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Based on a Complaint investigation ACTS Intake PR00000640, infection control observational tour, operating room (OR) tour, observation of delivery of care, review of policies and procedures, review of medical records, documents and interviews on 08/11/21 and 08/12/21 from 8:30 AM through 2:00 PM, it was determine that the facility fail to ensure that an effective infection control program follows appropriate infection control standards and include methods for preventing and control the transmission of infections, including maintaining clean and sanitary environment within the hospital which resulted in the hospitals inability to ensure the provisions of quality health care in a safe environment which makes this condition 42 CFR 482. 42 Infection Prevention and Control Not Met (Cross reference Tags A0749 and A750).

Based on a Complaint investigation ACTS Intake PR00000640, operating room (OR) tour and verification of the medication and crash carts it was determine that the facility fail to employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings. This deficient practice had the potential to affect all patients who receive care in the OR.

Findings include:

During the operating room (OR) observational tour on 08/11/21 and 08/12/21 from 8:30 AM through 11:30 AM with OR manager (employee #5) and anesthesia supervisor (employee #13) the following was identified:

The hospital has five OR suites with 3 changing areas, one for the Physicians (MD), one for the males staff and one for the female staff, have one pre operation (Pre- op) and two recovery areas (PACU 1 and PACU 2) with one isolation room. All those areas are inside the restricted zone.

Outside the restricted zone inside the obstetrical unit it was observe two OR suits, OR suite 6 and OR suite 7.

Employee # 5 refer that OR suites 6 and 7 are for obstetrics operations.

At the time of the inspection this two OR suites did not count with a staff changing room and pre-op. When the patient is prepare on the pre-op, they have to go outside the restricted area (common hallway) to enter any of the two obstetric OR suits. The staff also have to go outside the restricted area and pass through the common hallway with the scrub, shoe cover and the operating room cap.

During the observational tour it was observe multiples staff crossing from one side to another with the scrubs, shoe covers and operating room caps. Also it was observe multiples MD's going inside the restricted area without changing the their scrubs to the sterile scrubs

In all the seven operating room suites it was observe multiples equipments like cabinets, instrument stand, kick buckets, surgical tables, medications cart, medications cabinets, X- rays film viewer, infant warmer, ceiling cross tee and surgical lights with brown spots that has and appearance of mold and scratches on the paint.

On 08/10/21 at 10:43 AM during the anesthesia medication cart verification with employee #13 it was identified seven vials of Succinylcholine 200mg/10ml inj expire on 08/01/2021.

Based on a Complaint investigation ACTS Intake PR00000640, infection control observational tour, operating room (OR) tour on 08/11/21 and 08/12/21 from 8:30 AM through 2:00 PM, it was determined that the facility fail to include 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 affects 141 out of 141 admitted patients.

Findings include:

A mechanism to ensure facility 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 was not followed. This finding was identified during the infection control observational tour through facility on 08/11/21 and 08/12/21 from 8:30 AM through 9:30 AM.

1. While performing the infection control observational tour on 08/11/21 and 08/12/21 from 8:30 AM through 11:30 AM with Nurse manager (employee # 7) the following was identified on the first floor where clean linen and textiles and dirty (contaminated) linen and textiles are storage:

In the entrance area of the room where clean linen and textiles room are stored, broken tiles on the floor are observed. In addition to this floor is observed in need of repair and in need of cleaning.

Two rooms (one adjacent to the other) where clean linen and textiles are stored, was formerly used as staff and patient dressing room before entering to operating room. In both rooms it was observed that the area had plumbing for the handwashing and toilets facilities that were located and was removed and raw concrete seal remain. This rough cement finish did not permit a proper cleaning and disinfection of those areas.

The other room where dirty (contaminated) linen and textiles are stored was observed on 08/11/21 with wide open door down the hall, without hand washing facilities readily available to workers and in lack of a negative air pressure relative to the hospital clean areas.

On 08/12/21 an old sink is observed stored at this room.

On 08/11/21 at 11:55 AM infection control officer (employee # 4) stated on interview that facility had a contract with an outside private commercial laundry company and that facility only receive clean linen and textiles to be stored and distributed through hospital areas and stored dirty (contaminated) linen and textiles until on a daily basis the company comes to pick up those dirty linens and textiles to wash, disinfect, prepare and return to the facility.

Suggested citation: 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.

While performing the infection control observational tour on 08/11/21 from 8:30 AM through 11:30 AM with Nurse Manager (employee # 7) the following was identified on the labor and delivery room and maternity ward on the second floor:

In front of the nursing station of the labor and delivery room ceiling tiles stained with dark spots were observed.

In the maternity ward examination room, it was observed a package of 200 quantity 4 x4 gauzes open exposed to the environment.


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2. During performing the infection control observational tour on 08/10/2021 and 08/11/2021 from 8:45 AM through 2:00 PM with Infection Control Nurse (employee #4) and assistant supervisor (employee #15) the following was observed:

1. On floor number eight (8) the following was observed from 8:45 AM through 9:40 AM:

a. During the initial tour the Assistant Supervisor Nurse (employee #15) was observed entering the room #814 to cannulate the patient at area B. She did not wash her hands with soap and water, she only dry cleaning with hand sanitizer and then put on gloves. She placed materials directly on the patient's left side bed. She removed gloves and discard then applied hand sanitizer and left the room. She entered the room with gloves in her hands and removed patient belongings that were on the table cleaning the table, then removed gloves and discarded. Performed hand washing with water and soap however did not wet her hands before applying soap, performed hand washing in thirteen seconds, dry and then enter her right hand in the pocket of her uniform and took out two gloves put them on and then verified the area of the patient's left upper limb but she did not cannulate it because he was a complicated patient. She removed materials from the patient's bed and left the room to consult with the physician.

b. During the infection control tour acoustic with yellow spots were observed in patient's rooms #800 and #814.

c. In the dirty utility room, it was observed on the top of counter two air mattresses in a transparent plastic bag, the nurse supervisor reports that they are clean, the two air mattresses were removed.

d. In the patient room #804 it was observed broken window glass, rest chairs bed A and B broken, hooks missing in shower curtain and dirty floor were observed.

2. During observational tour on floor number five (5) Medicine and Surgery with the Infection Control Nurse (employee #4) and fifth floor Nurse Supervisor (employee #16) the following was observed at 9:45 AM through 10:55 AM:

a. Hooks missing in shower curtain in patient's rooms 500, 506, 508, 509, 510, 511, 512, 515, 516, 517 and 518.

b. Dirty floors, dull tiles, peeling wall paint, wet on door frames and sinks, peeling baseboards or missing baseboards, dirty bathrooms with presence of mold, dampness, acoustic with yellow and dark spots, acoustic broken, covers sink faults with the presence of mold, broken rest chairs were observed in all of the patient's rooms. All patient rooms were noted in immediate need of repair and cleaning.

c. The air-conditioning in-patient room #516 is not cooling properly.

d. The IV stand in patient room #509 was observed dirty and has trouble moving it.

e. During the visual infection control inspection the bathtub of patient room #518 accumulated water was observed drainage problem. Dirty floor, dust, peeling wall paint, acoustic with yellow and dark spots, presence of mold on door frames. The patient #25 located in this room received hemodialysis treatment on the Dialysis room area located on fourth floor room #406.

The patient was interview on 08/10/2021 at 11:30 AM and she stated that she was admitted at the hospital and is the first time that received hemodialysis three times a week Tuesday, Thursday and Saturday. Catheter was observed on right side of the chest.

f. In the dirty utensils area, a metal shelf was observed, inside a brown gallon with unknown liquid content was observed, this gallon is used for urine collection in the laboratory. The gallon was removed from the area and discarded by the nurse supervisor. Inside the right side of the shelf, it was observed abundant presence of mold, dust and piece of paper.

g. Bathroom visitor use was observed with dirty floor and with foul odor.

3. On 08/11/2021 at 8:00 AM during observational tour on floor number four (4) Medicine, Telemetry and Hemodialysis with the Infection Control Nurse (employee #4) and Nurse Director (employee #6) the following was observed:

a. Hooks missing in shower curtain in patient's rooms 400, 401, 402, 403, 404, 405, 407, 409, 410, 411, 413 and 414.

b. Dirty floors, dull tiles, peeling wall paint, wet on door frames and sinks, peeling baseboards or missing baseboards, dirty bathrooms with presence of mold, dampness, acoustic with yellow and dark spots, acoustic broken, covers sink faults and wall lamps with mold presence, broken crockery, broken rest chairs were observed in all of the patient's rooms. All patient rooms 401, 402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 413, 414, 415, 416, 417 and 418 were noted in immediate need of repair and cleaning.

c. Private room #407 the emergency call system does not work and wall lamp with mold presence.

4. On 08/10/2021 at 11:45 AM the Hemodialysis treatment area was visit located on fourth floor room #406 and the following was observed:

a. The weight scale was observed in the main entrance at left side outside of the dialysis room treatment area it was observed with dust and dirty. Near the weight scale a bathroom was observed, papers in the floor, acoustics with yellow spots, dirty and dust. Foul odor was detected.

b. On the interior of the dialysis treatment room two dialysis station was observed right and left side of the room. The interior of this dialysis room was observed with deteriorate physical plant, walls, ceiling and the whole area needs painting. Floor with vinyl tiles in extreme deterioration, accumulation of dirt and dust in spaces between the tiles. Absence of tiles in front of the medical surgical warehouse. This medical surgical warehouse did not have door and all the medical surgical materials used in the unit are exposed. It was observed the wooden frame of the warehouse and the wall where the frame is has detached cement. The interior of the warehouse does not have acoustics it is painted raw concrete.

c. Sinks with evidence of mold on metal caps covers gaps in drain area.

d. Next to the surgical medical material warehouse, a small room was observed where a bath was located, infection control nurse refers it was closed and enabled to place the Reverse Osmosis (RO) Machine. In this was observed a plastic cart according with the nurse this cart is used to move materials. This interior of this room was observed with deteriorate physical plant, dirty and dust, ceiling and walls area needs painting. Floor in extreme deterioration. The base of metal where it was initially was observed to be very moldy and the drain area uncovered. The room did not have door.

e. Housel Fabric curtain was observed in the window in the hemodialysis room.

f. The temperature of the dialysis treatment room #406 was verified on 08/11/2021 at 2:00 PM with the infection control nurse (employee #4) and provided values of below set parameters of 72 grades Fahrenheit (ºF). Temperature should be between 72.0 ºF to 78.0 ºF according with the guidelines for construction to ensure that the environment is properly maintained. On July 21, 2021 the temperature was maintain at 70 ºF, on 7/22/21 at 71.4 ºF, on 7/24/21 at 70.0 ºF, on 7/26/21 at 67.5 ºF , on 7/27/21 at 68.0 ºF , on 7/28/21 at 68.5 ºF, on 7/29/21 at 70.1 ºF , on 7/30/21 at 69.6 ºF and on 7/3/21 at 68.9 ºF.

On August 1,2021 the temperature was maintain at 70.2 ºF, on 8/2/21 at 68.9 ºF , on 8/3/21 at 68.5 ºF , on 8/4 /21 at 69.4 ºF , on 8/5/21 at 70.1 ºF , on 8/7/21 at 71.1 ºF, on 8/9/21 at 70.2 ºF , on 8/10/21 at 70.0 ºF and on 8/11/21 at 70.3 ºF.

g. The facility did not provided evidence of the corrective actions to resolve the problems related to the temperatures on the Hemodialysis treatment unit (room #406).

h. The Infection Control Nurse (employee #4) was interview on 08/11/2021 at 11:00 AM related of this situation because the facility did not have evidence of any reports related to temperatures or immediate actions in this regard. She stated that the hospital has a complete unit and will be in communication with the engineer to carry out inspections and follow up on this situation. She refers that the dialysis unit is pending to be relocated in another area. However, will be communicating with the dialysis staff to report changes in temperature that do not meet the established parameters and take corrective measures.

i. The Nurse Supervisor of the Hemodialysis treatment unit (employee #17) stated on interview on 8/10/21 at 8:30 AM: '' Our company started on July 19 of 2021 and we are in the best position to provide a quality service. Offer education to employees and evaluate competencies to continue improving professionally. I 'am well committed so that patients receive good treatment.''


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3. During the operating room (OR) observational tour on 08/11/21 and 08/12/21 from 8:30 AM through 11:30 AM with OR manager (employee # 5) and anesthesia supervisor (employee # 13) the following was identified:

The hospital has five OR suites with 3 changing areas, one for the Physicians (MD), one for the male's staff and one for the female staff, have one pre operation (Pre -op) and two recovery areas (PACU 1 and PACU 2) with one isolation room. All those areas are inside the restricted zone.

Outside of the restricted zone, inside the obstetrical unit it was observe two OR suits, OR suite # 6 and OR suite #7. Employee # 5 refer on 08/11/21 at 9:00 AM that OR suites #6 and #7 are for obstetrics operations.

At the time of the inspection this two OR suites did not count with a staff changing room and pre- op. When the patient is prepared on the pre- op, he/she must go outside the restricted area to a common hallway to enter any of the two obstetric OR suites. The staff also must go outside the restricted area and pass through the common hallway with the scrub, shoe cover and the operating room cap.

During the observational tour it was observe multiples staff crossing from one side to another with the scrubs, shoe covers and operating room caps. Also, it was observed multiples MD's going inside the restricted area without changing the scrubs.

In all the seven operating room suites it was observe multiples equipment like cabinets, instrument stand, kick buckets, surgical tables, medications cart, medications cabinets, X- rays film viewer, infant warmer, ceiling cross tee and surgical lights with brown spots that has and appearance of mold and scratches on the paint.

On 08/10/21 at 10:43 AM during the anesthesia medication cart verification with employee # 13 it was identified seven vials of Succinylcholine 200mg/10ml inj. expire on 08/01/2021.

Based on a Complaint investigation ACTS Intake PR00000640, operating room (OR) tour and verification of the medication and crash carts it was determine that the facility fail provides inpatient and outpatient surgical services, well organized and in accordance with acceptable standards of practice. This deficient practice had the potential to affect all patients who receive care in the OR.

Findings include:

During the operating room (OR) observational tour on 08/11/21 and 08/12/21 from 8:30 AM through 11:30 AM with OR manager (employee #5) and anesthesia supervisor (employee #13) the following was identified:

The hospital has five OR suites with 3 changing areas, one for the Physicians (MD), one for the male's staff and one for the female staff, have one pre operation (Pre op) and two recovery areas (PACU 1 and PACU 2) with one isolation room. All those areas are inside the restricted zone.

Outside the restricted zone inside the obstetrical unit, it was observed two OR suits, OR suite 6 and OR suite 7. Employee # refer that OR suites 6 and 7 are for obstetrics operations. At the time of the inspection this two OR suites did not count with a staff changing room and pre-op. When the patient is prepared on the pre-op they have to go outside the restricted area (common hallway) to enter any of the two obstetric OR suits. The staff also have to go outside the restricted area and pass through the common hallway with the scrub, shoe cover and the operating room cap.

During the observational tour it was observe multiples staff crossing from one side to another with the scrubs, shoe covers and operating room caps. Also, it was observed multiples MD's going inside the restricted area without changing their scrubs to the sterile scrubs

In all the seven operating room suites it was observe multiples equipment like cabinets, instrument stand, kick buckets, surgical tables, medications cart, medications cabinets, X- rays film viewer, infant warmer, ceiling cross tee and surgical lights with brown spots that has and appearance of mold and scratches on the pain.

On 08/10/21 at 10:43 AM during the anesthesia medication cart verification with employee # 13 it was identified seven vials of Succinylcholine 200mg/10ml inj expire on 08/01/2021.

Based on a Complaint investigation ACTS Intake PR00000640, operating room (OR) tour and verification of the medication and crash carts it was determine that the facility fail to assure the achievement and maintenance of high standards of medical practice and patient care. This deficient practice had the potential to affect all patients who receive care in the OR.

Findings include:

During the operating room (OR) observational tour on 08/11/21 and 08/12/21 from 8:30 AM through 11:30 AM with OR manager (employee #5) and anesthesia supervisor (employee #13) the following was identified:

The hospital has five OR suites with 3 changing areas, one for the Physicians (MD), one for the male's staff and one for the female staff, have one pre operation (Pre op) and two recovery areas (PACU 1 and PACU 2) with one isolation room. All those areas are inside the restricted zone.

Outside the restricted zone inside the obstetrical unit, it was observed two OR suits, OR suite 6 and OR suite 7. Employee # refer that OR suites 6 and 7 are for obstetrics operations. At the time of the inspection this two OR suites did not count with a staff changing room and pre op. When the patient is prepared on the pre op must go outside the restricted area to a common hallway to enter any of the two obstetric OR suits. The staff also must go outside the restricted area and pass through the common hallway with the scrub, shoe cover and the operating room cap.

During the observational tour it was observe multiples staff crossing from one side to another with the scrubs, shoe covers and operating room caps. Also, it was observed multiples MD's going inside the restricted area without changing their scrubs to the sterile scrubs

In all the seven operating room suites it was observe multiples equipment like cabinets, instrument stand, kick buckets, surgical tables, medications cart, medications cabinets, X- rays film viewer, infant warmer, ceiling cross tee and surgical lights with brown spots that has and appearance of mold and scratches on the pain.

On 08/10/21 at 10:43 AM during the anesthesia medication cart verification with employee # 13 it was identified seven vials of Succinylcholine 200mg/10ml inj. expire on 08/01/2021.

Based on an Emergency Preparedness (EP) survey, review of the EP manual performed on 08/12/21 on 10:30 AM it was determined that the facility failed to develop and maintain an emergency preparedness plan with specific approach to the location of the facility and surroundings including emerging infectious disease and COVID-19.

Findings include:

During the EP survey performed on 8/12/21 on 10:30 AM it was found that the facility fail to include emerging infectious disease (EID) threats such as, Influenza, Ebola, Zika Virus, and COVID-19.

Based on an Emergency Preparedness (EP) survey performed on 08/12/2021 at 10:30 AM to evaluate emergency preparedness requirements, it was determined that the facility failed to have in place policies and procedures related to shelter in place for patients, staff, and volunteers who remain in the facility.

Findings include:

The facility failed to provide evidence of policies and procedures related to shelter in place for patients, staff, and volunteers who remain in the facility.