygiene. The facility did not provide evidence of the policies and procedure for the central line dressing change.

b. On 9/23/2016 at 10:09 am during a venous catheter insertion to an 46 years old female patient (patient # 76) it was observed the Register Nurse (employee # 24) after disinfecting the venipuncture area touching the area again, after the venipuncture employee # 24 put on top of the bed the stylet without hand hygiene and gloves change employee # 24 took clean gauzes from the clean material basket.

The facility provides the surveyor two policies and procedure for the venipuncture one from the nursing department and the other from the infection control department however none of them were follow.

c. On 9/23/16 at 10:27 am during a left foot ulcer care to a 53 years old male patient (patient # 78) it was observed the Register Nurse (employee # 18) performing the ulcer care, after cleaning the ulcer without hand hygiene and gloves change employee # 18 applies the medication and the clean dressing.

The facility did not provide evidence of the ulcer care policies and procedure.

5. The facility failed to promote a sanitary and safe care through its infection control program in the emergency room, medical/surgical ward, Operating Room (OR) and laundry department related to improper infection control procedures and failed to follow infection control standards of practice.



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6. On 9/20/16 on shift 7:00 a. m. till 3:00 p. m. the patient #57 on Medicine Ward B fight floor was visit at 10:00 a. m. with the Nurse Supervisor (employee #30) and the Associated Nurse Director (employee #16).

During performed the patient visit it was observed that she did not stay on her bed and stay at the bathroom. The patient referred that she call the nurse long time but the nurses never come and she went to the bathroom to washing her mouth. The patient was assisted to the bed with the nurse personnel (employee #16 and employee 30). The patient was observed with tremors because she referred to much cold and the nursing personnel covered with her blanket.

The patient was observed with IV line on her left superior extremity, did not have a IV fluids regulator or IV pump machine, a yellow label indicated I.V. solution 1000 ml. of Normal Saline at 0.9 % 100 ml. / hr. and lacks the hour when initiated the solution and the angio catheter only read '' September 19.''

The patient room floor was observed dirty and small pieces of papers were observed around the bed room area.

The patient was interview and referred did not received nurse assistant for long time and did not received her medications during this day, she referred she use medication '' Metformin 500 mgs but before she take her breakfast and then the Metformin. However she referred at this time (10:10 a. m.) she did not received the mediations for diabetes and blood pressure.

At 10:25 a. m. a register nurse (employee #31) enters the patient room with a blue gloves and a canalization tray, she put a tray directly on the top of the patient bed then she closed the I.V. line and removed the angio catheter, however did not removed her gloves and did not used hand sanitizer before removed the angio catheter, when removed the angio catheter discard on the sharp container discard the I.V. solution then discard her gloves but did not wash her hands, then she goes to the exit room door go to the medication cart management the medication kardex but never wash her hands or used hand sanitizer.

At 10:30 a. m. the nurse enters the patient room with gloves I.V. Saline Solution and a label indicated 100 ml./hr. she put the I.V. bag solution and a label directly on the patient bed, then enters her hand on the canalization tray and takes a alcohol swap cleaning at the patient area on right superior extremity then put the used alcohol directly on the patient bed, take a angio catheter, with the same gloves touch the patient area canalized and fixed.

The associated nurse director (employee #16) goes out of the patient room and went again with a yellow label indicated Saline Solution 50 ml. / hr. and then put the label directly at the patient bed. The I.V. stand was maintain at the left side of the patient bed and the nurse moved the I.V. stand at right side and then removed the plastic cover of the I.V. line and put at the I.V. solution.

The nurse supervisor (employee #30) goes out of the patient room and went again with a ''heparin saline flush and a regulator '' provide at the nurse the heparin saline flush and put the regulator directly on the patient bed, the nurse flushing the heparin lock but did not disinfected the septum, then put the regulator at the I.V. line and put the solution at the patient, removed her gloves and discard, takes the canalization tray, goes out of the patient room, then put the tray over the medication cart located on the corridor discard the empty '' heparin saline flush vial '' take the canalization tray goes to the nurse station and put the tray on the medical surgical material area.

The R.N #31 failed to follow agency's policies and procedures related to the patient canalization. Did not clean her hands according with appropriate standards of infection control ,which pose risk of cross contamination.

The R.N #31 failed to follow agency's policies and procedures related to hand washing and failure to adequately set up the materials that she was going to use according with appropriate standards of infection control.

7. The Operating Room Department was visit on 9/22/16 from 8:50 am till 11:58 a. m. with Nurse Supervisor (employee #20), Anesthesia Nurse Supervisor (employee #21 ) and Associated Nurse Director (employee #16), during the initial tour for infection control it was determined that the facility failed to ensure a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice for infection control (IC) for 5 out of 5 operating suites (OS) (OS A, B, C, D and E).

a. During observations of the operating room '' women ' s dresser " area on 9/22/16 at 8:50 a. m. was observed on the left side of the washstand the hand soap dispenser lacks of hand soap.

b. A metal hamper to deposit the used scrubs was observed at left side of a washstand the lid of the hamper was observed with brown spots and mush mold around the lid. The nurse supervisor was observed on 9/22/16 at 8:55 a. m. with a ''gown '' on her right hand before initiated a hand washing she put the gown on top of the hamper lid the wash her hands and dry when finished she took a gown and then put on her head, this is not following acceptable infection control techniques.

c. During performed the observations for infection control on 9/22/16 at 9:22 a. m. till 11:58 a. m. '' a metal trash can '' was observed on the interior of the operating room suite A, B, C, D and E, the lids of the trash cans ware observed with brown spots and much mold.

d. On the operating room '' suite B '' the following was observed 9:30 a. m.:

The automatic call system of the operating room ''suite B'' was observed with a hospital adhesive tape above the cover system, the call system was observed out of function.

The posterior part of the shelf used to put the sutures was observed with mush mold.

e. On the operating room '' suite C '' the following was observed at 9:45 a. m.:

Various suction canisters were observed directly on the floor behind of the anesthesia equipment.

The entrance door of the operating suite ''C '' is opening to outside of the suite, when the operating room personnel has to enter a patient to operate or have to enter the suite has to open the door with their hands due to it do not have and automatic sensor accessible to enter, there is only an automatic sensor at the superior part right hand of the surgical washstand used per the anesthesiologist and the surgeon to performed the surgeries the automatic sensor was observed approximately at five feet high.

The nurse supervisor (employee #20) was interviewed and she stated: '' When remodeling the operating room department they made an error to place the door like that and they never fixed it " .'

On the left side near the surgical washstand on the entrance of the operating suite ''C '' a large stainless steel shelf was observed on 9/22/16 at 9:20 a. m., the two crystal doors was covered on the interior by two blue surgical paper used when sterilized the surgical instruments, a hospital adhesive tape was observed around the surgical paper.

The nurse supervisor (employee #20) was interviewed at 9:30 a. m. and she stated: '' The shelf was used to put different sterile surgical instruments used on different surgeries.''

On the interior of the shelf many sterile surgical materials (instruments) were observed, the hinges were observed with much mould. This is not following acceptable infection control techniques.

In the corridor front of the operating room suite " C '' was observed a un piece of floor with tiles, there are missing tiles on the floor and part of the floor is with rough cement. It was observed dirty and much dust due to the rough cement.

f. On the operating room '' suite D '' the following was observed at 10:15 a. m.

The operating room fold step was observed with much mould.

Various suction canisters were observed directly on the floor at right side on back of the suite.

One blade #3.0 was observed on the interior of the emergency cart and lacks of the date when sterilized and the date when ended the sterilization.

The lock hooks of the door of the stainless steel shelf used to put the sutures was observed with mould.

Two cars used to maintain the arthroscopy equipment were observed with much mould.

f. On the operating room '' suite E '' the following was observed at 10:30 a. m.

A black plastic resistant cart used to maintain the plastic surgery materials was observed with dust on the exterior and a handles of both side was observed with mould.

The IV stand was observed with white and yellow stains.

One small tank of ' ' nitroso '' was observed on the anesthetic cart with much mould.

g. The pediatric emergency car and the adult emergency cart were inspected at 10:40 a. m. dust was observed on the interior and the exterior of both emergency cars.

h. On the Recovery room equipment storage was visit at 11:00 a. m. and excessive accumulation of equipment ware observed, four shelves and IV stands were observed with much mould. Two small oxygen tanks and two small CO2 tanks were observed directly on the floor without security racks.

i. On 9/22/16 at 11:45 a. m. the operating room '' women ' s dresser " was detected that the washstand located at left side lacks of cold water and was observed a water leak under the washstand base.

j. The housekeeping room was visit at 11:55 a. m. and lacks of hand washing soap.

8. On 9/23/16 at 9:30 a. m. according of the facility's policies and procedures establish that the relative humidity stay between 30 % and 60 % and the temperature stay between 68.0 ºF and 73.0 ºF. The daily temperature and humidity register log was reviewed for the year 2015 and 2016 and reveled the following evidence:

a. The daily temperature of the '' Litotricia Operating Room '' for year 2015 reveled that on December 1 and 2 the daily temperature was maintain on 79 ºF

The daily Humidity of the '' Litotricia Operating Room '' for year 2015 reveled that on February 8 to 20, on March 8 to 30, on April 1 to 26, 28, and 30, on May 1 to 31, on June 1 to 30, on July 1 to 31, on August 1 to 19 and on December 1, 2, 22 to 24 and 26 to 28 the humidity exceeded the established parameters.

The facility did not provide evidence of the daily temperature and humidity log of the '' Litotricia Operating Room '' for year 2016.

b. The daily temperature of the '' Pre-op room '' for year 2016 reveled that on January 3 (55ºF), on 1/13 (64ºF), on 1/16 (55ºF), on 1/18 (50ºF), on 1/21 and 1/22 (66ºF), on 1/23(57ºF), on 1/24 (60ºF), on 1/30 and 1/31 (65ºF).

The daily temperature on February 13, 14 and 17 (64ºF), on 2/18 and 2/19 (50ºF), on 2/26 and 2/27 (66ºF).

The daily temperature on March 11 (65ºF), on 3/12 and 3/13 (60ºF), on 3/14 (65ºF), on 3/15, 3/16 and 3/17 (60ºF), on 3/18 (64ºF), on 3/19 (66ºF), on 3/24 (60ºF), 3/26 (74ºF), on 3/27, 3/28 and 3/30 (70ºF).

The daily temperature on April 15 (64ºF), on 4/16 (66ºF), 4/17 and 4/18 (65ºF), on 4/23 and 4/24 (60ºF).

The daily temperatures on May 6 and 5/8 (78ºF).

The daily temperatures on June 3 (70ºF), on 6/4 and 6/5 (74ºF).

The daily temperature on July 1 (60ºF).

The daily temperatures on August 29 and 30 (65ºF).

The daily temperature on September 2 (60ºF), on 9/3, 9/4 and 9/5 (55ºF), on 9/6 and 9/7(56ºF), on 9/8 (57ºF), on 9/9 (59ºF), on 9/11, 9/14, 9/15, 9/16 and 9/18 (65ºF).

c. The daily temperature of the '' Operating Room A '' for year 2016 reveled that on April 4, 5, 6, 7 and 8 was maintain on (60ºF).

No evidence of the daily register humidity log on January 29 of 2016.

d. During review of the daily temperature and humidity logs of all of the operating rooms suites provide evidence that the daily temperatures and humidity exceeded the established parameters or was maintain under the established parameters.

The nurse supervisor (employee #20) was interview on 9/23/16 at 9:30 a. m. related of this situation and what is the establish protocol of the department when identified that the temperatures and relative humidity did not stay between 30 % and 60 % and the temperature stay between 68.0 ºF and 73.0 ºF.

The nurse supervisor (employee #20) stated: '' I notified by telephone call at the engineer department and performed the intervention. However, when surveyor request the evidence of all interventions with contains the date, the hour, the name of employee who intervenes to resolved the problem and if the employee verified the relative humidity and the temperature post intervention and she referred that did not have evidence.

The facility did not provided evidence of the corrective actions to resolve the problems related to the relative humidity and temperatures on all of different areas of the Operating Room Department.

Based on a recertification survey, the review of policies and procedures and six medical records with the discharge planning coordinator, it was determined that the facility failed to ensure that ongoing reassessments are performed for patient's needs for factors that may affect continuing care.

Findings include:

Policies and procedures were reviewed on 9/23/016 at 11:00 am and provided evidence that they do not address the time frame that reassessments are to be performed.

Based on a recertification survey, five medical records reviewed (R.R) for respiratory therapy services, 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 3 out of 5 clinical records reviewed (R.R #23 #24 and #25).

Findings include:

1. Five medical records were reviewed on 9/23/16 from 2:00 pm till 4:30 pm of patients who received respiratory therapy and provided evidence that respiratory therapists did not administer respiratory therapy treatment in accordance with physician orders for R.R #23 #24 and #25. Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis (some received treatment eight hour before the scheduled time and others received treatment from twelve hours after the scheduled establish treatment hours).

a. R.R #23 is an 87 years old female who was admitted on 9/20/16 with a diagnosis of Bronchitis Asthmatic. The record review was performed on 9/23/16 at 2:30 pm, with the respiratory therapist supervisor (employee # 29) and provided evidence that on 9/20/16 at 3:00pm the physician ordered Albuterol 0.83%/ Atrovent 0.2% by power nebulizer every 4 hour and Pulmicort 0.5 mg every 12 hr. On 9/20/16 at 4:00 pm the respiratory therapist provides patient orientation related to treatment and performed an assessment and started the respiratory therapy treatment. On 9/22/16 the patient receive the treatment respiratory therapy with Albuterol 0.83% /Atrovent0.2% at 4:00 pm and the next therapy was provided on 9/23/16 8 hour later and no evidence was found that the physician was notified and justification for not administrating the treatment.

b. R.R #24 is a 55 years old male who was admitted on 9/19/16 with a diagnosis of Descompensed Congestive Obstructive Pulmonary Disease (COPD). The record review was performed on 9/23/16 at 2:50 pm, with the respiratory therapist supervisor (employee # 29) and provided evidence that on 9/19/16 at 8:45 am the physician ordered Albuterol 0.83% plus (+) Atrovent 0.2% by power nebulizer every 4 hour and Pulmicort 0.5 mg every 12 hr. On 9/19/16 at 5:00 pm the respiratory therapist provides patient orientation related to treatment and performed an assessment and started the respiratory therapy treatment. However the pulmicort treatment was started on 9/20/16 at 5:00 am twelve hour after physician order and no evidence was found that the physician was notified and justification for delay in administrating the treatment. On 9/22/16 at 5:00 pm the physician ordered Albuterol 0.83% plus (+) Atrovent 0.2% by power nebulizer every 6 hour and Pulmicort 0.5 mg every 12 hr. However the the albuterol + atrovent respiratory therapy was provided on 9/22/16 at 3:00 pm and the next treatment was provided on 9/23/16 at 7:00 am fifteen hour later. The Pulmicort treatment was provided on 9/22/16 at 7:00 am and the next treatment was provided on 9/23/16 7:22 am, 24 hour later not accordance to physician order. No evidence was found that the physician was notified and justification for delay to administrated the treatment.

c. R.R #5 is a 77 years old male who was admitted on 9/19/16 with a diagnosis of Left White Lung. The record review was performed on 9/23/16 at 3:15 pm, with the respiratory therapist supervisor (employee # 29) and provided evidence that on 9/19/16 at 5:30 pm the physician ordered Atrovent 0.2% by power nebulizer every 4 hour and Pulmicort 0.5 mg every 12 hr. On 9/19/16 at 5:00 pm the respiratory therapist provides patient orientation related to treatment and performed an assessment and started the respiratory therapy treatment. However the Pulmicort treatment was not provided by the respiratory therapist and no evidence was found that the physician was notified and justification for not administrating the treatment.