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Based on complaint investigation ACTS Intake PR00000580 review of fifty two closed and active records reviewed (R.R), policies/procedures manual with the emergency nursing supervisor (employee # 4), emergency room medical director (employee #1) and interviews, it was determined that the facility failed to ensure that complete documentation was maintained of every case who visit emergency room department on 11 out of 52 records reviewed ( R.R. # 4, # 7, # 8, # 18 # 25, # 28 , # 29, # 30, # 36,# 37 and # 39)and facility failed to ensure that two (2) physicians are licensed in accordance with state and local laws related to the renew of the physicians license, Health Certificate and Influenza Vaccine for 2 out 17 C.Fs (C.Fs #4 and #5).

Findings include:
1. A mechanism to ensure that personnel maintain appropriate and pertinent documentation of cases that visited emergency room department and receive services and treatment was not promoted or followed. The following findings were identified during survey procedures on 11/15/16 from 8:00 am through 3:30 pm and discussed with a physician (employee # 1) who was in charge of Emergency Room Sub Director duties on 11/16/16 at 10:45 am:
Cases #7, #25, # 28 and # 29 who elopes from emergency room as documented on the emergency room log registry book. However information who describes circumstances where patients elopes from the area were not found described on the medical record.
Facility policy ( " Abandono de Sala de Emergencia sin Exonerar Elopement " revised on April 2015") related with patient elopement from emergency room stated that personnel ( physicians, register nurses ) must call patient on three different occasions within intervals of 15-20 minutes and if patient did not answer document that patient elopes from emergency room . However none of the cases had the required documentation.
All elopement cases cited previously were discussed with a physician (employee # 1 who was in charge of Medical Director Duties on 11/16/16 10:45 am.
2. A mechanism to ensure that personnel maintain appropriate and pertinent documentation of cases that leave Against Medical Advice (AMA) from emergency room was not promoted or followed. The following findings were identified during survey procedures on 11/15/16 from 8:00 am through 3:30 pm and discussed with a physician who was in charge of Medical Director duties on 11/16/16 at 10:45 am:
Cases # 4, # 8 and # 30 leaves from emergency room Against Medical Advice (AMA) as documented on the emergency room log registry book. However information who describes details of the care provided before patient decision to leave the emergency room were not found described on the medical record.
All cases that leaves Against Medical Advice ( AMA ) cited previously were discussed with a physician ( employee # 1 ) who was in charge of Medical Director duties on 11/16/16 10:45 am.
3. A mechanism to ensure that personnel maintain appropriate and pertinent documentation of cases who are evaluated and for whom care is provided in the emergency room was not promoted or followed. The following findings were identified during survey procedures on 11/15/16 from 8:00 am through 3:30 pm and discussed with a physician who was in charge of Medical Director duties on 11/16/16 at 10:45 am:
Cases #36, #37 and #39 clinical course and medical decision documentation lacks of date and hour of cases evaluated on the initial assessment and the re-assessment.
Facility physicians failed to include date and hour on assessment formats that include clinically relevant documentation of aspects of the patient encounter including laboratory, radiologic, and other testing results.
All cases cited with lack of date and hour on the medical decision documentation format were discussed with a physician ( employee # 1)who was in charge of Medical Director duties on 11/16/16 10:45 am.
4. A mechanism to ensure that personnel maintain appropriate and pertinent documentation of cases that were transferred to another facility, to receive care and services was not promoted or followed. The following findings were identified during survey procedures on 11/15/16 from 8:00 am through 3:30 pm and discussed with a physician who was in charge of Medical Director duties on 11/16/16 at 10:45 am:
Case #18 is a 26 years old male, who visited the Emergency Room on 09/17/16 at 6:33 pm; patient chief complaint was Abdominal Pain. The case was classified as an urgent case and sent to the waiting room. Physician evaluates the patient on 09/17/16 at 8:20 am; on the physician evaluation patient refers abdominal pain, head pain, anorexia and episodes of chills. Physician order bed rest, NPO, .9 nss 500 ml to run at 70 ml hour, Demerol 25 mgs & Phenerghan 25 mgs intramuscular , CBC, BMP, Bilirubin levels , Amylase, Lipase, Liver profile, EKG, Chest Plate and Abdominal CT. Patient CT results( Appendicitis ) were notified to the physician in charge on 09/17/16 at 12:30 PM, case was re-evaluates by physician who begin made arrangements to transfer the patient because the emergency room does not have surgeon on call to refer the case.
On the physician emergency medical record, physician in charge documents five phone calls to arrange transfer of this case due to lack of surgeon on call. However this physician did not include the hour were each one of the phone calls begin and details and reasons why the case is not accepted on five hospitals.
Case was successfully transferred on 09/17/16 at 4:00 pm. Facility physician failed to include in this case all communication details with other providers contacted when trying to transfer a patient to another facility.
5. A mechanism to ensure that personnel provide pertinent information, to patients and relatives related with patient health status and treatment provided based on patient health condition evolution was not promoted or followed. The following findings were identified during survey procedures on 11/15/16 from 8:00 am through 3:30 pm and discussed with a physician who was in charge of Medical Director duties on 11/16/16 at 10:45 am:
On the medical record review of case # 18 performed on 11/16/16 at 10:45 am with emergency room medical director revealed that on 9/17/16 at 9:00 am emergency room physician in charge of the case provide information to patient and relatives related with procedures performed diagnostic tests and medications administered by the nurse in charge of the case. In addition to this as evidence in the " Evaluacion Fisica y Certificacion del Medico/Traslado Apropiado " aproximately at 4:00 pm the patient itself sign the consent for transfer and was informed that the reason for transfer was that he was diagnosed with Appendicitis. However not evidence was found documented on the medical record after 9:00 am related information given to patient or relatives of the reason for the acute abdominal pain. Physician in charge document abdominal CT results and reason to order antibiotics, but no information was found documented of information provided to patient and relatives.
6. A mechanism to ensure that facility perform quality assessment check of the appropriateness of the emergency room log registry book documentation were not followed.

Emergency room manager (employee # 2) stated on interview on 11/16/16 at 10:00 am that facility did not perform quality assessment to ensure that emergency room log registry book did not have crossing out marks and that personnel did not use correction fluid or white-out .


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7. Facility failed to ensure that two (2) physicians are licensed in accordance with state and local laws related to the renew of the physicians license, Health Certificate and Influenza Vaccine for 2 out 17 C.Fs (C.Fs #4 and #5).
On 11/16/16 at 11:00 am seventeen credential files were reviewed.

a. Two out of seventeen credential files did not have evidence of the updated physicians license (C.F #4 and #5).

b. One out of seventeen credential files did not have evidence of influenza vaccine updated
(C.F #4).

c. One out of seventeen credentials files did not have evidence of the Health Certificate. (C.F #4).

8. Facility failed to ensure that physicians are licensed in accordance with state and local laws had Health Certificate and Influenza Vaccine.