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Based on a recertification survey, the review of the State Law License regulations and the review of nursing (C.F.), it was determined that the facility failed to updated personnel credential files related to annual evaluations, Professional license cardio pulmonary Resuscitation certificates (CPR), health certificates, Hepatitis B vaccine, Influenza vaccine and Criminal record background check (Antecedentes Penales) for 34 out of 48 credential files reviews, ( Nursing CF #1, #4, #5, #7, #8, #9, #10, #11, #13, #14, #16, #15, #18 #19, #20 #23, #24 #25, #26, #27 #29, #30, #31, #32, #33, #34, #35, #37, #38, #40, #41, #42, #45 and #48)

Findings include:

During credential files review on 6/23/2017 from 11:30pm to 2:30 pm the following was found:

1. One out of forty eight nurse CF reviews, do not show an updated license, (CF#23)

2. Three out of forty eight nurses CF reviews, do not show an updated health certificate, (CF #5, #23 and #24).

3. Six teen out of forty eight nurses CF reviews, does not provide evidence of an Influenza vaccination, (CF #1, #4, #5, #8, #14, #23, #25, #26, #29, #32, #34, #35, #37, #40, #41 and #48). The facility does not comply with Department of Health Administrative Order Number 244 of October 10, 2008.

4. Seven out of forty eight nurses CF reviews, does not provide evidence of Hepatitis B vaccination. (CF #8, #23, #30, #33, #35, #38 and #43)

5. Eleven out of forty eight nurses CF reviews, does not provide evidence of and updated CPR (CF #13, #14, #16, #20 #23, #24, #26, #27, #30, #34 and 42)

6. Twelve out of forty eight nurses CF reviews, does not provide evidence of and updated Annual Evaluation (CF #7, #8, #9, #10, #11, #19, #23, #25, #30, #31, #45 and #48)

7. Seven out of forty eight nurses CF reviews, does not provide evidence of and updated Criminal record background check (Antecedentes Penales) (CF#7, #15, #18, #23, #27, #36, and #48)

The facility failed to updated personnel credential files related to annual evaluations, Professional license cardio pulmonary Resuscitation certificates (CPR), health certificates, Hepatitis B vaccine, Influenza vaccine and Criminal record background check (Antecedentes Penales)


20423


8. During the review of thirty-eight Physician Credential File (PCF) with the Medical Facultative Secretary (employee #23) on 6/23/17 at 11:15 am, it was determined that the facility medical staff failed to ensure that Medical Facultative Physicians meet applicable standards that are required by State or local laws related to updated license, updated health certificate, updated CPR, updated Influenza vaccines, Hepatitis B vaccine or Hepatitis B title, update Mal practice insurance, updated privileges, updated Narcotic Federal and State License, update professional association and updated criminal record certification as follow:

a. Eleven out of thirty-eight physician credential file, did not show an updated license Registry (PCF #24).

b. Eleven out of thirty-eight physician credential file, did not have an updated health certificate, (PCF #1, #3, #6, #8, #9, #12, #24, #32, #33, #34 and #36).

c. Seven out of thirty-eight physician credential file lack of a CPR Certification by the American Heart Association; Basic Life Support (BSL), Advance Life Support (ACLS), Pediatric Advance Life Support (PALS) or Neonatal Advance Life Support NALS). The physician has a CPR certification by Internet. (PCF #12, #19, #20, #23, #28, #31 and #37).

d. Nine out of thirty-eight physician credential file lack of an updated CPR Certification by the American Heart Association. Basic Life Support (BSL), Advance Life Support (ACLS), Pediatric Advance Life Support (PALS) or Neonatal Advance Life Support NALS), (PCF #3, #6, #9, #15, #16, #18, #24, #26, #33 ).

e. Twenty-Four out of thirty-eight physician credential file did not have evidence of updated Influenza vaccines or refuse certification, accordance to state administrative order #244 of 10/10/2008 of the Department of health and the state administrative order #362 of 12/8/16 of the Department of health (PCF #2, #3, #4, #5, #6, #7, #8, #10, #15, #16, #18, #19, #21, #22, #24, #27, #28, #29, #31, #32, #33, #36, #37 and #38).

f. Twenty-seven out of thirty-eight physician credential file did not have evidence of Hepatitis B vaccine or Hepatitis B title (PCF #2, #3, #5, #6, #7, #8, #9, #11, #12, #13, #14, #16, #17, #19, #20, #21, #22, #24, #25, #27, #28, #29, #30, #33, #36, #37 and #38).

g. Seven out of thirty-eight physician credential file did not have update Mal practice insurance (PCF ##1, #3, #9, #21, #24, #33 and #38).

h. Nine out of thirty-eight physician credential file did not have updated privileges (PCF #3, #5, #8, #9, #10, #21, #22, #24 and #36).

i. One out of thirty-eight physician credential file did not have updated Narcotic Federal License (PCF #33).

j. Three out of thirty-eight physician credential file did not have updated Narcotic State License (PCF #1, #15, and #22).
k. Two out of thirty-eight physician credential file did not have update professional association (PCF#24 and #29).

l. Twenty-two out of thirty-eight physician credential file did not have updated criminal record certification (PCF #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #15, #16, #17, #18, #20, #22, #23, #25, #29, #33 and #37).


17959

9. During the review of eight (8) Respiratory Therapist Credential Files with the (employee #56) on 6/22/17 at 4:10 p.m, it was determined that the facility respiratory therapist failed to ensure that meet applicable standards that are required by State or local laws related to updated license, updated CPR, updated Influenza vaccines, Hepatitis B vaccine or Hepatitis B title, and job description as follow:

a. One out of eight respiratory therapist CF reviews, does not provide evidence of the profesional licence (CF #7), the respiratory therapy credential file provide evidence of provisional licence #1 and this provisional licence number 11277-1 was Expired on April 13, 2017, however this employee has an agreement begining on March /7/2017 throught September /7/17.

b. Eight out of eight respiratory therapist CF reviews, does not provide evidence of an Influenza vaccination, (CF #1, #2, #3, #4, #5, #6, #7 and #8). The facility does not comply with Department of Health Administrative Order Number 244 of October 10, 2008.

b. One out of eight respiratory therapist CF reviews, does not provide evidence of and updated CPR (CF #8).

c. Two out of eight respiratory therapist CF reviews, does not provide evidence of and updated Job Description (CF #4 and #8).

Based on a recertification survey, documents reviewed and interviews performed on 6/20/17 through 6/23/17 from 8:00 am to 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: conditions of participation: 42 CFR § 482. 41 Physical Enviroment, § 482.42 Infection Control , § 482.55 Emergency Services and §482.57 Respiratory Care Services which makes this condition not met. (Cross refer Tag A700, A747, A1100 and A1151).

Based on a recertification survey, the review of medical Staff By laws, Rule and Regulation with the administrator (employee #33), the Sub- Medical Director (employee #21) and the Facultative President (employee #34), it was determined that the facility failed to ensure that the medical staff updated the bylaw and that those bylaws comply with State and Federal law.

Findings include:

On 6/20/17 at 2:54 pm during the review of Medical By Laws and the Rule and Regulation it was evidence that the Bylaws was from 2014-2016 and was approved by the governing Body on November 20, 2014. In the Appendix X, Section 1, Subsection H: Bylaws and Revision Committee, Item 2; state that "Conduct every two (2) years a review of the Bylaws, Rule and Regulation. In the Appendix XVI: Revision state "These Bylaws and Appended Rules And Regulation shall be review every Two (2) years.

Interview with the sub- director medical director on 6/21/17 at 1:00 pm state that the bylaws was in revision.

No evidence was provide related to an updated Bylaws, Rule and Regulations during the survey.

Based on a recertification survey, interview and review of the facility' s institutional plan documents performed on 6/20/17 at 2:00 pm, 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 6/20/17 at 2:00 pm 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 #33) performed on 6/20/17 at 2:00 pm stated: " I do my budget up to 2017. I am going to provide copy of the CMS appendix A Tag related to the facility budget and explain to the bookkeeper."

Base on recertification survey, observation of the emergency room department, it was determined that the facility's Governing Body failed to ensure that emergency services provided at the hospital complies with the requirements of §482.55 Emergency Services. (Cross refer TAG A1100).

Based on a recertification survey, medical record reviewed, it was determined that the facility failed to provide Medicare recipients "An Important Message from Medicare" (IM) on the admission and two days before discharge to execute their rights to appeal the facility discharge, The facility failed to provide the second IM form for signing and inform patients of the IM requirements for 3 out of 69 records reviewed (RR) (RR. #33, #34, and #37).

Findings include:

1. R.R. #33 is a 86 years old male who is admitted on 06/10/17 with a diagnostic of Congestive Heart Failure (CHF), Bacteremia E. Fecalis and Leukocytosis. The record was review on 06/20/17 at 3:58 pm and it was found that the Important Message from Medicare was provided upon admission however it was not provide 48 hours before the discharge. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be signed and dated by the patient to acknowledge receipt as per requirement.

2. R.R. #34 is a 69 years old female who is admitted on 06/17/17 with a diagnostic of Neutropenic Fever status post Chemotherapy, Breast adenocarcinoma, Hypothyroidism, Anemia and High Blood Pressure (HBP). The record was review on 06/21/17 at 10:15 am and it was found that the Important Message from Medicare was provided upon admission however it was not provide 48 hours before the discharge. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be signed and dated by the patient to acknowledge receipt as per requirement.

3. R.R. #37 is an 82 years old male who is admitted on 06/15/17 with a diagnostic of Chest Pain, Emphysema, Dysuria, and Acute Renal Failure. The record was review on 06/21/17 at 1:52 pm and it was found that the Important Message from Medicare was provided upon admission however it was not signed by the patient or legal representative. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be signed and dated by the patient to acknowledge receipt as per requirement.

Based on a recertification survey, review of facility policy and procedure (P&Ps), patient right policy with the Risk management (employee #22), it was determined that the facility failed to ensure and include the updated Medicare Hot line telephone number and inform each patient whom to contact to file a grievance.

Findings include:

On 6/22/17 at 8:10 am during the review of facility patient right policy with the risk management employee #22, the patient right policy lack of the Puerto Rico State Agency Medicare Hot Line to whom patient can contact in case of a grievance.

Based on observations made during the patient's rights tour with the facility's educational nurse (employee #49) performed on 6/22/17 at 9:00 am thru 11:00 a. m., it was determined that the facility failed to promote patients' rights related with personal privacy during patient's sleep and dressing time, for 1 out of 14 patients at the Medicine unit.

Findings include:

1. The patient room #416 was visit on 6/22/17 at 11:00 a. m. and was observed that the window lacks of a handle to open and closed. The patients' bed and the night table has much mold. The tiles around the room was observed with deteriorated borders, the floor was observed with spots and dull. The curtain of the bathroom and the curtain located around the patient bed to provide privacy lacks of hooks. Mush dust and dirt was observed on the windows.

During the interview with her daughter she stated: '' My mother was accompanied by her daughters all the time. The curtain around the bed has problem to close, and was maintain open all the time. We understand they are short of staff for mush patients. At the emergency room in Annex 2 there was only one nurse for 11 patients, mi mother had to wait three hours since she arrived. She is a Dialysis patient she came from her treatment at Levittown because of vomits, she did not tolerate the dialysis and also there is only one doctor. The services at the emergency rooms is bad, bad, bad. There are some nurses that are bad and some rude, they have no charisma as nurses. One nurse got upset with me when I ask her when they were going to evaluate my mom. ''

2. During observations at the fourth ward, room #416 with educational nurse (employee #49) performed on 6/22/17 at 11:00 a.m. it was observed that the protective curtain around the bed has problem to closed, and was maintain open all the time, did not provide privacy to the patient, are broken and lacks of hooks and allows that patients activities like sleeping or dressing can be seen by unauthorized people from the outside and the other bed. The facility failed to ensure patients' privacy during dressing and sleeping time.

Based on a recertification survey, observation, records revierd (RR) and interview with the nursing supervisor (employee #1) and random patient admitted on the ER area, it was found that the facility failed to promote the right of each patient to receive care in a safe setting for 3 out of 3 random patients and 3 out of 3 RR. (RR#57, #58 and #60).

Findings include:

During observational tour in the Emergency Area performed on 6/20/17 from 9:00 am until 3:00 pm it was found that the ER had three area Acute, Annex 1 and Annex 2.

1. At 11:15 am it was observed one patient admitted on Annex 2 in room #B. This patient was observed with naso gastric tube (NGT) and one side rail upward without call system cord installed in the room.

Interviewed performed to the patient on 6/20/17 at 11:30 am reveals: patient stated: "I was admitted yesterday at night. I am waiting for the surgeon to be consulted due to my intestinal obstruction. I feel lonely here. When I need to pee I scream to the nurse for helps. The problem is that they did not come fast; so with a lot of difficulty I step down from the stretcher and took the urine collector that they gave me and pee. The nurse left the side rail down because she says if I have to do pee I can do it by myself".

Interviewed with the nurse supervisor (employee #1) on 6/20/2017 at 11:35 am reveals that the emergency call system in that area it is not working properly.

Surveyor asked for job repair order for the nurse's call in that Annex and no evidence and documentation about the system failure was provide.

2. The ER Acute area was visited on 6/20/17 at 9:00 am and it was observed the following:

On CPR room #2 an admitted patient with ventilator was observed. The cord of the call system was behind the crash cart. Surveyor tested the system and it was functioning properly. However, the nurse did not come to the area to observe what it is wrong with the patient or what he needs. Also surveyor observed that the call system cord it is to short and it not available to be reach by the patient or a nurse in case of an emergency.

3. The facility failed to prevent patient from potential harm related to failure to provide care and supervision related to the lack of nurses call system on a treatment area with patient admitted.


17959

During observational tour in the fourth floor performed on 6/22/17 from 8:15 a.m. until 11:00 a.m. with the educational nurse (employee #49) and the nurse supervisor (employee #59) it was found the following:

1.The active patient #57 is a 82 years old female who is admitted on 06/13/17 with a diagnosis of Clinical Sepsis and (COPD) was visit on 6/22/17 at 9:10 a. m. and was observed with nasal cannula and received oxygen at 2 liters, Foley catheter and air mattress, the patient bed and the I.V. stand were observed with much mold, all of the tiles around the room was observed with deteriorate borders, the floor was observed with spots and dull, the cover of the bulb was observed loose. The curtain of the bathroom did not have four hooks. A roll of sanitary paper was observed on the top of the dispenser. Much mold and deteriorate frame of the bathroom was observed. The patient was accompanied by a female that referred is her personal caregiver that provide services during the morning Monday through Friday from 8:00 a.m. till 11:00 a.m. then received care of her daughters and grandchild.

During the interview she stated: '' The patients' bed has problem to elevate the head area, no problems related to the patient care.''

2. The active patient #60 a female who is admitted on 06/22/17 with a diagnosis of Diabetes Mellitus was visit on 6/22/17 at 11:30 a. m. The register nurse (employee #50) was observed with a cart designated to performed the Destrostix samples (quick glucose level test ), she placed the cart outside of the patient room, she puts a pair of gloves take a Destrostix machine and the materials used to performed the test enters the room puts the materials directly on the patient bed performed the Destrostix then goes out of the room take a disinfection towel entering the room to clean the machine, when finished removed her gloves however, did not wash her hands and goes out of the room put a pair of clean gloves then performed the same procedure to the patient of the same room bed B.

3. The patient room #416 was visit on 6/22/17 at 11:00 a. m. and was observed that the window lacks of a handle to open and closed. The patient bed and the night table has much mold. The tiles around the room was observed with deteriorate borders, the floor was observed with spot and dull without shine. The curtain of the bathroom and the curtain located around the patient bed to provide privacy lacks of hooks. Mush dust and dirty were observed on the windows. The patient was accompanied with her daughter all the time.

During the interview with her daughter she stated: '' My mother was accompanied by her daughters all the time. The curtain around the bed has problem to close, and was maintain open all the time. We understand they are short of staff for mush patients. At the emergency room in Annex 2 there was only one nurse for 11 patients, mi mother had to wait three hours since she arrived. She is a Dialysis patient she came from her treatment at Levittown because of vomits, she did not tolerate the dialysis and also there is only one doctor. The services at the emergency rooms is bad, bad, bad. There are some nurses that are bad and some rude, they have no charisma as nurses. One nurse got upset with me when I ask her when they were going to evaluate my mom. ''

4. R.R. #58 is a 57 years old male who is admitted on 05/21/17 with a diagnostic of Acute Bronchitis, Colon CA, and Sacral Ulcer Infected. The record was review on 06/20/17 at 12:10 p.m. and revealed that the patient has a positive cultures of a sacral ulcer reported on 5/26/17 with Enterococus Faecalis, abundant E.Colli and Klepsiella Pneumoniae-ESBL+. The patient place on contact isolation ordered per the physician by telephone call on 5/22/17 at 9:00 a.m. however, the order lacks of the physician signature as of today 6/20/17 at 12:10 p.m. during the survey.

During interview with the nurse supervisor related to the isolation measures, the local care of the infected ulcers she stated: '' The patient received the ulcer care per the practical nurse (LPN) every 72 hours with Apticoat".

The record did not provide evidence of the initial Epidemiology nurse assessment, no evidence of documentation related to '' contact measures precautions '' for all personnel, patient and families. No evidence of documentation on the nurse's notes related to the ulcer status and local care. No evidence of the Epidemiology nurse intervention during the admission to the date of the survey.

5. The facility failed to provide care according of patient needs, failed to documented all of the procedures according of the established protocols, failed to prevent patient from infections during performed the procedures, failed to performed an initial assessment and re-assessment to all the patients admitted with infections and failed to promote the right of each patient to receive care in a safe setting.

Based on a recertification survey, the review of facility complaint files with the Risk Management Claims Analyst (employee #2), it was determined that the facility failed to ensure that patient be free of abuse or harassment for 1 out of 1 case reviewed.

Finding include:

On 6/22/17 from 8:10 am 12:00 pm the complaint file was review with the employee #22 and was found the following:

1. The case #12012016 is a female patient that receive care in the emergency room (ER) on 12/25/17. In the Format for patient or family complaints the patient perform a grievance related to an ER nurse that on 12/25/16 at 10:30 pm refuse to help her when the patient request help to made Physiological needs due to nurse suffering from the back. The patient refer that she urinate three times over and did not receive help from the nurse. When her husband arrive to the ER found the patient urinated. The nurse did not help her husband and did not provide the material to change the patient. After this the nurse verbalizes sarcastically that the patient is not observed with pain. When the nurse canalized the vein, the patient requested that the right arm no by medical recommendation and the nurse did not take into consideration the patient's request and the patient felt offended, then the nurse says and quotes "Act as an adult since you are Not a child." The patient state that could not identified the nurse by name.

2. During the facility investigation process No evidence was found related to nurse interview, no evidence was found that abuse and neglect was identified, No evidence was found that the abuse and neglect protocol was activated, No evidence was found that the facility provide reorientation related to the abuse and neglect, facility policy and procedure and dress code and identification.

Based on a recertification survey, the review of medical Staff Credential file (CF) with the Medical Facultative Secretary (employee #23) on 6/23/17 at 11:15 am, it was determined that the facility failed to ensure that updated physician credential accordance to the medical staff bylaws and State law for 37 out of 38 CF. (CF #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #36, #37and #38)

Findings include:

1. During the review of thirty-eight Physician Credential File (PCF) with the Medical Facultative Secretary (employee #23) on 6/23/17 at 11:15 am, it was determined that the facility medical staff failed to ensure that Medical Facultative Physicians meet applicable standards that are required by State or local laws related to updated license, updated health certificate, updated CPR, updated Influenza vaccines, Hepatitis B vaccine or Hepatitis B title, update Mal practice insurance, updated privileges, updated Narcotic Federal and State License, update professional association and updated criminal record certification as follow: (Cross refer TAG 023)

a. Eleven out of thirty-eight physician credential file, did not show an updated license Registry (PCF #24).

b. Eleven out of thirty-eight physician credential file, did not have an updated health certificate, (PCF #1, #3, #6, #8, #9, #12, #24, #32, #33, #34 and #36).

c. Seven out of thirty-eight physician credential file lack of a CPR Certification by the American Heart Association; Basic Life Support (BSL), Advance Life Support (ACLS), Pediatric Advance Life Support (PALS) or Neonatal Advance Life Support NALS). The physician has a CPR certification by Internet. (PCF #12, #19, #20, #23, #28, #31 and #37).

d. Nine out of thirty-eight physician credential file lack of an updated CPR Certification by the American Heart Association. Basic Life Support (BSL), Advance Life Support (ACLS), Pediatric Advance Life Support (PALS) or Neonatal Advance Life Support NALS), (PCF #3, #6, #9, #15, #16, #18, #24, #26, #33 ).

e. Twenty-Four out of thirty-eight physician credential file did not have evidence of updated Influenza vaccines or refuse certification, accordance to state administrative order #244 of 10/10/2008 of the Department of health and the state administrative order #362 of 12/8/16 of the Department of health (PCF #2, #3, #4, #5, #6, #7, #8, #10, #15, #16, #18, #19, #21, #22, #24, #27, #28, #29, #31, #32, #33, #36, #37 and #38).

f. Twenty-seven out of thirty-eight physician credential file did not have evidence of Hepatitis B vaccine or Hepatitis B title (PCF #2, #3, #5, #6, #7, #8, #9, #11, #12, #13, #14, #16, #17, #19, #20, #21, #22, #24, #25, #27, #28, #29, #30, #33, #36, #37 and #38).

g. Seven out of thirty-eight physician credential file did not have update Mal practice insurance (PCF ##1, #3, #9, #21, #24, #33 and #38).

h. Nine out of thirty-eight physician credential file did not have updated privileges (PCF #3, #5, #8, #9, #10, #21, #22, #24 and #36).

i. One out of thirty-eight physician credential file did not have updated Narcotic Federal License (PCF #33).

j. Three out of thirty-eight physician credential file did not have updated Narcotic State License (PCF #1, #15, and #22).

k. Two out of thirty-eight physician credential file did not have update professional association (PCF#24 and #29).

l. Twenty-two out of thirty-eight physician credential file did not have updated criminal record certification (PCF #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #15, #16, #17, #18, #20, #22, #23, #25, #29, #33 and #37).

Based on a recertification survey, the review of medical Staff By laws, Rule and Regulation with the administrator (employee #33), the Sub- Medical Director (employee #21) and the Facultative President (employee #34), it was determined that the facility failed to ensure that the medical staff adopt, enforce and regulate updated bylaw and that those bylaws comply with State and Federal law.

Findings include:

On 6/20/17 at 2:54 pm during the review of Medical By Laws and the Rule and Regulation it was evidence that the Bylaws was from 2014-2016 and was approved by the governing Body on November 20, 2014. In the Appendix X, Section 1, Subsection H: Bylaws and Revision Committee, Item 2; state that "Conduct every two (2) years a review of the Bylaws, Rule and Regulation. In the Appendix XVI: Revision state "These Bylaws and Appended Rules And Regulation shall be review every Two (2) years.

Interview with the sub- director medical director on 6/21/17 at 1:00 pm state that the bylaws were in revision.

No evidence was provide related to an updated Bylaws, Rule and Regulations during the survey.

During the review of 2014-2016 facility Bylaws, Rules and Regulation on 6/20/17 at 254 pm revealed the following:

a. On Article IV Section 2 Subsection A item #27 state that Criminal record was requested every two (2) years not accordance to state law 101 requirement.

b. On Article IV Section 11: Specific Professional Person, Subsection A: Nurse Anesthetist, Subsection B: Qualification, item #7 Cardiopulmonary;monary Resucitation (CPR) not specific what kind of CPR was requested, the basic Life Support (BLS) or Advance Cardiac Life Support (ACLS) to the nurse anesthetist.

c. On Article IV Section 11: Specific Professional Person, Subsection A: Nurse Anesthetist, Subsection C, state that the anesthesia Director was responsible to assess credential of nurse anesthetist. In the facility organization program the anesthetist nurse response to the nursing department nurse director (DON) not to the anesthesia department.

d. The rules and regulation 2014-2016 the J. Restriction state see Appendix, however no evidence was found in the appendix area that the restriction protocol was included.

Based on a recertification survey, observation and medical record review (R.R.) performed on 06/20/17 thru 06/23/2017 with the Infection Control Coordinator (employee #24) it was determined that the facility failed to assess and evaluate nursing care for each patient due to lack of documentation and patient assessment for 4 out of 69 records reviewed. (RR #31, RR #32, RR #36 and RR #38).

Findings include:

1. R.R. #31 is a 82 year old female admitted to the facility on 06/14/2017 with a diagnosis of Respiratory Failure, Sepsis, Senile Dementia and Diabetes Mellitus. During the record review performed on 6/20/17 at 9:18 am it was found that the Physician MD write a physician order on 06/14/17 for glucose test every 6 hours with a scale for insulin cover that is on the medication Kardex (200 mg/dl to 250 mg/dl 3 units of regular insulin, 251 mg/dl to 300mg/dl 5 units of regular insulin, 301 mg/dl to 350 mg/dl 7 units of regular insulin and 351 notified the MD.

a. On 6/14/17 at 11:15 am on the diabetic record was found a glucose level of 289 mg/dl and no intervention was documented by the register nurse. On 6/15/17 no glucose test was found on the diabetic record. On 6/17/17 at 4:00 pm on the diabetic record was found a glucose level of 186 mg/dl and 6 units of regular insulin were administered. On 6/18/17 at 11:00 am on the diabetic record was found a glucose level of 400 mg/dl and no intervention was documented by the register nurse. On 6/18/17 at 12:00 am on the diabetic record was found a glucose level of 245 mg/dl and no intervention was documented by the register nurse. On 6/19/17 at 12:00 am on the diabetic record was found a glucose level of 228 mg/dl and no intervention was documented by the register nurse. On 6/19/17 at 5:00 pm on the diabetic record was found a glucose level of more than 500 mg/dl and no intervention was documented by the register nurse.

The facility failed to follow MD orders as written. The facility failed to assess and evaluate nursing care for each patient due to lack of documentation patient assessment.

2. R.R. #32 is a 56 year old male admitted to the facility on 05/13/17 with a diagnosis of Head and Neck Cancer, Sepsis, Respiratory Failure and bronchopneumonia (BKP). During the record review performed on 06/20/2017 at 10:40 am it was found that the patient have position changing every 2 hours. On the 06/08/17 position changing chart did not provide evidence of position changing at 8:00 pm and at 10:00 pm. On the 06/10/17 position changing chart did not provide evidence of position changing at 12:00 am, 2:00 am and 4:00 am. The facility failed to assess and evaluate nursing care for each patient due to lack of documentation and patient assessment.

3. R.R. #36 is a 90 year old female admitted to the facility on 06/13/2017 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), S/P Tuberculosis (TB) Hypertension (HTN), Thyroid Disease and Diabetes Mellitus. During the record review performed on 6/21/17 at 11:45 am it was found that the Physician MD write a physician order on 06/13/17 for glucose test with a chart for insulin cover however the insulin cover scale was not transcript to the patient medication Kardex. On 6/19/17 at 11:00 am on the diabetic record was found a glucose level of 217 mg/dl and no other intervention was documented by the register nurse in this page. The MD order for insulin written on 06/13/17 is, a glucose level from 200 mg/dl to 300 mg/dl 3 units of Humulin R subcutaneously no evidence of the administration or hold for this 3 units of Humulin R subcutaneously were found.

The facility failed to transcript the MD orders to the Kardex. The facility failed to follow MD orders as written. The facility failed to assess and evaluate nursing care for each patient due to lack of documentation patient assessment.

4. R.R. #38 is a 90 year old male admitted to the facility on 06/11/2017 with a diagnosis of Acute Bronchitis, Sepsis and Diabetes Mellitus. During the record review performed on 6/21/17 at 2:00 pm it was found on the Kardex an insulin cover chart.

a. On 6/11/17 at 12:00 mn on the diabetic record was found a glucose level of 265 mg/dl and no other intervention was documented by the register nurse in this page. The insulin cover chart is, a glucose level from 200 mg/dl to 300 mg/dl 5 units of Humulin R subcutaneously no evidence of the administration or hold for this 5 units of Humulin R subcutaneously were found.

b. On 6/12/17 at 4:00 pm on the diabetic record was found a glucose level of 248 mg/dl and no other intervention was documented by the register nurse in this page. The insulin cover chart is, a glucose level from 200 mg/dl to 300 mg/dl 5 units of Humulin R subcutaneously no evidence of the administration or hold for this 5 units of Humulin R subcutaneously were found.

c. On 6/16/17 at 1:00 am on the diabetic record was found a glucose level of 227 mg/dl and no other intervention was documented by the register nurse in this page. The insulin cover chart is, a glucose level from 200 mg/dl to 300 mg/dl 5 units of Humulin R subcutaneously no evidence of the administration or hold for this 5 units of Humulin R subcutaneously were found.

d. On 6/18/17 at 1:00 am on the diabetic record was found a glucose level of 267 mg/dl and no other intervention was documented by the register nurse in this page. The insulin cover chart is, a glucose level from 200 mg/dl to 300 mg/dl 5 units of Humulin R subcutaneously no evidence of the administration or hold for this 5 units of Humulin R subcutaneously were found.

The facility failed to transcript the MD orders to the Kardex. The facility failed to follow MD orders as written. The facility failed to assess and evaluate nursing care for each patient due to lack of documentation patient assessment.

Based on a recertification survey, observation and medical record review (R.R.) performed on 06/20/17 thru 06/21/2017 with the Medical Record Director (Employee #47), 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, as observed in 27 out of 30 records review (RR). (RR #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #23, #25, #26, #27, #28, #29, and #30).

Findings include:

1. During review of thirty close medical records perform from 6/20/17 thru 6/21/17 with the Medical Record Director (Employee #47) was found the following:

a. The Medical Order was found without the physician signature, date, time, illegible, telephone and verbal orders without the physician countersignature on 18 of 30 medical records. (RR#1, #5, #6, #7, #8, #12, #13, #15, #16, #17, #20, #21, #22, #23, #25, #26, #27, and #30)

b. The Consult was found without signature, date, time, illegible, unanswered, and answered out of the establish time frame on 17 of 30 medical records. (RR#1, #5, #6, #7, #8, #11, #13, #14, #16, #17, #18, #22, #23, #25, #27, #28, and #30)

c. The Medical History and Physical (H&P) was found incomplete without dates, times, vital signs, height, and weight for 4 of 30 medical records. (RR#9, #22, #27, and #30)

d. The Nursing History was found with an incomplete date, without time and no vitals signs for 1 of 30 medical records. (RR#11)

e. The Physician Progress note was found illegible, with words on top of words, and without time for 4 of 30 medical records. (RR#1, #4, #7, and #26)

f. The Nursing Progress note was found without date and time for 1 of 30 medical records. (RR#26)

g. The Medication Reconciliation was found without the physician signature for 19 of 30 medical records. (RR#3, #4, #6, #7, #8, #11, #12, #15, #16, #17, #18, #22, #23, #25, #26, #27, #28, #29, and #30)

h. The Vital Signs form was found incomplete for 4 of 30 medical records. (RR#4, #16, #21, and #23)

i. The Diabetic (DXT) Registry was found incomplete for 9 of 30 medical records. (RR#1, #5, #6, #7, #11, #12, #13, #18, and #25)

j. The Nursing Discharge Summary was found incomplete, without date, time, and registered nurse (RN) signature for 5 of 30 medical records. (RR#8, #13, #25, #27, and #29)

k. The Discharge Summary was found incomplete for 4 of 30 medical records. (RR#17, #21, #27, and #28).

Based on a recertification survey, observation and medical record review (R.R.) performed on 06/20/17 thru 06/23/2017 with the Infection Control Coordinator (employee #24), it was determined that the facility failed to ensure that the clinical records are countersigned by the physician within the first twenty-four hours after the telephone order is issued, as observed in 18 out of 69 records review. (RR#1, #5, #6, #7, #12, #13, #15, #16, #17, #21, #22, #23,#25, #26, #27, #30, #31, and #38).

Findings include:

1. R.R. #31 is an 82 year old female admitted to the facility on 06/14/2017 with a diagnosis of Respiratory Failure, Sepsis, Senile Dementia and Diabetes Mellitus. During the record review performed on 6/20/17 at 9:18 am it was found

a. A telephone order dated 6/17/17 at 8:30 pm however no evidence of the physician signature countersigning the telephone order

b. A telephone order dated 6/18/17 at 10:25 am however no evidence of the physician signature countersigning the telephone order

c. A telephone order dated 6/19/17 at 8:00 am however no evidence of the physician signature countersigning the telephone order.

2. R.R. #38 is a 90 year old male admitted to the facility on 06/11/2017 with a diagnosis of Acute Bronchitis, Sepsis and Diabetes Mellitus. During the record review performed on 6/21/17 at 2:00 pm it was found:

a. A telephone order dated 6/12/17 however no evidence the time taken. The physician signature was not found countersigning the telephone order

b. Respiratory Therapy Medical Order dated 6/15/17 was found sign and dated by the Register Nurse (RN) however no evidence of the physician signature countersigning the order.

c. Respiratory Therapy Medical Order dated 6/19/17 was found sign and dated by the Register Nurse (RN) however no evidence of the physician signature countersigning the order.

3. The facility policy and procedure (P&P) on the item 3 the nurse who follow the emergency telephone order must manage the physician signature a soon as possible on the first 24 hours.

4. The facility failed to ensure that the clinical records are countersigned by the physician within the first twenty-four hours after the telephone order is issued.


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5. R.R. #26 is a 51 year old female admitted to the facility on 11/03/2015 with a diagnosis of Left Leg Deep Venous Thrombosis (DVT). During the record review performed on 6/20/17 at 2:18 pm it was found:

a. A medical order from 11/7/15 was not signed by the nursing staff.

b. A telephone medical order was place on 11/9/15 at 8:10 am and was not countersign by the MD.

c. A verbal medical order from 11/9/15 at 5:50 pm was placed and was countersigned by the MD, however there was no evidence of the dated and time in which the order was signed.

6. R.R. #1 is an 76 year old female admitted to the facility on 02/02/2017 with a diagnosis of Anemia. During the record review performed on 6/20/17 at 2:37 pm it was found:

a. Three telephone orders were place on 02/06/17 at 8:30 am, 02/07/17 at 4:30 pm, and 02/07/17 at 10:40 pm were not countersigned by the MD.

7. R.R. #21 is a 91 year old female admitted to the facility on 05/02/2016 with a diagnosis of Hypoglycemia, Diabetes Mellitus (DM) type 2. During the record review performed on 6/21/17 at 8:30 am it was found:

a. A telephone medical order was place on 05/9/16 at 5:55 pm and was not countersign by the MD.

b. A telephone medical order was place on 05/5/16 at 5:20 pm and was countersign by the MD on 05/6/16 at 11:00 pm.

c. A Standing order was place on 05/7/16 at 10:10 am and was not countersign by the MD.

8. R.R. #30 is a 36 year old female admitted to the facility on 06/20/2013 with a diagnosis of Sinoatrial Node Syndrome. During the record review performed on 6/20/17 at 3:20 pm it was found:

a. A verbal medical order was place on 06/24/13 at 6:58 pm and was countersign by the MD, however there is no evidence of the time and date that the order was countersign.

b. A telephone medical order was place on 06/25/13 at 4:50 pm and was not countersign by the MD.

c. A telephone medical order was place on 06/26/13 at 12:55 md and was not countersign by the MD.

9. R.R. #12 is an 83 year old female admitted to the facility on 01/09/2016 with a diagnosis of Congestive Heart Failure (CHF). During the record review performed on 6/21/17 at 9:10 am it was found:

a. A telephone medical order was place on 01/10/16 at 9:15 pm, 01/11/15 at 4:30 pm, 01/12/15 at 1:10 am, 01/12/15 at 4:46 am, 01/13/15 at 1:41 am, 01/13/15 at 4:50 pm, and on 01/13/15 at 8:53 pm and was not countersign by the MD.

10. R.R. #16 is an 80 year old female admitted to the facility on 03/13/2016 with a diagnosis of Colon Cancer. During the record review performed on 6/21/17 at 9:26 pm it was found:

a. A telephone medical order was place on 03/16/16 at 2:45 pm and was not countersign by the MD.
b. A Standing order for Novelox- High Alert Medication was place, however was not signed by the MD.

11. R.R. #13 is a 67 year old female admitted to the facility on 01/20/2016 with a diagnosis of Acute Kidney Injury. During the record review performed on 6/21/17 at 9:55 am it was found:

a. A verbal medical order was place on 01/21/16 at 5:20 pm and 01/21/16 at 5:00 pm and was countersign by the MD, however there is no evidence of the time and date that were signed.

12. R.R. #17 is a 71 year old female admitted to the facility on 03/12/2016 with a diagnosis of Hypertension (HBP). During the record review performed on 6/21/17 at 10:07 am it was found:

a. A telephone medical order was place on 03/13/16 at 9:20 am and 03/18/16 at 9:00 am and was not countersign by the MD.

13. R.R. #23 is a 63 year old female admitted to the facility on 02/22/2016 with a diagnosis of Hypertension (HBP). During the record review performed on 6/20/17 at 10:30 am it was found:

a. A telephone medical order was place on 06/26/16 at 12:00 pm, 06/26/16 at 6:00 pm, 06/27/16 at 1:45 pm, and 06/27/16 at 10:30 am and 03/18/16 at 9:00 am and was not countersign by the MD.

14. R.R. #15 is an 83 year old male admitted to the facility on 02/03/2016 with a diagnosis of Breast Cancer. During the record review performed on 6/21/17 at 10:55 am it was found:

a. A telephone medical order was place on 02/7/16 at 9:00 am and 02/8/16 at 10:00 am and was not countersign by the MD.

15. R.R. #22 is a 96 year old female admitted to the facility on 08/11/2016 with a diagnosis of Cardiac Arrhythmia. During the record review performed on 6/21/17 at 11:20 am it was found:

a. A Telemetry Standing order was place however was not countersign by the MD, dated and timed.

16. R.R. #5 is a 57 year old female admitted to the facility on 04/20/2017 with a diagnosis of Malignant Colon Neoplasm. During the record review performed on 6/20/17 at 1:10 pm it was found:

a. A MD telephone medical order was place on 04/25/17, however the date is illegible and was not countersign by the MD.

17. R.R. #6 is a 71 year old female admitted to the facility on 04/22/2017 with a diagnosis of Atrial Fibrillation. During the record review performed on 6/21/17 at 1:20 pm it was found:

a. Admission orders from 4/22/17 at 12:05 am are illegible.

b. A telephone medical order was place on 05/9/17 at 2:40 pm, 5/10/17 at 2:30 pm, 5/12/17 at 10:20 pm, 5/14/17 at 7:00 am, 5/20/17 at 11:15 pm, and 4/22/17 at 10:00 am was not countersign by the MD.

c. A medical order was place on 04/28/17 at 8:00 pm and was signed by the MD, however the MD did not include the state and federal license for administering controlled substance as the policies and procedures of the facility establish for such orders..

18. R.R. #7 is a 72 year old female admitted to the facility on 05/04/2017 with a diagnosis of High Blood Pressure (HBP). During the record review performed on 6/21/17 at 2:30 pm it was found:

a. A telephone medical order was place on 05/5/17 at 2:20 pm, however was not countersign by the MD.

19. R.R. #25 is a 66 year old female admitted to the facility on 10/16/2015 with a diagnosis of Anemia. During the record review performed on 6/21/17 at 2:55 pm it was found:

a. A telephone medical order was place on 10/22/15 at 11:30 pm, however was not countersign by the MD.

20. R.R. #27 is a 52 year old male admitted to the facility on 11/06/2015 with a diagnosis of Pulmonary Emboli. During the record review performed on 6/21/17 at 3:25 pm it was found:

a. A telephone medical order was place on 11/6/15 at 4:20 pm, 11/7/15 at 10:10 am, 11/9/15 at 9:35 am, 11/10/15 at 10:45 am, and 11/12/15 at 8:30 am was not countersign by the MD.

21. During review of the policies and procedure related to Telephone and Verbal Orders on 6/20/17 at 1:40 pm the following evidence: "VIII. Medical Orders: They will be legible. The use of abbreviations must be in accordance with the approved by the Medical Faculty. They will contain date, time, signature and license. The narcotic s must include the registry number that authorizes to prescribe controlled substance (state and federal) and the number of the physician license. IX. Telephone and Verbal Orders: Countersigned in a timeframe off 24 hours. Will contain date, time, signature and license. The people who took the order will sign the order."

The facility failed to ensure that the clinical records are countersigned by the physician within the first twenty-four hours after the telephone order is issued.

Based on a recertification survey, observation and medical record review (R.R.) performed on 06/20/17 thru 06/23/2017 with the Infection Control Coordinator (employee #24) it was determined that the facility failed to ensure that the medical history and physical examination (H&P) is documented by a physician for each patient no more than 30 days before or 24 hours after admission or registration for 6 out of 69 medical record reviewed (R.R #9, #22, #27, #30, #31 and #42)

Findings include:

1. R.R. #31 is a 82 year old female admitted to the facility on 06/14/2017 with a diagnosis of Respiratory Failure, Sepsis, Senile Dementia and Diabetes Mellitus. During the record review performed on 6/20/17 at 9:18 am no evidence was found of the H&P however an H&P in blank with the RR#31emographic information was found in the medical record.

2. RR#42 is a 66 year old female patient admitted on 06/22/17 with a diagnosis of colon cancer/Medport removal. During record review perform on 6/22/17 at 2:36 pm it was found an H&P sign and dated on 5/19/17 thirty five days before the admission and procedure.

The facility failed to ensure that the medical history and physical examination (H&P) is documented by a physician for each patient no more than 30 days before or 24 hours after admission or registration.


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3. R.R. #9 is a 75 year old female admitted to the facility on 04/26/2017 with a diagnosis of Liver Adenocarcinoma. During the record review performed on 6/20/17 at 3:05 pm it was found:

a. The History and Physical was found incomplete and the date and time of the physician signature was illegible.

4. R.R. #30 is a 36 year old female admitted to the facility on 06/20/2013 with a diagnosis of Sinoatrial Node Syndrome. During the record review performed on 6/20/17 at 3:20 pm it was found:

a. The History and Physical was found incomplete (no evidence of the weight and height).

5. R.R. #22 is a 96 year old female admitted to the facility on 08/11/2016 with a diagnosis of Cardiac Arrhythmia. During the record review performed on 6/21/17 at 11:20 am it was found:

a. The History and Physical was found incomplete and the date and time of the physician signature was not documented.

6. R.R. #27 is a 52 year old male admitted to the facility on 11/06/2015 with a diagnosis of Pulmonary Emboli. During the record review performed on 6/21/17 at 3:25 pm it was found:

a. The History and Physical was found incomplete (no evidence of the Vital Signs).

7. During review of Policies and procedures related to History and Physical on 6/23/17 at 8:45 am was found: "III. History and Physical: Must be realize in a timeframe of 24 hours of the patient admission."

The facility failed to ensure that the medical history and physical examination (H&P) is legible and completely documented by a physician for each patient no more than 30 days before or 24 hours after admission or registration.

Based on a recertification survey, observation and medical record review (R.R.) performed on 06/20/17 thru 06/23/2017 with the Infection Control Coordinator (employee #24) it was determined that the facility failed to ensure that all medical record document the results of all consultative evaluations of the patient by clinical and other staff involved in the care of the patient for 17 out of 69 record review (R.R.#1, #5, #6, #7, #8, #18, #22, #23, #25, #27, #28, #30, #31, #32, #33, #34 and #37)

Findings include:

1. R.R. #33 is a 86 years old male who is admitted on 06/10/17 with a diagnostic of Congestive Heart Failure (CHF), Bacteremia E. Fecalis and Leukocytosis. The record was review on 06/20/17 at 3:58 pm and the following was found:

The Consult to the physician (employee #26) Requested on 6/10/17 at 6:30 am, was not completed and did not reflect the consultative evaluation.

Have three consults answered on 06/14/17 but the physician that request the evaluation failed to write the consult regarding, date and hour when he placed the consult in the clinical record.

2. R.R. #37 is a 82 years old male who is admitted on 06/15/17 with a diagnostic of Chest Pain, Emphysema, Dysuria, and Acute Renal Failure. The record was review on 06/21/17 at 1:52 pm and the following was found:

a. The Consult to the physician (employee #25) Requested on 6/15/17 at 12:20 pm, was not completed and did not reflect the consultative evaluation.

3. R.R. #34 is a 69 years old female who is admitted on 06/17/17 with a diagnostic of Neutropenic Fever status post Chemotherapy, Breast adenocarcinoma, Hypothyroidism, Anemia and High Blood Pressure (HBP). The record was review on 06/21/17 at 10:15 am and the following was found:

a.The Consult to the physician (employee #27) Requested on 6/18/17 at 11:05 am, was not completed and did not reflect the consultative evaluation.

4. R.R. #32 is a 56 year old male admitted to the facility on 05/13/17 with a diagnosis of Head and Neck Cancer, Sepsis, Respiratory Failure and bronchopneumonia (BKP). During the record review performed on 06/20/2017 at 10:40 am and the following was found:

Has a consults answered on 06/04/17 but the physician that request the evaluation failed to write the consult regarding, date and hour when he placed the consult in the clinical record.

Have three consults not answered and the physician that requesting the evaluation failed to write his name, the consult regarding, date and hour when he placed the consult in the clinical record.

5. R.R. #31 is a 82 year old female admitted to the facility on 06/14/2017 with a diagnosis of Respiratory Failure, Sepsis, Senile Dementia and Diabetes Mellitus. During the record review performed on 6/20/17 at 9:18 am and the following was found:

The Consult to the employee #26 Requested on 6/14/17 at 6:40 am, was not completed and did not reflect the consultative evaluation.

Has one consult answered but the physician that requesting the evaluation failed to write his the consult regarding, date and hour when he placed the consult in the clinical record.


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6. R.R. #1 is an 76 year old female admitted to the facility on 02/02/2017 with a diagnosis of Anemia. During the record review performed on 6/20/17 at 2:37 pm it was found:

a. A consult was place on 02/02/17 and was signed by the consultant, however there is no evidence of the date and time in which was signed.

7. R.R. #30 is an 36 years old female admitted to the facility on 06/20/2013 with a diagnosis of Sinoatrial Node Syndrome and Dilated Cardiomyopathy. During the record review performed on 6/20/17 at 3:20 pm it was found:

a. A consult answered on 06/21/13 at 9:00 am but the attending physician failed to write the consult regarding, date and hour when he placed the consult in the clinical record.

8. R.R. #16 is an 80 year old female admitted to the facility on 03/13/2016 with a diagnosis of Colon Cancer. During the record review performed on 6/21/17 at 9:26 pm it was found:

a. A consult was place by the attending Physician (Employee #60) and signed however there is no evidence of the date and time in which was signed.
b. A consult answered on 03/15/16 at 9:00 am but the attending physician (Employee #62) failed to write the consult regarding, date and hour when he placed the consult in the clinical record.

9. R.R. #13 is an 67 year old female admitted to the facility on 01/20/2016 with a diagnosis of Acute Kidney Injury. During the record review performed on 6/21/17 at 9:55 am it was found:

a. A consult answered on 01/20/16 at 5:30 pm, however the attending physician failed to write the date and hour when he placed the consult in the clinical record.

10. R.R. #17 is an 71 year old female admitted to the facility on 03/12/2016 with a diagnosis of Hypertension (HBP). During the record review performed on 6/21/17 at 10:07 am it was found:

a. The attending physician (Employee #64) failed to write the consult regarding, date and hour when he placed the consult in the clinical record. The consult was notified to consultant (Employee #27) on 3/13/16 and answered on 03/15/16 at 9:00 am, more than the time frame establish by the facility P&P's of Consult Evaluation.

11. R.R. #23 is an 63 year old female admitted to the facility on 02/22/2016 with a diagnosis of Hypertension (HBP). During the record review performed on 6/20/17 at 10:30 am it was found:

a. A consult was place on 06/23/16 however the date is illegible.

12. R.R. #22 is an 96 year old female admitted to the facility on 08/11/2016 with a diagnosis of Cardiac Arrhythmia. During the record review performed on 6/21/17 at 11:20 am it was found:

a. A consult answered on 08/12/16 at 8:15 am, however the attending physician (Employee #26) failed to write the signature, date, and hour when he placed the consult in the clinical record.
b. A consult answered on 08/12/16 at 1:00 pm, however the attending physician (Employee #26) failed to write the signature, date, and hour when he placed the consult in the clinical record.
c. A consult answered on 08/15/16 at 4:00 pm, however the attending physician (Employee #26) failed to write the consult regarding, signature, date, and hour when he placed the consult in the clinical record.

13. R.R. #5 is an 57 year old female admitted to the facility on 04/20/2017 with a diagnosis of Malignant Colon Neoplasm. During the record review performed on 6/20/17 at 1:10 pm it was found:

a. A consult was place on 4/12/17 at 2:51 am by the attending Physician (Employee #61), however the consult was answered on 04/19/17 at 7:30 am, taking more than the time frame establish by the facility P&P's of Consult Evaluation.

14. R.R. #28 is an 71 year old female admitted to the facility on 02/05/2014 with a diagnosis of Post-Operative Infection. During the record review performed on 6/20/17 at 1:10 pm it was found:

a. A consult was place on 02/05/14 at 12:00 pm by the attending Physician, however the consult was answered on 02/07/14 at 4:00 am, taking more than the time frame establish by the facility P&P's of Consult Evaluation.

15. R.R. #18 is an 76 year old female admitted to the facility on 04/23/2016 with a diagnosis of Sepsis. During the record review performed on 6/21/17 at 9:15 am it was found:

a. A consult was place on 4/23/16 at 8:00 am by the attending Physician (Employee #65), however the consult was answered on 04/25/16 at 7:00 pm by consultant (Employee #66), taking more than the time frame establish by the facility P&P's of Consult Evaluation.
b. A consult was place on 4/24/16 at 11:00 am by the attending Physician (Employee #65), however the consult was answered on 04/27/16 at 9:38 am by consultant (Employee #27), more than the time frame establish by the facility P&P's of Consult Evaluation.

16. R.R. #6 is an 71 year old female admitted to the facility on 04/22/2017 with a diagnosis of Atrial Fibrillation. During the record review performed on 6/21/17 at 1:20 pm it was found:

a. A consult was place at 10:00 am by the attending Physician (Employee #67), however the date is illegible.
b. A consult was place on 4/24/17 at 10:00 am by the attending Physician (Employee #67), however the consult was answered on 04/25/17 at 11:40 pm by consultant (Employee #66), taking more than the time frame establish by the facility P&P's of Consult Evaluation.
c. A consult was place by the attending Physician (Employee #67), however there is no evidence of the date and time in which was signed. The consultant answered the consult on 04/23/17 at 3:30 pm.

17. R.R. #8 is an 56 year old female admitted to the facility on 06/02/2017 with a diagnosis of Pneumonia. During the record review performed on 6/21/17 at 2:00 pm it was found:

a. A consult was place by the attending Physician (Employee #68), however there is no evidence of the date and time in which was signed.

18. R.R. #7 is an 72 year old female admitted to the facility on 05/04/2017 with a diagnosis of High Blood Pressure (HBP). During the record review performed on 6/21/17 at 2:30 pm it was found:

a. A consult was place on 5/7/17 by the attending Physician (Employee #25), however there is no evidence of the time in which was signed.
b. The consult was answered on 05/09/17 at 4:00 pm by consultant (Employee #69), more than the time frame establish by the facility P&P's of Consult Evaluation.

19. R.R. #25 is an 66 year old female admitted to the facility on 10/16/2015 with a diagnosis of Anemia. During the record review performed on 6/21/17 at 2:55 pm it was found:

a. A consult was place by the attending Physician (Employee #26), however the date is incomplete and there is no evidence of the time it was signed.

20. R.R. #27 is an 52 year old female admitted to the facility on 11/06/2015 with a diagnosis of Pulmonary Emboli. During the record review performed on 6/21/17 at 3:25 pm it was found:

a. A consult was place on 11/06/15 by the attending Physician (Employee #26), however failed to write the consult regarding, signature, and hour when he placed the consult in the clinical record.
b. The consult was answered on "XI/IV/15" (11/4/15) at 9:00 am by consultant (Employee #70), the dates are not congruent.
c. A consult was place on 5/11/15 at 10:30 pm by the attending Physician (Employee #71), however the consult was not answered by consultant (Employee #26), not following the facility P&P's of Consult Evaluation.
d. A consult was place by the attending Physician (Employee #26) failed to write the signature, date, and hour when he placed the consult in the clinical record, not following the facility P&P's of Consult Evaluation.

21. R.R. #11 is an 65 year old female admitted to the facility on 01/21/2017 with a diagnosis of Diabetes Mellitus Type II (DM). During the record review performed on 6/21/17 at 3:54 pm it was found:

a. A consult was place on 1/21/17 at 3:30 pm by the attending Physician (Employee #72), however the consult was not answered by consultant (Employee #65), taking more than the time frame establish by the facility P&P's of Consult Evaluation.

22. During review of the policies and procedure related to Consult Evaluation on 6/20/17 at 1:40 pm the following evidence: "IV. Consult Evaluation: The will be answer in a timeframe of 24 hours. The patient will be identified and the person that notified and to who is notified, with date and time documented."

The facility failed to ensure to comply with Consult Evaluation P&P's.

Based on recertification survey, observations, medications carts verifications, and interviews during survey performed on 6/22/17 from 8:00 am thru 3:35 pm, 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 2 out of 6 patients wards (PWs), (PW #5 and #8).

Findings include:

1. On 6/22/17 at 8:20 am a tour was perform for the verification of proper storage of the drugs and biological in the patients wards.

a. On 6/22/17 at 8:23 am on the 8th floor medicine ward it was found the medication cart for side A was unsecured in the hall. All the medication cart drawers were unlocked.

b. On 6/22/17 at 9:10 am on the 5th floor medicine and surgery ward it was found the medication cart for side A was unsecured in the hall. All the medication cart drawers were unlocked.

c. The drawer for room 503A had liquid medication already served in a medication cup.

During interview with Quality Assurance Assistance (employee #36) on 6/22/17 at 9:10 am she stated: "The medications are supposed to be prepared when they are going to be administered as our policy establishes. That medication could be spill in the drawer."

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 a recertification survey, observations with the Quality Assurance Assistance (employee #36) and the pharmacist (employee #46) from 6/22/17 thru 66/23/17, it was determined that the facility failed to ensure that unusable drugs are not available for patients' use related to expired medications on crash carts, Pyxis medication station, and pharmacy which can affect 95 of 95 admitted patients (PTE) (PTE #1 to #95).

Findings include:

1. The following expired medications were found in 1rst, 5th, and 8th floor wards and the pharmacy department:

a. On the 8th floor medicine ward crash cart on 6/22/17 at 8:30 am was found:

(4) Epinephrine 1 mg lot. 56-090-DK expired on 5/1/17
(2) 8.4% Sodium Bicarbonate 50mEq lot. 54-093-DK expired on 6/1/17

b. On the 8th floor medicine ward Pyxis medication station on 6/22/17 at 8:40 am was found:

(13) Levothyroxine 200 mcg/ 100 EA TABLETS lot. 3072563 expired on 6/1/17

c. On the 5th floor medicine and surgery ward crash cart was found:

(1) 8.4% Sodium Bicarbonate 50mEq lot. 54-093-DX expired on 6/1/17
(2) Lidocaine HCL inj. 100 mg lot. 54-403-EV
(1) Epinephrine 1 mg lot. 56-090-DK expired on 5/1/17
(1) Atropine Sulfate 1 mg lot. 54- 019-DK expired on 6/1/17
(1) Atropine Sulfate 1 mg lot. 54-018-DK expired on 6/1/17
(1) 0.9% Sodium Chloride inj. 250 ml lot 52-064-JT expired on 4/1/17

d. On the 1rst floor Operation Room suites A thru E on 6/22/17 from 1:55 pm thru 3:15 pm was found:

i. On operation room- suite E anesthesia medication cart was found:
(1) Neostigmine 10 mg expired on 10/18 that was open and unlabeled
(1) Furosemide 20 mg 2ml that was open and unlabeled
(1) Benadryl 50mg lot. 66555CC expired on 6/1/17

ii. On operation room- suite B anesthesia medication cart was found:

(1) Labetalol Hydrochloride inj. 100 mg/ 20 ml that was opened on 5/15/17, more than 30 days has passed since the medication was opened.

The facility failed to ensure that the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial, as the Centers for Disease Control and Prevention (CDC) establishes.

e. On the 1rst floor intensive unit I on 6/22/17 from 4:00 pm thru 4:25 pm was found:

(2) Atropine Sulfate 1 mg lot. 54- 019-DK expired on 6/1/17
(2) Atropine Sulfate 1 mg lot. 54-018-DK expired on 6/1/17
(4) 0.45% Sodium Chloride inj. 50 ml lot 60-059-JT expired on 6/1/17

f. On the 1rst floor intensive unit II on 6/22/17 from 4:30 pm thru 4:45 pm was found:

(4) Atropine Sulfate 1 mg lot. 54- 019-DK expired on 6/1/17
(2) Atropine Sulfate 1 mg lot. 54-018-DK expired on 6/1/17
(4) 0.45% Sodium Chloride inj. 50 ml lot 60-059-JT expired on 6/1/17
(1) Lantus 100 units/ml that was open and unlabeled
(7) 5% D5W + 0.9% nss lot. 49-602-FW expired on 1/1/17
(1) 5% Dextrose inj. Usp lot. 50-715-FW expired on 2/1/17

g. On the 1rst floor intensive unit II Pyxis medication station on 6/22/17 from 4:30 pm thru 4:45 pm was found:

(1) Dialtizem cd 180 mg cap lot 2135E151 expired on 5/31/17
(6)lidocaine 2% 5ml 100 mg lot. 54-403-EV expired on 6/1/17
(2) Atropine Sulfate 1 mg lot. 54-018-DK expired on 6/1/17

2. During observational tour through the pharmacy department on 6/23/17 at 12:40 pm the following expired medications were found:

a. Pre-Protein 1 gm lot. 1501226 expired on 5/4/17
b. One box of Stromectol 3mg tab lot K027167 expired on 5/17
c. Atorvastatin (Lipitor) 10mg tab lot. MM4084 expired on 5/17
d. Calcium Caltreta 600 mg tab lot. 46782 expired on 2/25/17
e. Glimepiride 4mg tab without lot number and expiration date, the tablet was cut by the half.
f. Lidocaine HCL 1% 5ml amp. lot. 381453A expired on 2/1/17

1. Based on review of Quality Assessment (Q.A.) Program review and interview with the blood bank testing personnel on June 26, 2017, it was found that the blood bank did not follow the established evaluation schedule.

The findings include:

a. On June 26, 2017 the blood bank testing personnel showed the Q.A. documents.
b. The established Q.A. program was reviewed at 11:11 AM.
c. The Q. A. schedule showed that evaluations to patient's tests results must be done daily.
d. The blood bank did not evaluated the patient's test results since March 15, 2017.
e. The Q. A. schedule showed that verification of reagents quality control (acceptable reactions, logbook verification and reagents expiration dates) must be done weekly.
f. The blood bank did not evaluate the reagents quality control since March 16, 2017.
g. The Q. A. schedule showed that evaluations to test requisitions (patient's name, identification, sample collection date and time and identification of the phlebotomist) must be done each month.
h. The blood bank performed the last evaluation in March 2017.

2. Based on bacteriology records, manufacturer's instructions, bacteriology procedures manual review and testing personnel interview on June 26, 2017 at 10:30 A.M., it was determined that the laboratory failed to perform verification studies when they modified an FDA-approved method (Bact/ ALERT microbial detection system) prior to report patient test results.

The findings include:

1. The laboratory uses the Bact/ALERT microbial detection system for recovery and detection of aerobic and anaerobic microorganisms (bacteria and yeast) from blood.
2. The Bact/ALERT system use two types of culture bottle: PF (pediatric samples) and FAN (adult patient in antibiotic therapy).
3. The Manufacturer's instruction establishes that for pediatric patient, the recommended blood volume is 4 ml. The Bacteriology procedures manual establishes that the sample volume for pediatric patient is 5 ml.
4. The Manufacturer's instruction establishes that for adult patient, the recommended blood volume is 10 ml. The Bacteriology procedures manual establishes that the sample volume for and for adult patient is 10 ml.
5. Bacteriology records showed that since March 2, 2017 the laboratory began to use the pediatric Bact Alert (PF) culture bottle for testing adult sample.
6. The laboratory established that for each blood culture taken in adult patient, the nursing personnel will use 2 pediatric blood cultures bottles and draw 10 ml of blood on each bottle.
7. The laboratory did not perform verification studies prior to modify and use the pediatric bottles with adult patients.
8. Since March 2, 2017, the laboratory processed and reported 691 blood culture performed to adult patient.
9. The bacteriology testing personnel stated that the modification was done and no evaluation was performed.

Based on a recertification survey perform on 6/20/17 thru 6/23/17 for recertification, the kitchen observational tour, review of official documents and interview with the Nutrition Director (employee #41) and Physical plant director (employee #6), it was determined that the facility failed to ensure a safety place for the store, prepare and serve food under sanitary conditions which can affect 95 of 95 admitted patients (PTE) (PTE #1 to #95).

Findings include:

1. During observations made on the dry food storage on 6/20/17 at 9:15 am the following was found:

a. A opened package of corn flour was unlabeled.
b. A opened package of refine sugar was unlabeled.
c. The shelve Formica was broken making it hard to clean.
d. One Quick Creamy Wheat package was open and unlabeled.

2. During observations made on the milk refrigerator on 6/20/17 at 9:20 am the following was found:

a. A tray of vegetables, juice and fruits were unlabeled.
b. A tray with jelly-O cups that had jelly-O all over the tray.
c. On the refrigerator inside walls above the door were observed black stains.

During review of kitchen Policies and Procedures on 6/23/17 at 3:45 pm was found on part II- Prevention, item (h): "If food is removed from the original package, it must be label with the name of the product and the date".

However the facility failed to ensure compliance of this policy.

3. During observations made on the vegetable refrigerator on 6/20/17 at 9:23 am the following was found:

a. On the air conditioning unit vents were observed with black and white spots.

4. During the food preparation area a pink cloth was observed left on the table.

During interview with the Nutrition Director (employee #41) on 6/20/17 at 9:25 am, she stated: "It seems that she served some juice and cleaned the spills with the pink cloth, but it is supposed to be submerged".

During review of the policies and procedure related pink cloth on 6/23/17 at 3:45 pm the following evidence: "3. Disposable cloths are used for cleaning and disinfecting. In each area there is a container with a disinfectant solution. The cloth used for cleaning is other than the one used to disinfect. These cloths are kept inside the disinfectant solution."

However the facility failed to ensure that kitchen staff complies with this policy.

5. During observations made on the meats freezer on 6/20/17 at 9:26 am the following was found:

a. On the freezer entrance floor were observed black stains.
b. Egg beaters boxes in a tray that had water spills.
c. Fifteen ham plates served that were unlabeled.

6. During observations made on the tray cleaning area on 6/20/17 at 9:35 am the following was found:

a. Sample trays were cleaned in the tray cleaning machine and the wash temperature was 140 F and the rinse temperature was 180 F.
b. The shower sink was observed with a pink cloth on the shower.

During interview with kitchen staff (Employee #42) on 6/20/17 at 9:40 am she stated: "someone put that pink cloth on the shower of the sink to avoid the water splash".

c. During review of the temperature registry of the tray cleaning machine on 6/23/17 at 3:45 pm was found the following evidence:

i. The tray cleaning machine temperature during the wash during 6/1/17 thru 6/23/17 never reached 160 F during the breakfast, lunch and dinner that the facility registers the temperature.
ii. However the tray cleaning machine temperature during the rinse and sterilization during 6/1/17 thru 6/23/17 always reached 180 F during the breakfast, lunch and dinner that the facility registers the temperature.

During review of the policies and procedure related Tray cleaning area on 6/23/17 at 3:45 pm the following evidence: "12. Tray cleaning area: The water temperature in this machine is maintained at 160 F in the wash tank and 180 F in the rinsing and sterilization tank. It will take a daily monitoring of these temperatures."

However the facility failed to ensure that tray cleaning machine complies with this policy.

7. During the area of cooking of foods on 6/20/17 at 9:47 am the following was observed:

a. A pink cloth was left in the preparation table unattended.
b. Two and a half package of spaghetti were open and unlabeled.

During interview with kitchen staff (Employee #43) on 6/20/17 at 9:50 am, he stated: "this spaghetti packages are supposed to be labeled once they are open".

c. Kitchen staff (Employee #44), was observed working with ground beef without disposable gloves.

During review of the policies and procedure related Food Preparation area on 6/23/17 at 3:45 pm the following evidence: "c. When handling foods that are ready for consumption, disposable gloves or utensils are used. Gloves are changed every time a different food is handled or when leaving the area (example: after going to the bathroom).

However the facility failed to ensure that kitchen staff complies with this policy.

8. During observations made on the formula area on 6/20/17 at 9:55 am the following was found:

a. One pink cloth was on the sink spout.
b. The formula staff (Employee #45) was observed preparing the formula without disposable gloves.
c. The formula staff (Employee #45) was observed placing disposable gloves without performing hand wash.

During review of the policies and procedure related Formula Room on 6/23/17 at 3:45 pm the following evidence: "Staff will wash their hands at least the following times: Before preparing food."

However the facility failed to ensure that kitchen staff complies with this policy.

9. During observations made on the provisional food storage area on 6/20/17 at 10:05 am the following was found:

a. The air conditioning vents has water that caused a leak in the center of the storage room.
b. There was water on the floor.
c. The room temperature was 75.5 F.
d. The shelves were rusty.

During review of the policies and procedure related to shop, food and material storage on 6/23/17 at 3:45 pm the following evidence: "Dry, canned foods and UHT milk are requisitioned from the central store. They are stored in an existing storage for this purpose. This store has slats not less than 12 inches from the floor, separated from the wall 3 inches, and 18 inches from the ceiling. No food is stored on the floor. Here food is stored for a day and weekend as the central store does not work on the weekend. In this area there is air conditioning so it maintains a suitable temperature of 70.0 F or less."

Facility failed to comply with its own policy.

10. During observations made on the Disposable storage on 6/20/17 at 10:10 am the following was found:

a. The air conditioning vents were humid by condensation causing water drops.
b. The room temperature was 73.5 F.

During review of the policies and procedure related to shop, food and material storage on 6/23/17 at 3:45 pm the following evidence: "Dry, canned foods and UHT milk are requisitioned from the central store. They are stored in an existing storage for this purpose. This store has slats not less than 12 inches from the floor, separated from the wall 3 inches, and 18 inches from the ceiling. No food is stored on the floor. Here food is stored for a day and weekend as the central store does not work on the weekend. In this area there is air conditioning so it maintains a suitable temperature of 70.0 F or less."

However the facility failed to comply with this policy.

Based on a recertification survey, observation with emergency room supervisor of nursing (employee # 1) on 5/20/17 at 11:15 am it was determined that the facility failed to prevent patients from harm. This constitute an Immediate Jeopardy to 1 out of 12 patients admitted at the emergency room of the facility.

Findings include:

During the observational tour performed on 5/20/17 at 11:15 am it was observed in the ER Department the following:

1. A room apart on the side of the floor with one patient on a stretcher with a NGT (naso gastric tube) and one side rail upward without call system cord installed in the room.

2. Beside that room there is a room designated for Respiratory Therapy with 3 call system out of service.

Interview with the patient on 6/20/17 at 11:30 am reveals that the patient admitted since yesterday 6/19/17 had to scream to the nurse when he needs helps.

Interview with emergency room supervisor (employee #1) on 6/20/17 at 11:35 am indicates that the system it is not functioning properly.

3. The facility failed to prevent patient from potential harm related to failure to provide care and supervision related to the lack of nurses call system on a treatment area with patient admitted.

4. Facility present a plan of correction for this situation on 6/20/17 at 4:00 pm :

a.New call cord was installed and tested. The nurse call system is now working in this room. The rest of the nurse call system for the patients in areas in Annex 2 were tested and are working correctly. For ongoing compliance a daily check of the nurse call station will be performed by the nurse supervisor.

b.The nurse call in the respiratory therapy room was tested and is working correctly. An orientation will be given to all nurses and secretarial staff on the use of the call system to the nurse. This will ensure correct use and remedy if there are doubts regarding its use. This orientation will be offered by Mr. Emmanuel Serrano, biomedical staff.

An orientation will be offered to all nursing staff regarding the importance and necessity of checking that the nurse call are working properly before placing a patient in a room or cubicle. As well as to orient the patient to the use of the nurse call.

In addition, as a preventive measure, rounds will be offered in the emergency department to identify if all the nurse calls are working and are accessible to the patient. This round will be daily enhanced by the department supervisor and / or the head.

The Plan of Correction action provided by the facility was accepted on 6/20/2017 at 4:08 PM.

Based on a recertification survey, observations performed on 06/20/2017 through 06/23/2017 for the physical environment , 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 patient's sleeping room windows tested from the first to the eight floors were found locked (could not be opened) from 6/20/17 to 6/23/17 from 8:00 am until 4:15 pm. The facility is designed with a central air conditioning system and each room has a thermostat, however in the event of a fire or explosion where electrical power is lost and smoke fills the hallways or enters the rooms, patients would not have access to fresh air.

Minimum requirements of "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) section 8.2.2.5(1) states if operable windows are provided in patient rooms, operation of such windows shall be restricted to inhibit possible escape or suicide (it states restricted, it does not state closed or sealed). Appendix A 3.1.1.3 also states that window use is essential for life safety reasons and in the event of mechanical ventilation system failure. Also the code of federal regulations for "Americans with Disabilities Act" appendix A4.12 (Windows) states that windows intended to be operated by occupants in accessible spaces should require no more than 5 lb. to open or close.

2. The entire hospital and off-site Radiology & MRI center and emergency room were visited from 6/22/17 through 6/22/17 from 8:30 am until 3:00 pm and provided evidence that patient's bathrooms can be locked from the inside, however personnel do not have a device to open the doors in the event that a patient needs assistance. Personnel need to be supplied with a device to open these doors in the event of an emergency and in-service training related to the use of this new device for all personnel from all shifts is required along with periodic testing for compliance.

3. Windows of all patient's sleeping rooms were observed from 6/20/17 through 6/22/17 from 8:30 am until 4:00 pm extremely dirty and with green spots (they are dirty from the outside) and dark paper observed ripped are used to control the brightness of the sun in most windows.

4. No nursing call system cord was found in a room on annex 2 on 6/20/17 at 11:15 am. This room had patient and the facility failed to identify this situation until it was brought to their attention. In-service training of all personnel related to the placement of this device for all patients seen at the emergency room is required along with periodic on-site revision for compliance.

5. Maintenance closets throughout the hospital were observed from 6/20/17 through 6/23/17 from 8:30 am until 4:00 pm. These closets were found with chemicals to clean the facility and equipment and were found unlocked and accessible to non-authorized persons.

6. The operating rooms in the hospital were visited on 6/22/17 from 1:00 pm through 3:00 pm provided evidence of the following:

a. The walls of operating suites #1 through #5 in the hospital and suites #1 through #3 in the ASC were not monolithic, holes were found in the tiles and the grout lines were not sealed between the wall tiles which can allow dirt to enter and does not allow for proper cleaning. The joint between the floor and the walls was broken in all the suites.

7. The storage room located on room #B in the Annex 2 it was observed on 6/20/17 at 11:05 am and it was found that the storage did not had thermometer for the register of the temperature and relative humidity, lack of smoke detector and fire extinguisher. It was observed dead roach in front open surgical medical equipment. The walls covered with peeling off painting and mold. The Formica of the shelves were broken and one of the shelve was broken. Ceiling tiles bended and with missing cross T. The extractor do not have the cover. (Cross reference tags A-749 and A-1104).

8. General Storage was observed on 6/21/17 at 8:52 am there is a large puddle of water in front of a metal shelf.

Interview with the assistant warehouse supervisor (employee # 5) on 6/21/14 at 9:06 am indicates that the puddle comes from the air conditioning bomb and had already been reported to the engineering department for long time ago.

9. The Pathology Department was visited on 6/22/17 at 10:18 a.m. and the following was found:

a) Cross T with a lot of rust and the ceiling tiles with water leak spots and mold.
b) The door frames are all filled with mold.
c) The floor is deteriorated, dirty and with a texture that does not allow the correct disinfection of the area. Boxes placed directly on the floor blocking the passage; and this can cause a fall to any staff working in that area.

10. The Ambulatory Surgery Department was observed on 6/22/17 at 10:35 am with Physical Plant engineer employee # 6 and the following was found:

a. Entrance doors to the operating room do not sealed completely.

b. The door to access the area of the ambulatory surgery rooms held with a little piece of rubber to keep it open.

c. It was observed the women restroom out of service.

d. The faucet for the hand washing sink broken.

e. Fire compartment door do not close properly. It is not doing the function required.

f. Dressing room for man was observed with ceiling tiles out of place, bended and with water leaks spots, missing wall tiles.

g. Storage room with ceiling tiles bended and with water leak spots.

11. Intensive unit care #2 was observed on 6/22/17 at 10:48 am and the following was found:

a. In front of the main entrance the hallway had a poor illumination.

b. Cubicle #9 with floor tiles broken.

c. Cubicle #10 with door glass (sliding door) broken and rubber base under hand washing sink unattached.

d. Cubicle #11 ceiling missing tiles and it was observed exposed cables covered with dust.

e. Cubicle #12 broken windows operators and rubber base under hand washing sink unattached.

f. Cubicle #13 Bed side rails with rust, broken and exposed cables in the ceiling, broken window operators and peeling off painting.

Interview with Physical Plant engineer (employee #6) performed on 6/22/17 at 10:57 am reveals that they have a special device because they start to open and close the windows and the humidity go high.

g. Cubicle #14 walls with peeling off paint.

h. Cubicle #15 bed with side rails with rust, side bed table with rust and the nurse call box attach with tape and it was observed with exposed cables.

i. Cubicle #16 floor tiles unattached, rubber base under hand washing sink unattached and Column in the room prevents visibility of the machines.

j. The Janitor closet was with door open exposing the chemical to visitors or patients.

k. Medical surgical equipment storage was found with the door open. No thermometer and no register log for the temperature and the relative humidity was found.

Interview with Intensive care #2 supervisor (employee #23) performed on 6/22/17 at 10:46 am indicates that the facility had an inspection from the Department of Health of Puerto Rico and the cite the thermometer and she is going to start using the new thermometer and register log soon.

12. Intensive care unit #1 was observed on 6/22/17 at 11:19 am, it was found the following:

a. Ceiling tiles out of places and bended. Receptacles no ground support.

b. Cubicle #1 walls with peeling off paint.

c. Cubicle #4 Oxygen valve cover with a glove.

d. Cubicle #5 curtains with spots, broken window and covered with white tape, glass window covered with blue pad to provide privacy between cubicles and oxygen valve panel with rust.

e. Cubicle #8 oxygen valves panel with rust.

13. Rooms #506, #801 (with broken ceiling tiles) #811 and #813 ceiling tiles with water leak spots.

14. Visitor chairs with broken cover in rooms' #207 (two lounge chairs with leg rest broken) #313 #402, #507and #516.

15. Hand washing sink with rust on patients' room #506 # 515, #517

16. Broken towel rack on patients room #811

17. Nurse call system in patient's bathroom in rooms #811 without pull cord.

18. Beds side rails with rust and scratches on side rails patients' rooms #511# 813(a &b)

19. Dinner tables on patients' rooms # 516 (both) with rust

20. Rubber base under hand washing sink and patients rooms #500 (with mold), #501,#504, #506 #511 and #512, #513 (missing rubber base) # 515 unattached.

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

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

23. Bathroom shower without call system in patients' room # 516

24. Missing tiles on patients' room # 503, #517

25. Uneven door in patients' room #503

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

27. A paper towel dispenser attached with tape on room #507

28. Bathroom door frame with rust in room #501, #507

29. Hand washing sink faucet in room # 504 (running water all the time).

30. Facility does not have food reserve available in the event of an emergency.

Based on a recertification survey, observations during the survey for Life safety from fire with the physical plant engineer (employee #6) and safety officer (employee #13), it was found that the facility failed to comply with other Life Safety Code requirements not in CMS-2786-R related to the storage of oxygen tanks, the lack of floor plans in the Emergency Room for adult, fire extinguisher test, defibrillator plugged into a receptacle that is supplied by the essential electrical system, Television and clock without being inspected by the facility.

Findings include:

1. Lack of floor plans were found in the Emergency Room adult department on 6/20/17 from 9:00 am until 4:00 pm.

2. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99. However, during the observational tour of the surgery area on 6/22/17 at 2:00 pm 1 type H oxygen tanks were found laydown on the floor on OR #A.

3. Television and clock were observed in the Cardiology intensive area as observed on 6/22/17 at 11:00 a.m. A total of one television and clock were observed in the cardiology intensive area without being inspected by the facility's safety officer and the infection control coordinator.

Based on a recertification survey, observations made during the survey for the physical environment with the facility's Plant Manager (employee # 6) and Safety Officer (employee # 13), it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety.

Findings include:

1. The operating room department was visited on 6/22/17 from 1:00 pm until 3:00 pm and provided evidence of the following:

a. Operating suites # A, #B, #C, #D and #E through #5 and recovery room were found with cables and multi-plugs directly on the floor

b. Operating suite #A was with phone box hold with tape in an electrical receptacle; the cover of the receptacle cover it with rust. It was found a small oxygen cylinder laying down over the floor. The cylinder was full and it was over the medication refrigerator cables. Anesthesia machine cables with 4 outlet metal case and a red metal outlet box entangled with oxygen hoses that come down from the ceiling. Extractors located at the lower level of the walls to allow fresh air to circulate were covered by stand and supply carts which will not allow air in these suites to change 20 to 25 times per hour as required by Guidelines for Health Care Facilities.

c. Operating suite #C was observed with the rubber base broken and old dirt. Extractor cover loose. Oxygen hose was found on the floor and the oxygen valves located in the ceiling without cap.

d. Operating suite #D walls tiles with unfinished plaster and porous surface.

e. Operating suite #E it was observed with broken tiles. Did not have air extractor to exchange air. The glass window of the door was cover it with a blue pad.

Interview with the OR supervisor (employee #14) performed on 6/22/17 at 2:45 pm indicates that they cover the window with that blue pad to give privacy to the patient because in that suite they perform a lot of OB Gyn surgeries.

f. Patient's stretchers at the recovery area were observed on 6/22/17 at 2:55 pm without identification by letters or numbers. All the curtains in the cubicles were thrown back, depriving privacy to the patients who were recovering in that area.

g. Escort radio charger next to sink located in recovery room, the receptacle is a regular one and not ground fault. This receptacle is less than 3 feet from the sink. There was a hole without cover in the same area.

h. Sterile Supply Room it was observed at 2:35 pm it was found floor tiles broken, old stain and peeling off paint in the walls, ceiling tiles with holes.

Interview with operating room technician (employee #15) on 6/22/17 at 2:30 pm reveals that she cleans the area, first she sweeps the floor with a broom and then mop the floor. That it is all the cleaning we performed in this area.

i. Sterile Supply Area (Pre-wash area) it was observed on 6/22/17 at 2:50 pm, accumulate dust and dirty it was observed in some corners of the room. The floor tiles in the corner are not monolithic and sealed to make the floor washable and scrubbable. The walls in the pre-wash are in gypsum board and not sealed to make the walls washable and scrubbable.

j. The hand scrub area between OR #C and #D was found with rust under the sink. In front of the sink there was side rails with broken covers. All the walls in the hallway were observed with all dirt and with scratches. A lot of ceiling tiles were observed with water leaks stains.

k. In the housekeeping room it was found the ceiling lamp without cover, the light switch without cover and rust where the regular garbage was located.

2. Mops and brooms were observed maintenance closets of the Ground floor on 6/22/17 leaning up against the wall (mop heads up and the poles down) and inside of a trash can. This procedure contaminates the walls and allows water from the wet mops to leak down the poles and is not an acceptable practice related to infection control standards. This closet was open all the time because the lock it is broken.

3. In The emergency room in the respiratory treatment area and the Room # B in the Annex 2 the nurses call system does not function.

Based on a recertification survey performed on 06/20/2017 through 06/23/2017, 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. Maintenance closets throughout the hospital and emergency room were observed from 6/20/17 through 6/23/17 from 8:30 am until 3:30 pm. These closets were found with chemicals to clean the facility and equipment and did not have air extractors or smoke detectors connected to the fire alarm system.

2. The hospital's emergency room was visited on 6/20/17 at 11:35 am and provided evidence that there are three lounge chairs that are placed in a room that are used to provide respiratory therapy to patients. The three lounge chairs were placed in three separate spaces but no curtains were found between the lounge chairs. It was observed a big oxygen hose touching the floor behind one of the lounge chair. Also, it was found that the nursing call it is not functioning properly.

Based on a recertification survey, observations made during the survey for the physical environment with the facility's Engineer (employee #6), it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas which are not equipped with an air disinfection system (such as ultraviolet lights).

Findings include:

The emergency room was visited on 6/20/17 from 9:30 am through 3:45 pm and provided evidence that emergency room had the two entrance and two waiting area, triage area and the observation area of the adult the areas are not equipped with an air disinfection system (for example: Ultraviolet lights), it was observed just one UV light in the waiting room and the UV light it is not enough for the all area.

In the annex area 2 there is a waiting room for patients waiting for results of Influenza no UV light was found in the area.

According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) the triage area is the point of entry of undiagnosed and untreated airborne infections and should be designed and ventilated to reduce exposure of staff, patients and families to airborne infectious diseases. Through the facility's infection control program, determinations must be made related to general ventilation and air disinfection similar to inpatient requirements for airborne infection isolation rooms according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". The waiting area and observation area are other areas to provide protection with an air disinfection system.

Based on a recertification survey, observation of delivery of care, review of medical records, department rounds, policies and procedures, documents, and interviews from 06/20/16 to 06/23/16 from 8:00 am to 4:00 pm, it was identified that the facility failed 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, the observational tour with the Infection Control Coordinator (employee #24), review of policies/procedures, observation of procedures, it was determined that the facility failed to ensure that appropriate standards of practice are followed for infection control practice for 2 out of 2 observed procedures, expiration date of the medical surgical material on the crash cart and the administrative order #284 of July 12, 2001 from the Health Department of Puerto Rico which can affect 95 of 95 admitted patients (PTE) (PTE #1 to #95).

Findings include:

1.R.R. #32 is a 56 year old male admitted to the facility on 05/13/17 with a diagnosis of Head and Neck Cancer, Sepsis, Respiratory Failure and bronchopneumonia (BKP). On 06/21/2017 at 10:00 am a dressing change and exit care of a catheter was observed and the following was found:

The register nurse (employee #30) perform hand hygiene put a new pair of gloves on and removed the dressing from the patient, then employee #30 removed her gloves and without performing hand hygiene put on a gown and open the exit care and dressing tray. Employee #30 put a surgical mask on and a new pair of sterile gloves then employee #30 put the Sterile field and clean the exit side with chloraprep and applied the new dressing.

2. R.R #76 is an 84 years old male admitted to the facility on 06/16/17 with rt. foot ulcer and sacral ulcer. On 06/22/17 at 9:05 am an ulcer care and dressing change was observed and the following was found:

The License Practical Nurse (LPN) (employee#31) perform hand hygiene and proceed to remove the dressing from the foot ulcers, clean the ulcer with solosite and apply the new dressing. No hand hygiene and gloves change performed during the procedure.

At 9:15 am employee#31 performed hand hygiene and put two pair of gloves one on top of the other then start removing the dressing from the sacral ulcer then clean the ulcer. Employee#31 proceed to remove a pair of gloves and start the medication application and the clean dressing. Employee#31 perform hand hygiene put a new pair gloves on and put the diaper to the patient.

The facility failed to ensure that appropriate standards of practice are followed for infection control practice


36632


3. On 6/22/17 at 1:55 pm during emergency cart inspection with the Quality Assurance Assistance (Employee #36) and the Nursing Supervisor (employee #14) at the Operation Room suite E, the following was found:

a. One 30 ml syringe was opened in the anesthesia medication cart
b. One Tracheal Tube Oro/Nasal lot 120102164X expired on 2017/01
c. One Laryngoscope blade in an open package

4. On 6/22/17 at 3:30 pm during observational tour and emergency cart inspection with the Quality Assurance Assistance (Employee #36) and the Nursing Supervisor (Employee #39) at the Nursery Room, the following was found:

a. Three mops and a broom were observed upside down in the Nursery housekeeping storage.
b. (3) Disposable syringe 10ml expired on 2013/03
c. (3) Suction Catheter 6FR lot 20090625 expired on 2014/06
d. (4) Suction Catheter 8FR lot 20100625 expired on 2015/06

5. On 6/22/17 at 4:30 pm during observational tour and emergency cart inspection with the Quality Assurance Assistance (Employee #36) and the Nursing Supervisor (Employee #38) at the Intensive Unit II, the following was found:

a. (2) Laboratory tubes lot. 6216922 expired on 5/31/17

6. During observational tour on Operation Room and Labor Room with the Quality Assurance Assistance (employee #36) on 6/22/17 from 1:55 pm thru 5:10 pm, the following was found:

a. It was observed that the Nursing Supervisor (employee #14) of the operation room was using a dark color nail polish that was chipped.

b. It was observed that one Registered Nurse (RN) (Employee #40) of the Labor room was using a dark color nail polish that was chipped.

Facility fails to have the medical surgical material up to date and complay with the administrative order #284 of July 12, 2001 from the Health Department of Puerto Rico to prevent infections and communicable diseases.


20423


7. R.R. #65 is an 84 year old female admitted on 5/25/17 with a diagnosis of Chronic Illness Miopathy. Accordance to the record review performed on 6/22/17 at 11:15 am, on 5/25/17 at 10:32 pm an throat culture was performed , On 5/28/17 at 10:52 am the laboratory inform the result of Abundant Growth of Staphilococcus Aureus MRSA. On 5/29/17 at 8:00 pm the primary physician documented in the progress note the plan of care with the patient Isolation room and stared in Vancomycin 1 gram Intravenous (IV) every 48 hour. On 5/29/17 at 9:20 pm the physician place a consult with infectology, the infectology perform their evaluation on 5/30/17 at 2:00 pm. On 5/30/17 at 3:20 pm the physician place an order for Contact Isolation and Vancomycin 1,125 milligram (mg) IV every 48 hour.
However, no evidence was found on the nurse's note of patient and relative orientation related to the contact isolation measure. No evidence was found that the infection Control Coordinator evaluate this case and oriented the patient or relative.

8. R.R. #68 is an 48 year old male admitted on 6/16/17 with a diagnosis of Urosepsis. Accordance to the record review performed on 6/22/17 at 11:45 am, on 6/18/17 at 1:36 pm an urine culture was performed. On 6/21/17 at 1:16 pm the laboratory report positive urine culture result with Klebsiella Pneumoniae. On 6/21/17 at 7:00 am the physician place an consult with infectology, the infectology evaluate patient on 6/21/17 at 10:30 am. On 6/21/17 at 9:00 am place and order of Contact Isolation.
However, no evidence was found on the nurse's note of patient and relative orientation related to the contact isolation measure. No evidence was found that the infection Control Coordinator evaluate this case and oriented the patient or relative.


33725


9. On the Emergency Room (ER) observational tour with the ER Nursing supervisor (employee #1) performed on 6/20 and 6/21/2017 it was found deficient practices on infection control measures:

a.During venipuncture procedure for extraction of blood sample and intravenous administration medication it was observed on 6/20/17 at 10:38 am register nurse (employee #3) and the following was found:

b.It was observed that employee #3 prepare the material without gloves and do not performed hand washing before started the procedure. It was observed the IV Line touching the floor without the cap. She did all the procedure of the blood sample and the IV cannulate with the same gloves. She documented on the computer and touch the trash can with her hands. After she finished with these two procedure she located the patient on cubicle. She did not remove the gloves. She administered with the same gloves an IM (intra muscular) medication. After that she went to the minor surgical room to wash her hands. During all the procedure it was observed the (employee #3) chewing gum. The jacket that the register nurse was wearing a jacket that the fabric is furry.

Interview with (employee #3) performed on 6/20/17 at 10:53 am reveals that all the nurse have to wash their hands in that area because the other hand washing sink is in CPR #2 and if you can see there is a patient with the caregiver there and I do not want to interrupt. The area for the blood sample and the venipuncture procedure did not have hand washing sink just hand sanitizer.

c.In the Annex 2 in the emergency room it was observed on 6/20/17 at 11:00 am in the examination room the chair use for blood sample that the arm rest and the left leg of the chair covered with tape. The box used to store venipuncture equipment was observed with a dead mosquito, the material full of hairs and dust. The STAT lab blood sample tray was observed with trash in and one tourniquet.

d.The storage room located on room #B in the Annex 2 it was observed on 6/20/17 at 11:05 am and it was found that the storage did not had thermometer for the register of the temperature and relative humidity, lack of smoke detector and fire extinguisher. It was observed dead roach in front open surgical medical equipment, cotton under cast padding opened and it was observed with dead mosquitoes inside. The walls covered with peeling off painting and mold. The Formica of the shelves were broken and one of the shelve was broken. It was found one gloves box open with dead mosquitoes all over it and the plastic for gown opened. (Cross reference A-701).

10. On Operating room #A it was found in the crash cart on 6/22/17 at 2:10 pm one Labetalol 100mg/20ml lot. 74365D exp. 2/1/19, Atropine 8mg/20ml lot. 106363 exp. date: 10/2018 and one Neostigmine 10 mg/10 ml lot. 096361 exp. Date: 09/2018 opened without labeled when was open.

11. Hand dispensers were observed without paper at cubicles minor surgical room, in the Annex near the nursing station and the Annex 2 in the respiratory therapy room in the emergency room. During observational tour on 6/20/17 through 6/22/17 on floors 1st, 2nd, 3rd, 4th, 5th and 8th it was observed in all the patient's rooms the Hand dispenser were observed without paper. (Cross reference tag A-701)

Interviewed with patient caregiver on room # 314-A performed on 6/22/17 at 11:46 am reveals that the room did not have paper towel since she was admitted in the room. The caregiver state: "I told to the housekeeping personnel that the paper towel was finished but they never bring the paper towel".

12. The facility failed to observe that professional staff performs hands hygiene according to the hand washing guidelines published by the CDC.

13. Medication preparation room observed on 6/20/17 at 1:30 pm the Formica covering the counter broken and tapes covering the scratches. Two pixie machine covered with rust, the medication fridge handle attach with tape dirty inside, tape holding the rubber around the fridge door from the inside and with Ice.

14. General Storage: Metal shelf with two boxes BP Vacuntainer next to office materials.
Boxes on the floor of Cavi wipes. Sharp container boxes placed directly on the floor. Surgical medical material next to office supplies. 8 boxes of nebulizers placed directly on the floor.

15. The cistern has not been cleaned or disinfected since 2010. However, through record review of the culture results and interview to the personnel of physical plant could be evidenced that the facility chlorine and culture the cistern every month. Kitchen general Storage Area: There is a large puddle of water in front of a metal shelf.

Interview with the warehouse supervisor on 6/21/14 at 9:06 am indicates that the puddle comes from the air conditioning bomb and had already been reported to the engineering department for long time ago.

16. In the general Storage here is no record of temperature in the storage where the intravenous solution are. No thermometer was found in the area.

17. Morgue (Fridge) Inside the Pathology Department

a. It was observed that the walls had a termination with a material that not permitted a proper sanitization and disinfection of the room.

b. It was observed the room without clean.

c. It was observed a lot of condensation inside the room.

d. No temperature, humidity and cleaning log report was provided.

e. The fridge uses to stock the dead people and the specimen sample was observed located in the same area where they do the tests.

18. The cistern has not been cleaned or disinfected since 2010. However, through record review of the culture results and interview to the personnel of physical plant could be evidenced that the facility chlorine and culture the cistern every month.

19. Windows of all patient's sleeping rooms were observed from 6/20/17 through 6/22/17 from 8:30 am until 4:00 pm extremely dirty and with green spots (they are dirty from the outside) and dark paper observed ripped are used to control the brightness of the sun in most windows. (cross reference tag A-701)


17959

20. On 6/20/17 at 9:15 a.m. till 11:45 a.m. during performed the visual Inspection on the Respiratory Therapy Department with the Educational Service Nurse (employee #49) and the Respiratory Therapy Supervisor (employee #48)) the following was found:

a The room designated to receive the dirty ventilators to performed cleaning, disinfection and then take the culture after disinfection it was observed that the dispenser lacks of hand paper.

b. The washstand was observed dirty and with black spots. Dust was observed on the interior of the cabinet.

c. Outside of this room a large cardboard box was observed on a top of the regular trash can.

d. On the interior of a room designated to '' Mechanical Ventilators Warehouse '' was observed at right side eleven tanks of '' Nitric Oxide 800 ppm,'' two smalls tanks of '' Nocal N O2 Calibration Gas,'' directly at the floor and around of the tanks was observed a chain with small links. On the top of the tanks four cardboard boxes were observed, two of the boxes with' "Regulators kit used to connected the tanks and the other two boxes with '' Inomax (Nitric Oxide for inhalation product 300-302 800 ppm size D). Various lines used to calibrate the tanks were observed in the top of the boxes. One large tank of air compressed unit 1002 Medical Air USP 2000 psa weigh and one tank of Oxygen Praxair 010063503. All of this tanks lacks of security base.

e. One ventilator 2640 used for adults was observed on a clean area has a label with a date 6/18/17 9:35 p.m. Intensive Unit A room #6 #2640 and signed per respiratory therapist employee # 57 however, did not indicated if the ventilator was clean and disinfected and no evidence if the ventilator was cultivated.

According of the Respiratory Supervisor (employee #48) the facility has a label used to identify the ventilators indicating the following: '' Date of culture, Ventilator serial number, Patient's record number, Respiratory therapist's sign and indicated ''Pending to Results '' however the ventilator did not have this label '' and did assure if the ventilator was clean and disinfected and if cultivated.

f. Two BPAP's with plastic covers without identification labels and two ventilators without covers and without identification labels were observed on a clean area.

g. A small closet was observed near the room designated to receive the dirty ventilators, this room has a label indicating " Hand washing area '' was observed a dirty washstand, a refrigerator used for the personnel to put dinner the bulb not function, did not have a thermometer and was observed dirty, one microwave on top of the refrigerator with a label indicating '' no sirve '' Not Funtioning ,on back of the wall was observed a small blue dispenser without label the Respiratory supervisor stated that the dispenser was used to deposit the used oximeters used for patients on the different areas of the hospital, then the personnel discard on this dispenser to recycle.

One dirty biohazard trash can and one dirty regular trash were observed on the interior of the closet. Four woods shelves were observed at the left side of the closet on the shelves were observed the following: One cardboard box of Vitalograph .3 liters Presicion Syringe Model: 2040 Reference: 36020, Navity articles, aluminum paper, one coffee pot, various used papers, biohazard bags, toaster and a lunch bag. One broom and a dustpan were observed at right side of the closet. The ceiling has a broken acoustic. The area designated to place a bulb located on the ceiling lacks of the cover and exposed electrical cables was observed. The closet was observed with poor cleaning, the floor was very dirty, much dust, black spots and dirty was observed on the interior of this room.

h. At 10:15 a.m. the Medical Surgical and Respiratory Material Storage area was visit and the following was found:

- Forty one (41) bags of Sterile Water for Inhalation 1000 ml. Expired on April / 2017.

- Four (4) packages of Syringes approximately of 50 syringes per package of ''Arterial Blood Samples '' (1 ml. wer slip 3.2 IU (N) Heparin no needle) Expired on May / 2017 Lot: 11195634

i. Two (2) small tanks 25 CF OXME, two (2) cardborad boxes of " Sensor and Reagent Cartridge Instrumentation Laboratory and one (1) cartoon box of Pasive Humity filters (Gibeck Humid) directly at the floor were observed on the supervisor office on 6/20/17 at 10:40 a.m.

j. On 6/20/17 at 10:45 a.m. forty four (44) patients records were observed in a stainless steel open cart near the supervisor office in front of the closet designated for personnel to wash hands in open area without security, without privacy and did not comply with HIPPA Law.

The respiratory therapist supervisor (employee #48) was interviewed related to this and he stated: '' The medical record department notified me that the respiratory personnel has incomplete medical records all of the records were brought per the medical record personnel on 6/19/17 to complete. I put them on this area because I do not have space in my office.''

In the first shelve of this stainless steel cart one plastic tray was observed with various respiratory materials the tray lacks of lid. On a second shelve three (3) plastic trays were observed and has a label indicating '' piezas de oxido nitrico, pieces of nitric oxide, lineas gordas, fat lines" and blue and red pieces to connected at the oxilator. '' The trays lacks of lid to protect from dust.

k. The respiratory department area included the floor, ceiling, walls and other areas used to maintain the sterile materials, ventilators used for all of the patients to received respiratory services, failed to ensure that appropriate standards of practice are followed for infection control practice.

21. On 6/22/17 at 2:00 p.m. during performed the visual inspection on fourth floor with the Educational Service Nurse (employee #49) and the Respiratory Therapy Supervisor (employee #48) it was observed the that the fourth floor has room with the identification label '' Medical surgical room '' on this room was observed a refrigerator used to put the patients and employees foods, a canalization cart, two sphygmomanometers, one scale, a metal cabinet and on the interior were observed isolation masks, ventury mask, spirometers, I.V. solutions, gauzes, syringes, irrigation trays, humidifiers, transfusion lines, oxygen cannulas, condom Foleys, central lines, Foleys and other materials used per the nursing and respiratory personnel. According to the nurse supervisor and the respiratory therapy supervisor the floor lacks of an individual area for therapy materials and nursing materials and this room used to put all of the materials and equipment used on the department. However, this room was found open without security lock, dust and dirty was observed on the walls and floor. The room did not ensure the quality control and the security of the medical surgical materials, the respiratory therapy materials and equipment and the I.V. infusions located on this room.

Based on a recertification survey, the review of the policies and procedures, eight closed medical records with the Nursing Quality Director and OPO (employee #58), it was determined that the facility failed to ensure that all deaths or imminent deaths are being referred to the Organ Procurement Organization (OPO) in a timely manner and is documented in the patient's medical records for 4 out of 9 medical records for OPO (R.R#3, #4, #7 and #9).

Findings include:

1. The facility's policies and procedures reviewed on 6/21/17 at 8:00 a. m. states that nursing professional must write on the referral sheet to Life Link the date and the time of death and date and time that the death is reported to Life Link. The nurse failed to write in the medical record the reference number that Life Link provides and the name of the person who took the information.

2. According of the facility's policies and procedures reviewed on 6/21/17 at 8:00 a. m. and interviewed with the Nursing Quality Director and OPO (Employee #58 ) she stated that the facility staff must reported the death to OPO in the term not greater of thirty minutes (30) of the patient death.''

However, two (2) out of eight (9) closed medical records reviewed on 6/21/17 at 8:15 a.m. through 11:00 a.m. provide evidence that the facility reports all information needed in the Life Link referral Sheet, this sheet is part of the medical record, however failed to assure that all of deaths are being referred to the '' OPO '' in a timely manner.

The following was found:

a. R.R. #3 is an 66 years old male with diagnosis of Dehydration, Sepsis, Pneumonia, Respiratory Failure, Renal Failure death was on 8/11/16 at 5:00 p. m. the dead was notified at Life Link at 5:00 p. m. however, the nurse failed to documented on the nurses note hour of death.

b. R.R. #4 is female with diagnosis of Hipoxia, death was on 9/12/16 at 3:15 p. m. the dead was notified at Life Link at 7:50 p. m. four hours and thirty minutes later.

c. R.R. #7 is an 52 years old female with diagnosis of Respiratory Difficulty death was on 5/20/17 at 6:30 p. m. the dead was notified at Life Link at 6:30 p. m. however, the nurse failed to documented on the nurses note hour of death.

d. R.R. #9 is female with diagnosis of Clinical Sepsis and Pneumonia, death was on 11/17/16 at 5:05 p. m. the dead was notified at Life Link on 11/22/16 at 10:20 a. m. five days later.

Based on a recertification survey, observations made of the surgical department and interview with the Infection Control Coordinator (employee #24), it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice for patient's care.

Findings include:

1. On 6/22/17 at 1:40 pm accompany with the Infection Control Coordinator employee #24 it was observed an employee dress with surgical scrub going out the restricted area with a bag of trash for disposal out of the restricted area in front of the dressing rooms.

Interview with the employee #24 stated "they do not supposed to go out of the restricted area with surgical scrubs".

2. On 6/22/17 at 1:44 pm accompany with employee #24 it was observed the operating room supervisor (employee #29) dress with surgical scrub going out the restricted area to receive us in front of the dressing rooms.

Interview with the employee #24 stated "they do not supposed to go out of the restricted area with surgical scrubs.

3. On 6/22/17 at 2:30 pm it was observed one employee with a nurse jacket and another employee with a black scrub inside the restricted area.

Interview with the employee #24 stated "they do not supposed to go in the restricted area with scrubs or any clothes not provide by the Hospital. The hospital did not wash their scrubs or jackets."

4. RR#40 is a 61 years old female patient admitted on 06/22/2017 for a hernia surgery. On 6/22/17 at 3:02 pm the surgery. During the surgery at 3:23 pm the register nurse (employee #28) open the trash can with the hands with no gloves. At 3:31 pm two suction tubes were under the emergency cart and the employee #24 ask her to pick up the suctions tubes and put it in the trash however the employee #28 pick up the suctions tubes and put them inside the emergency cart.

5. On 6/22/17 at 4:09 pm accompany with the employee #24 it was observed a patient escort (employee#32) enter to the restricted area without scrubs in jeans and t-shirt.

Interview with the employee #24 stated "they do not supposed to go in the restricted area with scrubs or any clothes not provide by the Hospital."

The facility failed to ensure that surgical services maintains a high standard of medical practice for patient's care.

Based on a recertification survey, observation and medical record review (R.R.) performed on 06/20/17 thru 06/23/2017 with the Infection Control Coordinator (employee #24) it was determined that the facility failed to ensure that the medical history and physical examination (H&P) is documented by a physician for each patient no more than 30 days before or 24 hours after admission or registration prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies for 1 out of 69 medical record reviewed ( R.R#42).

Findings include:

1. RR#42 is a 66 year old female patient admitted on 06/22/17 with a diagnosis of colon cancer/Medport removal. During record review perform on 6/22/17 at 2:36 pm it was found an H&P sign and dated on 5/19/17, thirty five days before the admission and procedure.

The facility failed to ensure that the medical history and physical examination (H&P) is documented by a physician for each patient no more than 30 days before or 24 hours after admission or registration prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies.

Based on a recertification survey, observation with emergency room supervisor of nursing (employee # 1) on 5/20/17 at 11:15 am it was determined that the facility failed to prevent patients from harm. This constitute an Immediate Jeopardy to 1 out of 12 patients admitted at the emergency room of the facility.

Findings include:

During the observational tour performed on 5/20/17 at 11:15 am it was observed in the ER Department the following:

1. A room apart on the side of the floor with one patient on a stretcher with a NGT (naso gastric tube) and one side rail upward without call system cord installed in the room.

2. Beside that room there is a room designated for Respiratory Therapy with 3 call system out of service.

Interview with the patient #37 on 6/20/17 at 11:30 am reveals that the patient admitted since yesterday 6/19/17 had to scream to the nurse when he needs helps.

Interview with emergency room supervisor (employee #1) on 6/20/17 at 11:35 am indicates that the system it is not functioning properly.

3. The facility failed to prevent patient from potential harm related to failure to provide care and supervision related to the lack of nurses call system on a treatment area with patient admitted.

4. Facility present a plan of correction for this situation on 6/20/17 at 4:00 pm:

a.New call cord was installed and tested. The nurse call system is now working in this room. The rest of the nurse call system for the patients in areas in Annex 2 were tested and are working correctly. For ongoing compliance a daily check of the nurse call station will be performed by the nurse supervisor.

b. The nurse call in the respiratory therapy room was tested and is working correctly. An orientation will be given to all nurses and secretarial staff on the use of the call system to the nurse. This will ensure correct use and remedy if there are doubts regarding its use. This orientation will be offered by the biomedical staff employee #10.

An orientation will be offered to all nursing staff regarding the importance and necessity of checking that the nurse call are working properly before placing a patient in a room or cubicle. As well as to orient the patient to the use of the nurse call.

In addition, as a preventive measure, rounds will be offered in the emergency department to identify if all the nurse calls are working and are accessible to the patient. This round will be daily enhanced by the department supervisor and / or the head.

The Plan of Correction action provided by the facility was accepted on 6/20/2017 at 4:08 PM.

Based on a recertification survey, observation tour at the emergency on 6/20/17 at 9:40 am it was determined that the facility failed to post the EMTALA signs in the entering of the emergency department.

Findings include:

On 6/20/17 at 9:40 am during the observational tour of the emergency rooms it was observed that the facility have just one EMTALA sign near the entrance of the annex 2.
The emergency room has two entrance and an ambulance area entrance. All the entrance of the emergency room need sign posting (entrance, waiting, treatment and admitting) as required by EMTALA regulation.

Based on a recertification survey, the review of two closed medical records reviewed (R.R), policies/procedures manual and the observational tour with the emergency room (E.R) nursing supervisor (employee # 1), it was determined that the facility failed to maintain infection control standards of practice, 2 out of 5 active record and 1 out of 2 closed medical records provided evidence that emergency room personnel failed to document treatment, consent forms and pain re-assessments after treatment or transfer for 3 out of 7 records reviwed. (R.Rs #69, #70 and #75).

Findings include:

1. During the observational tour in the Emergency Room (E.R) on 6/20/17 from 9:00 am until 3:45 pm and 6/21/17 from 8:30 am until 10:45 am the following was found:

2. No signs were posted in the entrance area for the notification of the rights of the individuals who enter the E.R as observed on 6/20/17 at 9:40 am.

3. No evidence was found on 6/20/17 at 9:15 am that emergency personnel have a plan or assignments for all specific tasks in the event of an emergency.

4. The storage room located on room #B in the Annex 2 it was observed on 6/20/17 at 11:05 am and it was found that the storage did not have a thermometer for the register of the temperature and relative humidity, lack of smoke detector and fire extinguisher. It was observed dead roach in front of open surgical medical equipment. The walls covered with peeling off painting and mold. The Formica of the shelves were broken and one of the shelve was broken. Ceiling tiles bended and with missing cross T. The extractor do not have the cover.

5. The medication preparation room was visited on 6/20/17 at 1:30 pm and it was observed: The entrance door do not close because it is uneven and the lock do not latch, counter broken Formica, medication fridge attach with tape, hand washing sink unattached from the wall and with mold on the back, the faucet of the hand washing sink with rust, the floor tiles broken and with stains, ceiling tiles over the Pixie machine out of place.

6. Electrical breaker box in front of the medication room was observed with the door loose and open it.

7. The following was observed in the emergency room on 6/20/17 from 9:00 am until 4:00 pm related to infection control procedures:

a.It was that (employee #3) ER register nurse prepare the material without gloves and do not performed hand washing before started the procedure. It was observed the IV Line touching the floor without the cap. She did all the procedure of the blood sample and the IV cannulate with the same gloves. She documented on the computer and touch the trash can with her hands. After she finished with these two procedure she located the patient on a cubicle. She did not remove the gloves. She administered with the same gloves an IM (intra muscular) medication. After that she went to the minor surgical room to wash her hands.

During all the procedure it was observed the (employee #3) chewing gum. The jacket that the register nurse was wearing a jacket that the fabric is furry.

Interview with (employee #3) performed on 6/20/17 at 10:53 am reveals that all the nurse have to wash their hands in that area because the other hand washing sink is in CPR 2 and if you can see there is a patient with the caregiver there and I do not want to interrupt. The area for the blood sample and the venipuncture procedure did not have hand washing sink just hand sanitizer".

b. oxygen valves box was observed covered with dust.

c. Medication preparation room observed on 6/20/17 at 1:30 pm the Formica covering the counter broken and tapes covering the scratches. Two pixie machine covered with rust, the medication fridge handle attach with tape dirty inside, tape holding the rubber around the fridge door from the inside and with Ice. (Cross reference tag A-749)

d. Registered nurse (employee #8) was observed assisting in a green code in annex # 1 on 6/21/17 at 9:30 am with a bracelet and with long and loose hair.

e. Registered nurse (employee #9) was observed with dark polish on her nails.

f. Registered nurse (employee #7) was observed with a gray long coat during the green code.

g. The facility failed to ensure that the register nurses comply with the Facility Dress Code reviewed on 6/20/17 at 2:55 pm indicate the following:

Woman: Longer hair should be collected and kept tied to a higher level of the neck of the uniform.
Nails should be short and clear; use natural color enamel.
White or selected color coats may be worn except when direct care is given to the patient.
Chewing gum is not allowed while you are working.

8. The medication room located at the acute area was observed on 6/20/17 at 9:01 am with its doors unlocked. A cabinet used to store medications in this room was found open and could be accessed by non-authorized persons.

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

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

11. A cabinet used to store respiratory therapy equipment and blood gas kits located on CPR #2 in acute area was found open and could be accessed by non-authorized persons on
6/20/17 at 11:20 am.

12. The cardiac monitor in the annex 2 was found without the battery light on when observed on 6/20/17 at 9:46 am. When the monitor's cable was observed it was not plugged into the receptacle. When it was plugged into the receptacle the cardiac monitor was found with the battery light on low. Review of the preventive maintenance of this monitor provided evidence that the last revision by the biomedical technician was in December of 2016. The monitor was tested with electrical power and it worked, however when tested using the battery it did not. The monitor indicates that the battery needs to be replace. The facility failed to verify essential medical equipment to ensure it is working properly.

13. The medication and material storage room in the annex #2 was visited on 06/20/17 at 11:30 am and was found that do not have thermometer. The facility failed to ensure that the material and medications in this storage room is maintained at the appropriate temperature and humidity.

14. Hand dispensers were observed without paper at minor surgical room, in the Annex near the nursing station and the Annex 2 in the respiratory therapy room. (Cross reference tag A-749)

15. In the annex area 2 there is a waiting room for patients waiting for results of Influenza no UV light was found in the area. (Cross reference tag A-1104)

16. During observation on Annex #1 on 6/21/17 at 9:08 am cubicle #8 and cubicle #9 the curtains were observed with stains, the floor was observed dirty and there was metal rack with rust. Ceiling tiles broken and bended.

17. Nursing station in Annex 1 was observed on 6/21/17 at 9:15 am and it was found that the ceiling tiles were out of place and bended, the chair in the nursing station was observed with broken and the cover is ripped. Paper towel dispenser without paper. The cover of the lamp in cubicle #7 was observed deteriorate and yellow. All the walls with peeling off paint.

18. Annex II observed on 6/21/17 at 9:20 am: The bathroom for patient and visitors was observed dark the light was dim, call system box with rust, the hand washing sink faucet broken, rubber base at the nursing station unattached, ceiling tile at the nursing station out of place. Cubicle #4 ceiling tile with water leaking spots.

19. ER Acute Area observed on 6/21/17 at 10:00 am: Medication room soap dispenser attach with tape. Blood sample room with emergency light with broken cover and loose bulb. Clock Cover attached with tape. Cubicle #6 curtain rail with tape.

Interview with (employee #6) on 6/21/17 at 10:09 am indicates that this tape is to grab the hooks of the curtain and prevent them from coming out.

20. Annex I as observed on 6/21/17 at 9:08 am: Employee Pantry Microwave connected to receptacle loose and with exposed wires. No smoke detector, uneven door does not close.

21. Housekeeping closet unlock. Garbage storage with uneven door and do not close, broken wall tiles and wall missing tiles.

22. Gastro room was observed on 6/21/17 at 11:00 am with Oxygen hose running on the floor, three call system out of service, wall hole with exposed wires next to the sink, ceiling plug no cover, sink with mold, rusty drawer and rusty drawer with IV lines and one box of glove open.

23. No evidence was found on 6/20/17 from 3:00 pm until 4:00 pm that emergency room personnel are reassessing patient's pain levels after the initial assessment or duration of pain management for patients' seen at the triage of the emergency room for 3 out of 7records reviewed (R.R #69, #70, and #75).

24. On 6/21/17 at 11:00 am it was performed the reviewed of the policies/procedures manual:

a. Policies and procedures related to compliance with EMTALA requirements did not include the following related to: sign posting to notify of the rights of the individuals who enter the emergency room, maintain transfer records for five years, on call physician roster, emergency room log, appropriate medical screening, stabilizing treatment, no delay in examination or treatment about payment status, whistleblower protection and recipient hospital responsibilities.

25. Five active medical records and two closed medical record were reviewed on 6/20/17 from 1:30 pm until 3:45 pm for emergency room services and 3 out of 7 medical records provided evidence of the following:

a. R.R #70 is a 55 years old female admitted to the emergency room on 6/20/17 at 10:36 pm with a diagnosis of Asthma. During the record review performed on 6/20/17 at 1:45 pm, the triage nurse failed to document the location of the patient after the initial evaluation of the emergency room visit. The physician ordered Bed rest-NPO, CBC, BMP, Influenza test, U/A, U/C, Respiratory Therapy, ABgs STAT, Solumedrol 125 mg IV, Rocephin 2 gr IV and Zitromax 500 mg IV on 6/19/17 at 10:50 pm, the physician order is taken and signed by the nurse on 6/20/17 at 11:00 pm, however the initial assessment / nursing note indicates was taken on 6/19/17 at 11:00 pm. The nursing note is incomplete and lacks information such as the area where the patient was cannulate, the size of the intravenous catheter that was used and time of the vein canalization.

b. R.R #69 is a 38 years old female admitted to the emergency room on 6/09/17 at 8:25 pm with a diagnosis of Colitis. During the record review performed on 6/20/17 at 2:09 pm. The registered nurse failed to complete and sign the internal transfer sheet "Traslado Interno de Paciente "Hand Off". No evidence was found related to pain re-assessment at the moment of the internal transfer.

c. R.R #75 is a 71 years old male admitted to the emergency room on 6/9/17 at 10:07 am with a diagnosis of Cellulitis. During the record review performed on 6/20/17 at 2:50 pm, the E.R work clerk failed to identify the treatment consent and authorization form with the patient's name and record number. The triage nurse failed to document the Allergic assessment "Estimado para Alergias" location of the patient after the transfer initial evaluation of the emergency room visit.

Based on observations at the respiratory therapy department and the review of medical records, documents on 6//20/17 throught 6/22/17 from 9:00 a.m. till 3:00 p. m, it was determined that the facility failed to meet the needs of its patients in accordance with acceptable standards of practice, no evidence was provided of in-services training for the department and failed to ensure that meet applicable standards of practice that are required by State or local laws. (Cross refer Tag A1154, A1160, A1163 and A1164).

Based on the re-certification survey review of the State Law License regulations and the review of Respiratory Therapist Credential Files (C.F.), it was determined that the facility failed to updated personnel credential files related to Updated license, Updated CPR, Updated Influenza Vaccines, Hepatitis B Vaccine or Hepatitis B title, and Job description for 8 out of 8 credential files reviews (C.F.'s #1, #2, #3, #4, #5, #6, #7 and #8).

Findings include:

During review of eight (8) Respiratory Therapist Credential Files with the (employee #56) on 6/22/17 at 4:10 p.m, it was determined that the facility respiratory therapist failed to ensure that meet applicable standards that are required by State or Local Laws related to updated license, updated CPR, updated Influenza vaccines, Hepatitis B vaccine or Hepatitis B title, and job description as follow:

a. One out of eight respiratory therapist CF reviews, does not provide evidence of the professional license (CF #7), the respiratory therapy credential file provide evidence of provisional license #1 and this provisional license number 11277-1 was Expired on April 13, 2017, however this employee has an agreement beginning on March /7/2017 through September / 7/17.

b. Eight out of eight respiratory therapist CF reviews, does not provide evidence of an Influenza vaccination, (CF #1, #2, #3, #4, #5, #6, #7 and #8). The facility does not comply with Department of Health Administrative Order Number 244 of October 10, 2008.

b. One out of eight respiratory therapist CF reviews, does not provide evidence of and updated CPR (CF #8).

c. Two out of eight respiratory therapist CF reviews, does not provide evidence of and updated Job Description (CF #4 and #8).

Based on the observational tour with the facility's educational nurse (employee #49) and facility respiratory therapy supervisor (employee #48), interviews and review of policies/procedures (P&P), it was determined that the facility failed to promote sanitary and safe care through its infection control program in the respiratory therapy department related to maintain a sanitary physical environment in the department and failed to implement policies and procedures that address infection control hospital staff related measures.

Findings include:

1. On 6/20/17 at 9:15 a.m. till 11:45 a.m. during performed the visual Inspection on the Respiratory Therapy Department with the Educational Service Nurse (employee #49) and the Respiratory Therapy Supervisor (employee #48) the following was found:

a The room designated to receive the dirty ventilators to performed cleaning, disinfection and then take the culture after disinfection it was observed that the dispenser lacks of hand paper.

b. The washstand was observed dirty and with black spots. Dust was observed on the interior of the cabinet.

c. Outside of this room a large cardborad box was observed on a top of the regular trash can.

d. On the interior of a room designated to '' Mechanical Ventilators Warehouse '' was observed at right side eleven tanks of '' Nitric Oxide 800 ppm,'' two smalls tanks of '' Nocal N O2 Calibration Gas,'' directly at the floor and around of the tanks was observed a chain with small links. On the top of the tanks four cartoon boxes were observed two of the boxes with '' Regulators kit used to connect at the tanks and the other two boxes with '' Inomax (Nitric Oxide for inhalation product 300-302 800 ppm size D). Various lines used to calibrate the tanks were observed in the top of the boxes. One large tank of air compressed unit 1002 Medical Air USP 2000 psa weigh and one tank of Oxygen Praxair 010063503. All of this tanks lacks of security base.

e. One ventilator 2640 used for adults was observed on a clean area has a label with a date 6/18/17 9:35 p.m. Intensive Unit A room #6 #2640 and signed per employee # 57 however, did not indicated if the ventilator was clean and disinfected and no evidence if the ventilator was cultivated.
According of the Respiratory Supervisor (employee #48) the facility has a label used to identified the ventilators indicated the following: '' Date of culture, Ventilator serial number, Patient's record number, Respiratory therapist's sign and indicated ''Pending to Results ''

However the ventilator did not have this label '' and did assure if the ventilator was clean and disinfecting and if cultivated.

f. Two BPAP's with plastic covers without identification labels and two ventilators without covers and without identification labels were observed on a clean area.

g. A small closet was observed near the room designated to receive the dirty ventilators, this room has a label indicated " Hand washing area '' was observed a dirty washstand, a refrigerator used for the personnel to put dinner the bulb not function, did not have a thermometer and was observed dirty, one microwave on top of the refrigerator with a label indicated '' no sirve '' Not Functioning ,on back of the wall was observed a small blue dispenser without label the Respiratory supervisor stated that the dispenser was used to deposit the used oximeters used for patients on the different areas of the hospital then the personnel discard on this dispenser to recycle. One dirty biohazard trash can and one dirty regular trash were observed on the interior of the closet. Four woods shelves were observed at the left side of the closet on the shelves were observed the following: One cardboard box of Vitalograph .3 liters Precision Syringe Model: 2040 Reference: 36020, Navity articles, aluminum paper, one coffee pot, various used papers, biohazard bags, toaster and a lunch bag. One broom and a dustpan were observed at right side of the closet. The ceiling has a broken acoustic. The area designated to place a bulb located on the ceiling lacks of the cover and exposed electrical cables was observed. The closet was observed with poor cleaning, the floor was very dirty, much dust, black spots and dirty was observed on the interior of this room.

h. At 10:15 a.m. the Medical Surgical and Respiratory Material Storage area was visit and the following was found:

- Forty one (41) bags of Sterile Water for Inhalation 1000 ml. Expired on April / 2017.

- Four (4) packages of Syringes approximately of 50 syringes per package of '' Arterial Blood Samples '' ( 1 ml.wer slip 3.2 IU (N) Heparin no needle ) Expired on May / 2017 Lot: 11195634

i. Two (2) small tanks 25 CF OXME, two (2) cartoon boxes of " Sensor and Reagent Cartridge Instrumentation Laboratory and one (1) cardboard box of Pasive Humity filters (Gibeck Humid) directly at the floor were observed on the supervisor office on 6/20/17 at 10:40 a.m.

j. On 6/20/17 at 10:45 a.m. forty four (44) patients records were observed in a stainless steel open car near the supervisor office in front of the closet designated for personnel to washing hands in open area without security, without privacy and did not comply with HIPPA Law.

The respiratory therapist supervisor (employee #48) was interviewed related to this and he stated: '' The medical record department notified me that the respiratory personnel has incomplete medical records all of the records were brought per the medical record personnel on 6/19/17 to complete. I put them on this area because I do not have space in my office.''

In the first shelve of this stainless steel cart one plastic tray was observed with various respiratory materials the tray lacks of lid. On a second shelve three (3) plastic trays were observed and has a label indicating '' piezas de oxido nitrico, pieces of nitric oxide, lineas gordas fat lines, and blue and red pieces to connected at the oxilator. '' The trays lacks of lid to protect from dust.

k. The respiratory department area including the floor, ceiling, walls and other areas used to maintain the sterile materials, ventilators used for all of the patients to received respiratory services failed to ensure that appropriate standards of practice are followed for infection control practice.

2. On 6/22/17 at 2:00 p.m. during performed the visual Inspection on fourth floor with the Educational Service Nurse (employee #49) and the Respiratory Therapy Supervisor (employee #48) it was observed the that the fourth floor has room the identification label '' Medical surgical room '' on this room was observed a refrigerator used to put the patients and employees foods, a canalization cart, two sphygmomanometers, one scale, a metal cabinet and on the interior were observed isolation masks, ventury mask, spirometers, I.V. solutions, gauzes, syringes, irrigation trays, humidifiers, transfusion lines, oxygen cannulas, condom Foleys, central lines, Foleys and other materials used per the nursing and respiratory personnel.
According of the nurse supervisor and the respiratory therapy supervisor the floor lacks of an individual area for therapy materials and nursing materials and this room used to put all of the materials and equipment used on the department. However, this room was found open without security lock, dust and dirty was observed on the walls and floor. The room did not ensure the quality control and the security of the medical surgical materials, the respiratory therapy materials and equipment and the I.V. infusions located on this room.

Based on a recertification survey, the review of eight medical records, policies/procedures, it was determined that the facility failed to ensure that services are provided in accordance with the physician's orders related to how many minutes was administered the therapy and lacks of how many hours was given, re-assessment post therapy, physician's lack of written respiratory therapy notes in accordance to standards of practice, medical orders not according of policies and procedures for 4 out of 5 clinical records reviewed (RR #54, #55, #56 and #57).

Findings include:

1. Five medical records were reviewed on 6/20/17 thru 6/22/17 from 8:30 a.m. till 3:00 p.m of patients who received respiratory therapy and provided evidence of the following:

a. R.R #54 is an 65 years old female admitted on 5/21/17 at 9:30 p.m. at eight floor (General Medicine) with a diagnosis of Coronary Heart Failure Decompensated (CHF), Respiratory Failure, Diabetes Mellitus and High Blood Pressure and on 5/22/17 was transferring at Intensive Unit Care (ICU). The record was review on 6/22/017 at 1:50 p.m. and reveled that on 5/21/15 at 3:30 p.m. the physician ordered on Emergency Room ABG's then Atrovent therapy 0.02 every 20 minutes per 3 times and the order lacks of route and written when finished notify for reevaluation. On 5/21/017 at 9:00 (not specified if a.m. or p.m.) a physician ordered Atrovent 0.02 n/c every 4 hours the order lacks of per how minutes was given the therapy and per how many hours was given (12, 24 or 72 hours). On 5/23/17 at 11:00 a.m. Atrovent therapy 0.02% nebulizer c/6 hours per 15 minutes and lacks of how many hours was given (12, 24 or 72 hours). On 6/11/17 at 9:00 a.m. and 6/15/17 at 8:00 a.m. Atrovent therapy 0.02% nebulizer c/6 hours per 15 minutes and lacks of how many hours was given (12, 24 or 72 hours).

b. R.R #55 is an 68 years old female admitted on 6/18/17 at 1:50 p. m. per emergency room at floor #8 room 814 B with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Acute Bronchitis. The record was review on 6/20/17 at 1:00 p.m. According of the physician orders on 6/18/17 at 11:30 a.m. on Emergency room the patient received oxygen by nasal cannula at 2 liters/minute and Albuterol 0.83% and Atrovent .02% ventury mask pn x 15-20 q 6 hr. The physician order lacks to written 15-20 (minutes) and the label was not legible. On 6/21/17 at 8:00 a.m. "Respiratory Therapy Medical Order '' was performed and signed per the nurse for Atrovent therapy 0.02% every 6 hours per 15 minutes and lacks of how many hours was given (12, 24 or 72 hours) and Albuterol Sulfate 0.083% /3ml. N/SS every 6 hours by nebulation for 15 minutes, the order lacks of how many hours was given (12, 24 or 72 hours) and the order lacks of the physician signature, license number, date and hour.

c. R.R #56 is an 83 years old female admitted on 6/16/17 at 7:00 p.m. at fight floor with a diagnosis of Asmatic Bronchitis. The record review on 6/20/17 at 2:30 p.m. provided evidence that the physician ordered on 6/16/17 '' Respiratory therapy of Atrovent 0.05 every 4 hours and Pulmicort 0.5 every 12 hours, however the physician order lacks of the hour when he placed the order and physician license number. The order lacks per how many hours 24, 48 or 72 hours, per how many minutes and if was given by nebulation. The order was taken by the nurse (employee #52) on 6/16/17 at 10:40 p.m. and she written " notified '' however did not written the hour of notification and the respiratory personnel who notified. The next re-assessment was performed on 6/20/17 at 7:00 a.m. to continue on Atrovent 0.5 mg. /2.5 ml. (premix) every 6 hours by nebulization for 15 minutes per 72 hours and Pulmicort 0.5 mg./2 ml. every 12 hours by nebulization for 15 minutes per 72 hours. The respiratory therapy medical order lacks of the physician signature, license number, date and hour of the order.

d. R.R #57 is an 82 years old female admitted on 6/13/17 at 11:12 a.m. with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Clinical Sepsis. The record was review on 6/22/017 at 8:15 a.m. and no evidence on the initial orders written per the physician on Emergency Room. On 6/13/17 at 10:10 a.m. a physician ordered '' Atrovent q 2 hr. x 3 then q 4 hr.'' the order lacks to specify the percent of the Atrovent, route, per how minutes if 15 or 20 minutes and lacks per of how many time was given (12, 24 or 72 hours). The '' Respiratory Therapy Medical Order '' was performed and signed per the nurse for Atrovent therapy 0.02% every 4 hours per 15 minutes and lacks of how many hours was given (12, 24 or 72 hours) , the order lacks of the physician signature, license number, date and hour.

Facility policies and procedures reviewed on 6//11 at 11:00 am stated that the written order for aerosolized drug therapy should contain: Name of medication, administration route, volume or quantity to be administered, duration of medication, special precautions /directions and the number of times a day to be administered.

Based on five medical clinical records reviewed and interviews with the nursing staff on a re-certification survey, it was determined that the facility failed to ensure that the organization of the respiratory care services is appropriate to the scope and complexity of the services, offered for 4 out of 5 records reviewed (R.R #54, #55, #56 and #57) who received respiratory treatment by the respiratory care staff.

Findings include:

During an interview with the respiratory supervisor (employee #48) on 6/20/17 at 10:30 a. m. he stated "the respiratory personnel are responsible for administering respiratory therapy. The facility has a contracted personnel to provide the services seven days a week twenty four hours. The respiratory therapists covered three shifts and divided from 6:00 a. m. till 2:00 p. m. first shift, second shift covered from 2:00 p. m. till 10:00 p. m. and the third shift covered from 10:00 p. m. till 6:00 a. m".

1. Five medical records were reviewed with the nurse supervisor and the educational nurse on 6/20/17 from 1:00 p.m. till 3:30 p.m., 6/21/17 from 8:30 a.m. till 11:55 a.m. and 6/21/17 from 8:30 a.m. till 11:45a. m. and 6/22/17 from 8:30 a.m. till 12:30 p.m. of patients that were receiving respiratory therapy and reveled the following:

a.R.R #54 is a 65 years old female admitted on 5/21/17 at 9:30 p.m. at eight floor (General Medicine) with a diagnosis of Coronary Heart Failure Decompensated (CHF), Respiratory Failure, Diabetes Mellitus and High Blood Pressure and on 5/22/17 was transfer to Intensive Unit Care (ICU). The record was review on 6/22/017 at 1:50 p.m. and reveled that on 5/21/15 at 3:30 p.m. the physician ordered on Emergency Room ABG's then Atrovent therapy 0.02 every 20 minutes per 3 times.

According of the respiratory therapist progress notes the patient received the first treatment at 4:10 p.m., at 4:30 p. m. and at 5:00 p.m. At 5/21/17 at 9:00 p.m. the physician ordered '' Atrovent 0.02 every 4 hours signed per the nurse at 10:00 p.m. The first treatment of Atrovent was administered according of the respiratory therapist progress notes on 5/22/17 at 8:00 a.m., 12:00 p.m. and 7:00 p.m. according of the respiratory note the patient received power nebulizer 0.5 mgs. Pulmicort and 0.02% Atrovent and 3 ml. N/SS and ABG's at room air was taken.
On 5/22/17 the patient was transferred to Intensive Unit Care and continue with a respiratory therapy treatment however, the respiratory therapist progress notes revealed that the therapies were administered but not every four hours, the notes reveled that was administered between one hour before and 3 hours later.

On 5/23/17 at 9:30 a.m. a respiratory note revealed that the patient was entubated orotraqueal and connected to a ventilator.

On 6/22/17 during the record review revealed that the patient continue on mechanical ventilator B-840 orotraqueal via and continue with power nebulizer with 0.02 Atrovent every 6 hours however the '' Respiratory Therapist Progress Notes '' revealed that the patient did not received the respiratory therapies with Atrovent 0.02% every 6 hours according of the physician orders, the patient received the respiratory therapies with between 1 till 3 or more hours before or after of the hour that supposed to received. The signature, documentation and other importance documentation performed per the respiratory therapist were not legible.

b. R.R #55 is an 68 years old female admitted on 6/18/17 at 1:50 p. m. per emergency room at floor #8 room 814 B with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Acute Bronchitis. The record was review on 6/20/17 at 1:00 p.m. According of the physician orders on 6/18/17 on Emergency room the patient received oxygen by nasal cannula at 2 liters/minute and Albuterol 0.83% / 3 ml.of Saline Solution every 20 minutes per 3 times.

According of the therapy progress note the patient received the first therapy at 9:30 a. m., the second therapy was received at 10:00 a. m. and the third therapy was administer at 10:30 a. m. At 11:15 a. m. ABG's was taken per the respiratory therapist according of the physician order.

The physician orders for admission was placed at 11:30 a.m. signed per the emergency room nurse (employee #50) at 12:00 p.m. and the physician ordered Albuterol 0.83% and Atrovent .02% with power nebulizer every 15-20 minutes every 6 hours, the order was signed per emergency room nurse (employee #50) at 12:00 p.m.

According of the therapy progress notes the patient received the first therapy at 2:00 p. m. three hours and thirty (3 hours 30 minutes) before not according with the physician order written at 11:30 a. m.

The next therapy was at 8:00 p. m. and was given at 6:00 p. m. two hours before. The next therapies was given on 6/19/17 at 12:44 a.m., 7:00 a.m., 1:00 p. m. and 8:00 p.m. On 6/20/17 the therapy was administered at 12:30 a.m., at 6:30 a.m., 12:30 p.m. and 6:30 p.m.

No evidence on the patient record if the patient received therapies on 6/21/17 at 12:30 a.m. On 6/21/17 at 1:00 a.m. a physician ordered by telephone call repeat a respiratory therapy in one hour and no evidence on the patient record if the patient received the respiratory therapy.

On 6/21/16 at 8:30 a.m. a respiratory note was performed per therapist (employee #55) and reveled '' patient quiet, received a respiratory therapy however, did not written at what hour administered the therapy (the other information written per the respiratory therapist was legible).

On 6/21/17 at 8:50 a.m. a physician progress note reveled: '' The patient has respiratory distress temporal last night.'' At 9:00 a.m. a physician ordered Chest X Ray PA and Lateral and ABG's.

The form used for '' Respiratory Therapy Medical Order '' reveled that on 6/21/17 at 8:00 a.m. the nurse signed the respiratory therapy order for Atrovent 0.5 mgs./2.5 ml. every 6 hours, Albuterol Sulfate o.083%/3ml.NSS every 6 hours per 15 minutes by nebulization however not established per how many hours the patient was received the therapies 24, 48 or 72 hours. The orders lacks of the physician signature, license number, date and hour when ordered the treatment. No evidence on the patient record the daily chart respiratory treatment form.

c. R.R #56 is an 83 years old female admitted on 6/16/17 at 7:00 p.m. at fight floor with a diagnosis of Asthmatic Bronchitis. The record review on 6/20/17 at 2:30 p.m. provided evidence that the physician ordered on 6/16/17 '' Respiratory therapy of Atrovent 0.05 every 4 hours and Pulmicort 0.5 every 12 hours, however the physician order lacks of the hour when he placed the order and physician license number. The order lacks per how many hours 24, 48 or 72 hours, per how many minutes and if was given by nebulation.

The order was taken by the nurse (employee #52) on 6/16/17 at 10:40 p.m. and she written " notified '' however did not written the hour of notification and the respiratory personnel who notified.

The next re-assessment was performed on 6/20/17 at 7:00 a.m. to continue on Atrovent 0.5 mg./2.5 ml. (premix) every 6 hours by nebulization for 15 minutes per 72 hours and Pulmicort 0.5 mg./2 ml. every 12 hours by nebulization for 15 minutes per 72 hours. The respiratory therapy medical order lacks of the physician signature, license number, date and hour of the order. The nurse signed the order however the sign and the license number were illegible.

According to the form used per the respiratory care therapist '' progress notes '' the patient received the respiratory therapies on 6/16/17 at 3:30 p.m., at 9:00 p.m. (2 hours later), 6/17/17 at 1:00 a.m., at 6:30 a.m. (1 hour 30 minutes later), at 12:30 p.m. (2 hours and 30 minutes later), on 6/18/17 at 1:00 a.m. (1 hour later), at 5:00 a.m. (1 hour later), at 8:00 a.m. (1 hour before), at 12:30 p.m., at 5:00 p.m. (1 hour later), at 9:00 p.m. (1 hour later), on 6/19/17 the therapies was administered every 4 hours. On 6/20/17 at 1:00 a.m. the physical therapy progress note revealed that the '' power nebulizer on Hold '' then the next therapy was given at 6:30 a.m., at 12:30 p.m. and at 6:30 p.m.

According of the facility policies and procedures and interview with the respiratory supervisor (employee #48) on 6/20.17 at 1:00 pm the physician re-evaluate the patient and writes the orders every 72 hours.

However, this patient initiated the respiratory care treatment on 6/16/17 and no evidence of re-assessment by the physician. The Respiratory Therapy Medical Standing orders was performed by the nurse on 6/20/17 at 7:00 a.m. not per physician, the order was signed per the nurse.

During reviewed the patient record on 6/20/17 at 1:30 p.m. provide evidence that the physicians, nurses and respiratory therapist documentation was illegible.

d. R.R #57 is an 82 years old female admitted on 6/13/17 at 11:12 a.m. with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Clinical Sepsis. The record was review on 6/22/017 at 8:15 a.m. and no evidence on the initial orders written per the physician on Emergency Room.
According of the respiratory therapist progress notes the patient received the first treatment at 3:00 a.m., at 3:20 a. m. and at 3:45 a.m. On 6/13/17 at 10:10 a.m. the physician ordered '' Atrovent every 2 hours per 3 then every 4 hours '' the order lacks of the dose of Atrovent, the time, liters and what kind of method used if per power nebulizer.

According of the respiratory therapist progress notes the patient received the first treatment at 10:15 a.m., at 12:15 p.m. however, the respiratory progress notes revealed that the patient did not received the third therapy at 2:15 p.m. On 6/14/17 at 12:10 (did not specified if a.m. or p.m) a new telephone order for respiratory therapy written per the nurse (employee #54) was written for Atrovent 0.02% per power nebulizer every 4 hours.
Acording of the respiratory progress notes the next therapy was given on 6/14/17 at 1:00 a.m. (12 hours and 45 minutes later) not according with the physician initial order to continue every 4 hours.

According of the respiratory therapist progress notes the patient received the first treatment on 6/14/17 at 1:00 a.m., at 8:00 a.m. (2 hours later), at 1:00 p.m. (1 hour later), at 5:00 p.m. and at 9:00 p.m. On 6/15/17 at 1:00 a.m., at 8:00 a.m. (2 hours later), at 1:00 p.m. (1 hour later), at 4:00 p.m. (1 hour before) and at 8:00 p.m. On 6/16/17 at 1:00 a.m., at 5:00 a.m., at 8:20 a.m. (10 minutes before), at 12:30 p.m., at 5:00 p.m. and at 9:00 p.m. On 6/17/17 at 1:00 a.m., at 5:00 a.m., at 8:00 a.m. (1 hour before), at 12:30 p.m. the respiratory therapy progress note revealed that the patient did not received the treatment and was notified to the register nurse ( employee #53) and until 6/17/17 at 12:30 p.m. The respiratory progress notes revealed that the therapies was '' Hold''.
On 6/18/17 the '' Respiratory Therapy Medical Order '' revealed that the physician reevaluated the patient and ordered to continue with respiratory therapies with Atrovent 0.02% every 4 hours by p/n per 15 minutes for 72 hours however, the order lacks of the license number and the hour when the physician signed the order, only specified a.m. and lacks of the register nurse signature, license number, date and hour.

The patient record revealed that the patient did not received respiratory therapy treatment per 24 hours. The next treatment was administered on 6/19/17 at 1:00 a.m. (24 hours later), then at 5:00 a.m., at 8:00 a.m., 12:30 p.m., at 4:40 p.m. and at 8:30 p.m. On 6/20/17 at 1:15 a.m. (15 minutes later), at 5:00 a.m., at 9:30 a.m., at 1:30 p.m., at 5:00 p.m. and at 9:00 p.m. On 6/21/17 the '' Respiratory Therapy Medical Order '' revealed that the nurse signed a new order for patient to continue with respiratory therapies with Atrovent 0.02% every 4 hours by p/n per 15 minutes however did not established per how many hours and lacks of the hour when the nurse signed only mark p.m.

The order was not signed per the physician and lacks of the license number, the date and the hour. The patient received the respiratory therapies on 6/21/17 at 1:00 a.m., at 5:00 a.m., at 8:00 a.m. (3 hours before), at 12:00 p.m., at 4:00 p.m. and at 8:00 p.m. not according of the facility policies and procedures.