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Based on the review of documents and the interview with the Therapy Department Supervisor (employee #17), it was determined that the facility failed to ensure the credentials files (CF) for contracted services were updated for 5 out of 12 respiratory therapy credentials. (CF#1, 2, 6, 7 and 12)

Findings include:

1. The facility has respiratory therapy under contracted services. During review of twelve personnel credential files with Therapy Supervisor performed on 07/16/2025 from 1:00 PM through 2:00 PM provided evidence of the following:

a. One out of twelve credential files failed to show updated evidence of the Health Certificate (C.F #1).

b. Four out of twelve credential files failed to show updated evidence of the chickenpox vaccine titers (C.F #1, C.F #2, C.F #6, C.F #12).

c. One out of twelve credential files failed to show updated evidence of the annual evaluation (C.F. # 7).

d. One out of twelve credential file failed to show updated evidence of the competency document (C.F. #7).

e. The facility failed to ensure that contracted professional staff comply with requirements.

Based on records reviewed (RR) and interviews conducted with six patients on 07/17/2025, it was determined that the facility failed to ensure that the hospital inform each patient, or when appropriate, the patient's representative, of the patient's right, in advance of furnishing or discontinuing patient care for 3 out of 6 records reviewed (RR#11, 48 and 49).

Findings include:

Admission Supervisor (employee #19) provided the last update facility policy update on 05/2025, Derecho de Paciente: Patients Rights Livanta on 07/17/2025 at 11:43AM. The policy states on page 3: 6. A new "Important Message from Medicare" sheet should be provided as a follow-up and reminder of the right to appeal the discharge. 7. The follow-up sheet should be provided when it is anticipated.8. If the likelihood of discharge cannot be determined, the letter should be delivered the same day and at least four hours should be given for the beneficiary to consider his or her appeal rights and Livanta to review his or her case.

1. During interviews conducted on July 17, 2025, from 1:15 p.m. to 2:45 p.m., with six randomly selected patients, three of the following patients: RR#11, #48, and #49. These patients indicated that they were discharged early that day and did not receive the letter "Important Message from Medicare About Your Rights" within 48 hours prior to discharge. After the records reviewed of these patients the Important Message from Medicare About their rights was not in the record.

The interview conducted with Admissions Supervisor (employee #19) on 07/15/2025 at 1:18 PM, stated that when the patient is admitted they are oriented of the Important Message from Medicare About Your Rights letter, they sign, and a copy is given to the patient to read their rights while they are in the hospital. When the patient is discharged, they are oriented and given the letter again to sign.

Based on records reviewed (R.R), advance directive policy and procedure, it was determined that the facility failed to ensure that patients or their representatives formulate advance directive and comply with these directives related to lack of physician order and justification for the consent of Do Not Intubate (DNI) and advance directive orientation for 4 out of 15 records reviewed of patient with Do Not Resuscitate DNR and DNI (R.R #6, 8, 10, and 25 ).

Findings include:

1. Facility policy provided by Supervisor of the Medicine One Department (employee #16) on 07/16/2025 at 9:40 AM was reviewed. Document # ENF-88 was reviwed on 02/2024, "Rol del Personal de Enfermería En El Cumplimiento De Los Derechos Del Paciente Cuando Firma DNR-DNI (DO NOT RESUCITATE OR DO NOT INTUBATE)".

Policy states in section #1(a) that all physician-generated orders must be dated, time-stamped, legibly marked, and signed by the ordering physician. Section #1(c) states that the physician must make a progress note in the patient's record, and Section #1(d) states that the physician must document family counseling regarding their current decision.

a. R.R #6 is an 84-year-old woman who was admitted on 07/14/2025, with a diagnosis of Acute Respiratory Failure, Unspecified Whether with Hypoxia. During the record review performed on 07/16/2025, at 10:00 A.M., revealed for consent not to intubate (DNI) and do not resuscitate (DNR), signed by a family member.

However, no date or time was observed on the document, and no evidence was found related to physician order for DNI/DNR and physician initial and subsequent progress notes for that justify the DNI/DNR and family orientation of the DNI/DNR.

b. R.R #8 is a 90-year-old female who was admitted on 06/11/2025, with a diagnosis of CVA (Cerebro Vascular Accident) ARF on MV (acute respiratory failure on mechanical ventilator), Bedridden, HTN (hypertension) and DM II (diabetes mellitus type II). During record review performed on 07/16/2025, at 10:40 A.M., revealed for consent DNI and DNR, signed by a family member.

However, no date or time was observed on the document DNI.
No evidence was found of the medical progress notes justifying the DNI and DNR on 06/25/2025, 06/26/2025, 06/27/2025, 07/02/2025, 07/03/2025, 07/05/2025, 07/06/2025, 07/08/2025, 07/11/2025, 07/12/2025, 07/13/2025, 07/14/2025 and 07/15/2025.

c. R.R #10 is an 80-year-old woman who was admitted on July 10, 2025, with a diagnosis of Elevated White Blood Cells Count, Unspecified. During record review performed on 07/16/2025, at 9:31 A.M., revealed a medical order in the system dated July 12, 2025, at 7:42 P.M., for consent to DNI and DNR, signed by a family member.

However, no date or time was observed on the document. No evidence was found of the medical progress notes justifying the DNI and DNR on July 13, 2025, July 14, 2025, and July 15, 2025.

In an interview with the supervisor (employee #16), of the medicine 1 department on 07/16/2025 at 9:45 AM, she indicates that once the patient has the signed DNR or DNI consent, a green band is placed on the patient's arm and the record is identified with the same color and that when shift handover is done on each shift patient by patient, visiting all the rooms, they notify which patient has signed consent.


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d. R.R #25 is a 91-year-old female who was admitted on 07/15/2025 to the emergency room (ER) with a diagnosis of Congestive Heart Failure (CHF), Fluids Overall with Anasarca, Effusion Pleural, Pleural Edema, and Cystitis. During the record reviewed performed on 07/16/2025 at 1:00 PM provide evidence that on patient has an Affidavit # 9598 date March 17, 2018, that refuses transfusion and attention to prolongation life. On 07/16/2025 at 9:3 AM the patient signed Do Not Intubate (DNI) and Do Not Resuscitate (DNR) consent.

However, no evidence was found related to physician order for DNI and DNR. No evidence was found related to physician progress notes that justify the DNI and DNR and patient orientation.

Based on four (4) medical records reviewed (R.R.) for restraint, review of restraint policy and procedure (P&Ps), review of Mandatory Nursing Activities, it was determined that facility failed to ensure that restraint be used when least restrictive intervention have been determined be ineffective to protect patient and staff, for 1 out of 4 patients in restraint. (RR #25).

Findings include:

The Patient Restraint policy and procedure was reviewed on 07/16/2025 at 1:10 PM.

1.R.R #25 is a 91-year-old female who was admitted on 07/15/2025 to the emergency room (ER) with a diagnosis of Congestive Heart Failure (CHF), Fluids Overall with Anasarca, Effusion Pleural, Pleural Edema, and Cystitis.

During the record reviewed performed on 07/16/2025 at 1:00 PM provide evidence that nurse documented that the patient family refer that patient try to remove the Intravenous (IV) and that was aggressive with nursing personnel, patient be restrictive according to physician order. The family was oriented to notify any change in condition, refer understand.

On 07/16/2025 at 4:14 AM the physician places physician order and writes Restraint of patient physician Order.

On 07/16/2025 at 4:10 AM the nurse documented the clinic document 234 title RN-Restricted Patient
and documented that patient was anxious, level of consciousness: aggressive, behavior: attempts to move intravenous lines and other tubes, aggressive.

In the second re-assessment performed on 07/16/2025 at 6:10 AM the nurse documented the clinic document 234 title RN-Restricted Patient and documented that patient level of consciousness: confuse,, behavior: attempts to move intravenous lines and other tubes.

No evidence was found documented to remove or discontinue the restraint.

The physician failed to evaluate the patient to determine if it needed or not to continue the use of restraint.

The next assessment for restraint was performed on 07/16/2025 at 11:42 AM.

However, no evidence was found related to the less restrictive measure and when determined that was ineffective proceed to restrain the patient.

The physician failed to write a complete restraint physician order that included purpose of the restriction, duration of the restriction, type of restriction, and parts to be restricted.

The physician failed to document in the physician's progress notes a justification and a face-to-face assessment previous to restraint.

No evidence was found that the nurse activates the plan of care for physical restraint.

Based on four medical records reviewed (R.R.) for restraint, review of restraint policy and procedure (P&Ps), review of Mandatory Nursing Activities, it was determined that facility failed to ensure that restraint be used when least restrictive intervention have been determined be ineffective to protect patient and staff, for 1 out of 4 patients in restraint. (RR #25).

Findings include:

The Patient Restraint policy and procedure was reviewed on 07/16/2025 at 1:10 PM. and stated in the following items:

#2. The physician or nursing professional who identifies a patient at risk of harming themselves, other patients, or hospital staff should initiate the following preventive process before deciding to restrain the patient:
a. Assess physiological, environmental, and behavioral needs.
b. Promote environmental alternatives and evaluate their effectiveness before restraining the patient.
e. Continually assess levels of consciousness.
g. Evaluate whether the condition can be resolved with sedative medications, therapy, or other means.

#5. The medical order or progress note must include:
a. Date
b. Time
c. Purpose of the restraint
d. Length of restraint
e. Type of restraint
f. Body parts to be restrained
g. Medications (if applicable)


1. R.R #25 is a 91-year-old female who was admitted on 07/15/2025 to the emergency room (ER) with a diagnosis of Congestive Heart Failure (CHF), Fluids Overall with Anasarca, Effusion Pleural, Pleural Edema, and Cystitis.

During the record reviewed performed on 07/16/2025 at 1:00 PM provide evidence that nurse documented that the patient family refer that patient try to remove the Intravenous (IV) and that was aggressive with nursing personnel, patient be restrictive according to physician order. The family was oriented to notify any change in condition, refer understand.

On 07/16/2025 at 4:14 AM the physician places a physician order and writes Restraint of patient physician Order.

On 07/16/2025 at 4:10 AM the nurse documented the clinic document 234 title RN-Restricted Patient and documented that patient was anxious, level of consciousness: aggressive, behavior: attempts to move intravenous lines and other tubes, aggressive.

However, no evidence was found related to the less restrictive measure and when determined that was ineffective proceed to restrain the patient.

Based on review of restraint policy and interviews, it was determined that the facility failed to ensure that hospitals must report deaths to CMS associated with the use of seclusion or restraint.

Findings include:

1. Facility policy provided by Social Worker (employee #15) on 07/16/2025 at 2:07 PM was reviewed. Document # TS/EN-25 was revised on 02/2024, "RESTRICCIÓN DE PACIENTES"- Patient Restrain , stated on page 65 in section K that any death that occurs within 24 hours after the patient has been removed from a restriction must be reported to the administration and the risk management program immediately.

a) During the review of the patient restraint facility policy, performed on 07/16/2025, at 2:07 PM, there was no mention that deaths associated with patients in restraints should be reported to CMS accordingly with State Operation Manual Appendix A (Rev. 220; Issued:04/19/24) TAG A 0213 s §482.13(g)(1) & (3)(i) the hospital must report the following information to CMS by telephone, facsimile, or electronically.

In an interview with the Social Worker, (employee 15), performed on 07/16/2025, at 2:15 PM, she indicated that such a policy was not available to her and that she had not had any incidents involving deaths to report.

In an interview with the Director of Institutional Programs (employee #9), she indicated that she did not have a policy for reporting deaths due to restraints, but that she was aware that if such cases occurred, they should be reported to CMS and designated as sentinel events.

Based on the review of eighteen medical staff credential files (CF) perform on 7/15/2025 at 10:00 AM with the Human Resources (employee #8), it was determined that the facility failed to comply with federal and state local law related to Health Certificate and updated Cardiorespiratory certification (CPR) and ACLS for 3 out of 18 Physician (MD) Credential Files (C.F.) reviewed (C.F. MD#3, MD#4 and MD#17).

Findings include:

1. During the review of eighteen medical staff credential files on 07/15/2025 at 10:00 AM with the Medical Staff Clerk (employee #20), the following was found:

a. One out of eighteen medical staff's credential files did not have evidence of their Health Certificate. (CF #3 expired on 06/22/2025)

b. One out of eighteen medical staff's credential files did not have evidence of their updated cardiorespiratory certification (CPR). (CF #4).

c. One out of eighteen medical staff's credential files did not have evidence of their updated ACLS certification expired on 06/2025. (CF #17).

Based on forty-nine closed and active clinical records reviewed (RR) from 07/15/2025 to 07/17/2025, it was determined that the facility failed to ensure that all patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedure, 4 out of 49 Records Review (RR#13, 14, 15, and 23).

Findings include:

1. RR# 13 is a 77-year-old female admitted to the facility on 06/12/2025 with Metabolic Acidosis. During the observation made to the clinical record with the Supervisor Department of Medicine I (employee #16) on 07/15/2025 at 10:45 AM, in the progress note on 07/13/2025 10:05 PM the respiratory therapy staff omitted his signature, date and time of order taking.

2. RR# 14 is a 60-year-old male admitted to the center on 07/14/2025 with viral pneumonia. During a review of his medical history by the supervisor of the Department of Medicine I (employee no. 16) on 07/15/2025 at 11:15 AM., he was prescribed Xoponex inhalation 1.25 milligrams (mg)/3 milliliters (ml), one ampoule every six hours, and Atrovent 0.02% inhalation, one ampoule every six hours, on 07/14/2025 at 7:00 p.m. No notes were found regarding the progress of respiratory therapy treatments administered by staff.

3. RR# 15 is a 69-year-old female admitted to the facility on 07/14/2025 with Respiratory distress. During the observation made to the clinical record with the Respiratory Therapy Supervisor (employee #16) on 07/15/2025 at 10:06 AM, in the progress note on 07/14/2025 6:51 PM and 3:00 AM the respiratory therapy staff omitted his signature, date and time of order taking.

The facility failed to ensure date, timed, and appropriately authenticated by the person who is responsible for ordering, providing or evaluating the services provided.



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4. RR#23 is an 23-year-old female visit the emergency room on 07/15/2025 at 1:23 PM Reactive posterior Cervical Lymph Node.

During the record review performed on 07/16/2025 at 10:00 AM provide evidence that the patient was evaluate and discharge home on 7/15/2025 at 9:49 AM, however no evidence was found that the nurse takes the vital sign before the discharge.

Based on observation tour of the facility and interviews from 07/15/2025 through 07/17/2025 between 8:30 AM to 3:30 PM, it was determined that the facility failed to ensure that the condition of the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients as well as for employees and visitors.

Findings include:

1. On 07/15/2025 at approximately 9:20 AM the area of the regular trash containers and biomedical waste was observed. This area is open and unrestricted for access by staff and visitors. The container was observed with its hatches open (without locks), allowing free access to unauthorized individuals.

2. On 07/16/2025 at approximately 10:30 AM during observation of Medicine Area 1 and Medicine Area 2 it was found that Bio Bazard and dirty linen rooms were unlocked and gave free access to personnel or unauthorized persons.

Based on tests to equipment, interviews and observations made during the survey for Life Safety from fire with a facility Engineering Director (employee #3) and the Compliance Director (employee#1), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed from 07/15/2025 through 07/17/2025 from 8:30 AM till 3:30 PM with the facility Engineering Director (employee #3) and Compliance Director (employee #1); for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form (K0225, K0347, K0353, K0908, K0909, K0914, K0916 and K0918).

Based on observations and interview during the observational tour with the infection control officer ( employee# 7) on 07/15/25 at the hospital, it was determined that the facility failed to maintain adequate facilities for its services.

Findings include:

1. At 9:33 AM in the Emergency Room isolation room area the bathroom sink was not turning on the faucet to turn on the hot water.

2. At 9:41 AM the intensive care area was checked and only 1 sink had the hot water faucet open, this being the one in the staff lounge.

3. Between 11:45 AM and 12:30 PM two inpatients on the Medicine 1 floor were interviewed and verbalized "the water is cold like the freezer".

4. During the review of patient web complaints conducted on 07/15/2025 at 2:30 PM several patients were observed expressing no hot water during their hospital stay.

In an interview conducted on 7/15/2025 at 2:45PM the infection control officer (employee #7) states that she was reviewing all the policy to make sure they comply with CDC requierements.

5. The facility failed to provide a policy for the use of hot water in patients areas.

According to the Guidelines for Environmental Infection Control in Health-Care Facilities from 2003 updated on 2019, the facility must have hot water distribution systems serving patient-care areas operated under constant recirculation to provide continuous hot water at each outlet.

Based on observation tour of the facility and interviews on 07/15/2025 between 9:00 AM to 3:30 PM, it was determined that the facility failed to ensure that technological equipment, medical supplies and medical equipment must be maintained acceptable level of safety and quality.

Findings include:

1. On 07/15/2025 at 9:17 AM a tour of the morgue area was made accompanied by the infection control program coordinator (employee #7) and the following was observed:

a. In the anteroom of the morgue is the data server room which was observed with humidity and water filtration from the ceiling area.

b. No smoke alarm or water sprinkler was observed in the server room.

c. There was no thermometer available to measure temperature and humidity, however, the temperature of the morgue, which is measured daily, is maintained between 38 to 40 degrees (º) Fahrenheit (F)

2. During the tour conducted on 07/15/2025 at 3:06 PM in the supply storage where medical surgical products such as: IV solutions injections, IV lines, needles, alcohol preps and other materials are stored, an area of the ceiling was observed with the treatment or paint completely peeling off due to water filtration and humidity in that area. This deficiency was corrected on site prior to the completion of the inspection on 07/17/2025.

According to the Guidelines for Design and Construction of Health Care Facilities FGI 2010 edition page 79, the technology equipment center (TEC) must be a sufficiently sized, environmentally controlled, power conditioned, fire protected, secure space with limited access that is located strategically to avoid any floodplain or other known hazard and the temperature and humidity in the technology distribution rooms (TDR) shall be controlled to an operating range of 64 to 75 degrees F (18 to 24 degrees C) with 30 to 55 percent relative humidity.


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3. During observation of the Radiology Department on 07/16/2025 approximately at 1:56 PM, it was observed that the entrance door to the Densitometry area did not have the glass completely sealed. The glass had an uncovered space which does not provide the required protection for a detailed area such as "Radiation Risk".


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Infection Control Coordination (employee #7) provided the last update of the facility policy on 2024, Registro de Temperatura y Humedad on 07/17/2025 at 1:03PM. The policy states on page 2: 2. If there is a failure, the physical plant is contacted, and the log is recorded. The log sheet has a few spaces to record the follow-up. 3. if not in compliance, notify the physical plant department of follow-up and notify the infection control program and the engineer. 4. Follow-up actions are evidenced in writing documented by date, signature and comments.

4. During the observations made with the respiratory therapy supervisor on 07/15/2025 at 9:10 AM, it was observed that in the temperature and humidity log of the Clean Ventilator Room in the months of January, February, March, April, May, June, and July the Humidity was outside the accepted ranges. No corrective actions were found on the log sheet during those months.

During the interview with the respiratory therapy supervisor, she stated that she had already notified the physical plant staff that the humidity in the clean ventilator room was out of range. She was asked for evidence of the notifications made and indicated that the notifications were verbal.

Based on an infection control observational tour, on 07/15/25 and from 9:00 AM through 11:30 AM, it was determined that the facility fails to implement methods for preventing and control the transmission of infections, including maintaining clean and sanitary environment within the hospital. This deficient practice has the potential to affect 54 out of 54 admitted patients.

Findings include:

1Facility failed to promote a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections and comply with established requirements by Center for Disease Control and Prevention.

The following findings were identified on 07/15/25 and from 9:00 AM through 11:30 AM during observational tour on medicine ward 1:

While performing the infection control observational tour with the infection control officer (employee #7), it was identified on the second floor where dirty linen (contaminated) linen is stored that there is no available hand washing facilities readily available to workers and room did not have negative air pressure relative to the hospital clean areas.

Not acording to CDC infectioon control guidance: http://www.cdc.,gov/infectioncontrol/guidelines/environmental/background/laundry.html Guidelines for Environmental Infection Control in Health-Care Facilities (2003)Background G. Laundry and Bedding.


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Policy and procedure related to terminal cleanings, last revision Feb 2024, was review with the infection control officer (employee #7) on 07/16/2025 at 10:04 AM

2. Facility failed to perform an isolation room complete disinfection according with Guidelines for Environmental Infection Control in Health-Care Facilities (2003) accordingly with the following findings:

3. While performing observation tour performed on 07/15/2025 at 2:43 PM of the isolation room without a patient, the mattress was observed to be tilted sideways without a sheet, at a 45-degree angle. However, belongings (shoes) were observed in the room, and (clothing) was seen on the floor in the bathroom.

In an interview with the supervisor of the medicine 1 department, (employee #16) on 07/15/2025 at 2:50 PM indicated that upon seeing the mattress in that position, the terminal cleaning was finished. When asked, the environmental services staff stated that they only performed terminal cleaning of the bed.


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4. During observation of the facility, 3 eye wash stations were observed without dust covers, had water hardness marks indicative of lack of cleaning and did not have signed inspection cards. Facility's "Programa de Manejo de Agua" states that this equipment must be inspected at least weekly.


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5. During the Infection Control tour by the Medical Record Department on 07/15/2025 at 8:55 AM with the Information Management Officer (employee #22) the following was observed:

a. On 07/15/2025 at 8:55 AM a strong odor of humidity and dust was detected inside the medical record room.

b. Floor and edges of the medical record room were observed porous, dirty tiles with dark spots and mold on the edges of the tiles.

c. Inside of the Medical Record room, all the shelves were observed with dust on the tablets and accumulation of abundant dark dust on the floor behind the shelves.

d. Walls and edges were observed with dust, dark spots and mold on the edges.

e. Gap between the shelves on the right side and the one on the front wall, there was an accumulation of dust and rubber base detached from the column.

f. In the bases of the metal shelves, pieces of cardboard were observed which are used to reinforce the unevenness of the floor; the pieces of cardboard were observed deteriorated and with dust.

g. On the left side, between the first shelf and the second shelf in front of desk number eight, a column was a loose plastic cover with cable exposed was observed.

Based on interviews with the Discharge Planning coordinator (employee # 15), document review and six record review (RR) performed on 07/17/2025 at 10:35 AM, it was identified that the facility failed to implement a discharge planning process at an early stage of hospitalization for all patients. This deficient practice was identified in 3 out of 6 cases reviewed (RR # 4, RR # 9 and RR # 10).

Findings include:

The policy named: "Proceso de Planificación de alta" Discharge Planning Process (PA/TS-002, 2/2024 revision) was discussed and reviewed with the Discharge Planning Coordinator on 07/17/2025 at 10:35 AM. The facility policy states that a discharge planning assessment must be performed 24 hours after admission, with the exceptions of holidays. In the latter case, the assessment can be done on the next working day.

During interview with the Discharge Planning coordinator (employee # 15), she stated that to any patient that complies with the approved criteria (65 years old or more, medicare patients, staff or physician referral, patient or family member's request and patients without medical insurance), the discharge planning assessment must comply with the mentioned time frame.

During the interview with the Discharge Planning coordinator (employee # 15), she stated that is the sole resource, acting both as a social worker and as the hospital discharge planning coordinator.

1. RR # 4 is a 52 - year - old male who was admitted on 07/05/2025 (Saturday) with a diagnosis of Advance Cirrhosis and End Stage Chronic Liver Disease. The initial discharge planning assessment was done on 07/08/2025 (Tuesday).

2. RR # 9 is a 91 - year - old female who was admitted on 07/11/2025 (Friday) with a diagnosis of Sepsis, Infected Sacral Ulcer, Acute Respiratory Failure and Alzheimer Disease. The initial discharge planning assessment was done on 07/14/2025 (Monday).

3. RR # 10 is a 80 - year - old female was admitted on 07/10/2025 (Thursday) with a diagnosis of Alzheimer Disease, Anemia and Hypertension. The initial discharge planning assessment was done on 07/14/2025 (Monday).

4. The facility failed to implement a discharge planning process at an early stage of hospitalization for all patients.