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Based on the review of institutional plan documents, 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 06/29/16 at 4:00 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.

Based on the review of the Facility Contracted Service with the facility's Administrator (employee #16), and interview of Finance Director (Employee #15) and Administrative Assistant (Employee #17), it was determined that the Governing Body is not notified about services furnished under contract at this facility to ensure that these services comply with all applicable conditions of participation and standards for 87 out of 107 contracted services.

Findings include:

1. Contracted service list was reviewed on 9/28/10 at 9:00 am with the Administrative Assistant (Employee #17) and was found evidence of non-updated contracts.

a. The contract with Suar-Med Ambulance Service that had expired the ambulances certification for three units (4033-CP expired 06/19/16, 6902-CP expired 3/24/16, and 1693-CP expired 08/25/12). However, Administrative Assistant (employee #17) provides evidence of updated Ambulance unit ' s certifications of the contract.

b. The contract with Geneizaak Medical Transit, Inc. had staff credential that were not updated (Paramedic (T.E.M) #1 license expired 01/15/16, T.E.M #2 license expired 05/26/15, T.E.M #3 license expired 03/18/15, and T.E.M #4 license expired 04/20/16). However, Administrative Assistant (employee #17) provides evidence of updated staff credentials of the contract.

c. It was found evidence that the contract of Radiology and Computerizes tomography (CT) was expired since 2014. The evidence in the contract specifies that de duration of the contract is for one year. When discussed with the facility's Administrator (employee #16) and Finance Director (Employee #15), the facility's Administrator (employee #16) state: It seems the contract does not included the automatic renovation after the first year term ". The Finance Director (Employee #15) stated: " We can make a new contract right now " .

2. A list "Contracted Suppliers " was provided on 6/28/16 at 9:00 am, the list included one hundred and seven (107) services provided at the facility under contract (which include: Ambulances, Extermination, Generators, Bio-hazardous Waste, Elevators, Fire Alarm System, Medical Equipment, Cistern, Air Conditioner, Radiology, Security, laboratory, between others).

a. It was found that 87 of 107 services contracted by the facility were expired and did not show evidence of an automatic renewal after the expiration date of the contract.

b. It was found that 13 of 107 services contracted by the facility did not show evidence of the expiration date of the contract.

Based on sixty-eight medical record reviewed, it was determined that the facility failed to provide Medicare recipients "An Important Message from Medicare" (IM) two days before discharge to execute their rights to appeal facility ' s discharge for 5 out of 68 records reviewed (RR) (RR. #28, #29, #31, #32 and #33).
Findings include:

1. R.R. #32 is a 94 years old male who is admitted on 12/26/15 with a diagnostic of Acute Respiratory Failure, Acute Kidney Failure, Acute Myocardial Infarction, Left Ventricular Failure and Mechanical Ventilator. The record was review on 06/28/16 at 8:41 am. The Important Message from Medicare was provided upon admission however the two days prior discharge Important Message from Medicare was not provide. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

2. RR #33 is a 66 years old female who was admitted on 01/06/16 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Obesity and Mechanical Ventilator. The record was reviewed on 06/28/2016 at 9:09 am. The Important Message from Medicare was provided upon admission however the two days prior discharge Important Message from Medicare was not provide. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

3. R.R. #29 is a 65 years old male who is admitted to on 12/29/15 with a diagnosis of Gastrointestinal Hemorrhage, Diverticulitis, Hepatic Failure and Alcohol Dependence. The record was reviewed on 06/28/2016 at 9:57 am. The Important Message from Medicare was provided upon admission however the two days prior discharge Important Message from Medicare was not provide. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

4. R.R. #28 is a 72 years old male who is admitted on 03/20/16 with a diagnosis of Sepsis, Acute Kidney Failure, Diabetes type II Alzheimer, Dementia and Bed Confinement. The record was reviewed on 06/28/2016 at 11:20 am. The Important Message from Medicare was provided upon admission however the two days prior discharge Important Message from Medicare was not provide. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

5. R.R. #31 is an 80 years old female who is admitted on 12/19/16 with a diagnosis of Acute appendicitis, Atelectasis and Pleural Effusion. The record was reviewed on 06/28/16 at 11:35 am. The Important Message from Medicare was provided upon admission however the two days prior discharge Important Message from Medicare was not provide. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

Based on review of four grievance reports with the Quality Assessment Officer (employee #9) it was determined that the facility s ' governing body failed to ensure the effective operation of the grievance process, and must review and resolve grievances and inform each patient the result of the investigation.

Findings included:

During the review of four grievance report with the Quality Assessment Officer (employee#9) from 6/29/16 at 3:30 pm thru 5:00 and 6/30/16 at 9:00 am 2:00 pm the following was identified:

1. On 5/25/16 the facility receive a grievance report from Quality Improvement Organization LIVANTA related to patient management. This report was evaluated by the quality assessment officer (employye#9) that is the person on charge of Risk management program. On 5/31/16 she send this report to the executive committee to be evaluated and contact LIVANTA to discusses the case and send a report of the investigation between 15 days. On 6/3/16 the employee #9 follow up with the Financial Director employee #15, and response that the case was discussed with the medical director or the internal medicine chief. On 6/28/16 the assessment officer (employee #9) receives from LIVANTA for the attention and immediately action to the concern before 7/1/16.

a. The facility failed to meet with the time frame established by LIVANTA.

2. On 4/12/16 a patient daughter present a grievance with concern related to medical management on Emergency Room, the assessment officer (employee #9) started the investigation. On 4/15/16 at 2:00 pm was send by email the nursing director, interview with nursing personnel of the Emergency Room (ER), to the President of the Med Solution (arrangement of medical group for the ER). On 5/6/16 at 10:38 am the Quality coordinator (employee#9) send an e-mail to the Financial Director, to the bookkeeper of Medical Group of ER and to the Medical Director of the medical Group of ER to inform them that the interview of the facultative physician of the case of the grievance is not received accordance to the meeting at the ER committee discussion on 4/27/16.

a. On 6/29/16 at 4:55 pm during interview with employee #9 states that she does not have the peer review of the case and the interview of the physician by the Medical Group ER Director.

3. On 4/11/16 at 9:00 am an employee present a grievance related to two ER patient physician management. On 4/11/16 at 11:01 am the employee #9 sent by e-mail to the Financial Director (employee #15) related to the employee grievance and inform that this case is related to clinical physician management is to be refer to the medical director or authorized facultative to performed a peer review of both cases.

a. On 6/30/16 at 10:00 am during the review of the grievance, no evidence was found related to the grievance investigation, interview with the physician involve in this case and the resolution inform.

b. On 6/30/16 at 10:30 am was provided an document with the plan of action to resolve the grievance, however no evidence was provide related to the physician interview and record peer review of this case.

c. No evidence was found that this case be evaluated accordingly with the abuse and neglect protocol.

4. No evidence was provided related to a grievance committee, their member and the minutes of the reunion performed to discusses each grievance investigation.

5. The facility failed to review, investigate, and solve each patient's grievance within a reasonable time frame accordance to their Grievance protocol reviewed on 6/29/16 4:00 pm that establish that all grievance has to be investigate with a plan of action a resolution and the complainant be notified about the resolution within 30 calendar days of be submitted the grievance.

6. The facility failed to manage the grievance investigation protocol accordance to facility police and procedure.

Based on review of four grievance report with the Quality Assessment Officer (employee #9), it was determined that he facility governing body failed to ensure that the grievance process meets with specify time frames for review of the grievance and the provision of a response.

Findings include:

During the review of four grievance report with the Quality Assessment Officer (employee#9) from 6/29/16 at 3:30 pm thru 5:00 and 6/30/16 at 9:00 am 2:00 pm the following was identified:

1. On 5/25/16 the facility receive a grievance report from Quality Improvement Organization LIVANTA related to patient management. This report was evaluated by the quality assessment officer (employee #9) that is the person on charge of Risk management program. On 5/31/16 she send this report to the executive committee to be evaluated and contact LIVANTA to discusses the case and send a report of the investigation between 15 days. On 6/3/16 the employee #9 follow up with the Financial Director employee #15, and response that the case was discussed with the medical director or the internal medicine chief. On 6/28/16 the assessment officer (employee #9) receives from LIVANTA for the attention and immediately action to the concern before 7/1/16.

a. The facility failed to meet with the time frame established by LIVANTA.

2. On 4/12/16 a patient daughter present a grievance with concern related to medical management on Emergency Room, the assessment officer (employee #9) started the investigation. On 4/15/16 at 2:00 pm was send by email the nursing director interview with nursing personnel of the Emergency Room (ER) to the President of the Med Solution (arrangement of medical group for the ER). On 5/6/16 at 10:38 am the Quality coordinator (employee#9) send an e-mail to the Financial Director, to the bookkeeper of Medical Group of ER and to the Medical Director of the medical Group of ER inform them that the interview of the facultative physician of the case of the grievance not be received accordance to the meeting ER committee discussion on 4/27/16.

a. On 6/29/16 at 4:55 pm during interview with employee #9 states that no have the peer review of the case and the interview of the physician by the Medical Group ER Director.

3. On 4/11/16 at 9:00 am an employee present an grievance related to two ER patient physician management. On 4/11/16 at 11:01 am the employee #9 send by e-mail to the Financial Director (employee #15) related to the employee grievance and inform that this case related to clinical physician management is to be refer to the medical director or authorized facultative to perform an peer review of both cases.

a. On 6/30/16 at 10:00 am during the review of the grievance, no evidence was found related to the grievance investigation, interview with the physician involve in this case and the resolution inform.

b. On 6/30/16 at 10:30 am was provided an document with the plan of action to resolve the grievance, however no evidence was provide related to the physician interview and record peer review of this case.

c. No evidence was found that this case be evaluated accordingly with the abuse and neglect protocol.

4. No evidence was provided related to a grievance committee, their member and the minutes of the reunion performed to discusses each grievance investigation.

5. The facility failed to review, investigate, and solve each patient's grievance within a reasonable time frame accordance to their Grievance protocol reviewed on 6/29/16 4:00 pm that establish that all grievance has to be investigate with a plan of action a resolution and the complainant be notified about the resolution within 30 calendar days of be submitted the grievance.

6. The facility failed to manage the grievance investigation protocol accordance to facility police and procedure.

Based on review of four grievance report with the Quality Assessment Officer (employee #9) it was determined that he facility failed to ensure that an resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

During the review of four grievance report with the Quality Assessment Officer (employee#9) from 6/29/16 at 3:30 pm thru 5:00 and 6/30/16 at 9:00 am 2:00 pm the following was identified:

1. On 5/25/16 the facility receive a grievance report from Quality Improvement Organization LIVANTA related to patient management. This report was evaluated by the quality assessment officer (employee#9) that is the person on charge of Risk management program. On 5/31/16 she send this report to the executive committee to be evaluated and contact LIVANTA to discusses the case and send a report of the investigation between 15 days. On 6/3/16 the employee #9 follow up with the Financial Director employee #15, and response that the case was discussed with the medical director or the internal medicine chief. On 6/28/16 the assessment officer (employee#9) receives from LIVANTA for the attention and immediately action to the concern before 7/1/16.

a. The facility failed to meet with the time frame established by LIVANTA.

2. On 4/12/16 a patient daughter present a grievance with concern related to medical management on Emergency Room, the assessment officer (employee #9) stated the investigation. On 4/15/16 at 2:00 pm was send by email the nursing director interview with nursing personnel of the Emergency Room (ER) to the President of the Med Solution (arrangement of medical group for the ER). On 5/6/16 at 10:38 am the Quality coordinator (employee#9) send an e-mail to the Financial Director, to the bookkeeper of Medical Group of ER and to the Medical Director of the medical Group of ER inform them that the interview of the facultative physician of the case of the grievance not be received accordance to the meeting ER committee discussion on 4/27/16.

a. On 6/29/16 at 4:55 pm during interview with employee #9 states that no have the peer review of the case and the interview of the physician by the Medical Group ER Director.

3. On 4/11/16 at 9:00 am an employee present a grievance related to two ER patient physician management. On 4/11/16 at 11:01 am the employee #9 send by e-mail to the Financial Director (employee #15) related to the employee grievance and inform that this case related to clinical physician management is to be refer to the medical director or authorized facultative to perform a peer review of both cases.

a. On 6/30/16 at 10:00 am during the review of the grievance, no evidence was found related to the grievance investigation, interview with the physician involve in this case and the resolution inform.

b. On 6/30/16 at 10:30 am was provided an document with the plan of action to resolve the grievance, however no evidence was provide related to the physician interview and record peer review of this case.

c. No evidence was found that this case be evaluated accordingly with the abuse and neglect protocol.

4. No evidence was provided related to an grievance committee, their member and the minutes of the reunion performed to discusses each grievance investigation.

5. The facility failed to review, investigate, and solve each patient's grievance within a reasonable time frame accordance to their Grievance protocol reviewed on 6/29/16 4:00 pm that establish that all grievance has to be investigate with a plan of action a resolution and the complainant be notified about the resolution within 30 calendar days of be submitted the grievance.

6. The facility failed to manage the grievance investigation protocol accordance to facility police and procedure.

Based on observations and interviews, it was determined that the facility failed to promote the
right of each patient/relative to know and distinguish personnel in charge of their direct care and employees who work in other hospital areas, to ensure safety and consistency with a professional health care environment and to follow guidelines for safety management in the endoscopic procedure room .

Findings include:

1. A mechanism to ensure that facility establishes dress code guidelines to ensure confidence and professional image are not promoted not performed. The following were identified during survey procedures on 6/27/12 through 6/30/16 from 8:35 am through 3:30 pm:

a. Three health care employees were observed giving direct care (triage, administering medications and performing phlebotomy) to patients who visited emergency room department. Each one of those employees were observed using scrub sets of different colors

Emergency room nursing supervisor (employee #7) stated on interview on 6/29/16 at 1:30 pm that personnel use scrub set of different color because there is not a color scheme for uniforms established by the administration of the facility.

Emergency room patient relative stated during an interview on 6/27/16 at 10:49 am that he did not know who were the nurses, respiratory personnel and physicians because they use multi-color shaded uniforms.

Emergency room patient stated during an interview on 6/27/16 at 1:54 pm that he could not identify who are the direct care health personnel who are responsible for his care because they were not in a coordinated professional appearance who permit that patients and relatives identified them as emergency room department personnel.

b. Six medical-surgical ward health care employees were observed giving direct care (changing bed sheets, providing patient care and administering medications) these employees are wearing multi-color shaded scrubs sets and uniforms.

Relative of a patient admitted to the medical-surgical ward stated on interview on 6/28/16 at 10:30 am that hospitals must establish white scrubs as the standard nursing uniform. Because the white color not only indicates purity and service, but also looks traditional.

c. During food tray line serving on 6/29/16 at 11:00 am with kitchen supervisor (employee #4) it was identified that two employees are wearing gray color scrub sets and one employee are wearing a white chef coat. However one of the employee who was locating food trays on the delivery cart was observed wearing multi-color shaded scrubs set.

Administrative dietitian (employee #3) stated on interview on 6/28/16 at 3:30 pm that to the kitchen personnel facility provide 4 sets of gray color scrub sets or uniforms every 2 two years. She also stated that if before those 2 years uniforms are no longer in good condition employees buy other scrub sets or uniforms but they usually buy those uniforms in a different color to differentiate from the ones provided by the facility.

Relative of a patient admitted to the intensive care unit stated on interview on 6/28/16 at 1:00 pm that if nursing staff and other health care professionals are all allowed to wear different color scrubs sets and uniforms, patients can get very confused. Because it ' s hard to distinguish who the nurses are; patients under treatment cannot be expected to remember faces and names. Patient ' s need a point of reference and a standard color use of a uniform could provides this reference. Elderly patients, especially, can get very confused with different uniforms and scrubs and struggle to understand whom to approach.

Relative of a patient who was receiving services on the intensive care unit stated on interview on 6/29/16 at 1:25 pm that the establishment of standard dress code color' s for facility employees helps patients to differentiate between nurses, doctors, escorts, food services personnel and respiratory therapy personnel. She also stated that a regulated dress code color makes the health care facility look professional and reliable; giving patients the much needed boost of confidence.

A patient who receives services at the emergency room stated on interview on 6/30/16 at 10:00 am that personnel who provide care to him are wearing scrubs in different colors. He does not know if they are register nurses or licensed practical nurses because he assumed that nurses use the traditional white uniforms.

A patient who receives services at the emergency room stated on interview on 6/30/16 at 11:50 am that if not white, then nurses should be issued uniforms of standard colors and fits. She said that a well fitting scrub top and pants neatly pressed, this indicates that the person is a member of the nursing staff.
2. A mechanism to ensure that facility follows guidelines for safety management in the endoscopic procedure room are not promoted not performed. The following was observed during survey procedures on 6/27/12 through 6/30/16 from 8:35 am through 3:30 pm:
a.Endoscopic procedure room bathroom door were observed with holes and signs of woodworm, with live infestation showing powder (feces) around the holes.
b. A stretcher located on this procedure room was observed with orange-brown coloring on the surface and edges. This oxidation or rusting does not permit complete cleaning, encourage the growth of bacteria and may harm patient skin if contact with those areas.
c. Pathogen transmission prevention plan (hand hygiene) Written policies and procedures for staff use of personal protective equipment (PPE) while performing endoscopic procedures were not available to be review.

d. Reprocessing protocol or policies based on infection control standards of practice and recommendation of the manufacturer for the endoscopes were not available to be review.
e. Sedation and analgesia protocol and polices for patients undergoing endoscopic procedures were not available to be review.

f. Adherence to safe medication administration practices established by the facility, policies and procedures for infectious material cleaning and decontamination; terminal cleansing plan and protocol for reusable medical equipment polices were not available to be review.

g. Policies for safety considerations for sedation related environments, equipment, medications and patient monitoring were not available to be review.

Based on sixty eight records reviewed (R.R) review of policies and procedures and interview with the Quality Coordinator (Employee #9), it was determined that the facility failed to include a written care plan for restrain in 5 out of 68 records reviewed (RR) (RR. #28, #29, #31, #32 and #33).

Findings include:

1. R.R. #32 is a 94 years old male who is admitted on 12/26/15 with a diagnostic of Acute Respiratory Failure, Acute Kidney Failure, Acute Myocardial Infarction, Left Ventricular Failure and Mechanical Ventilator. The record was review on 06/28/16 at 8:41 am. During the record review no evidence was found of the plan of care for restraint or seclusion
2. RR #33 is a 66 years old female who was admitted on 01/06/16 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Obesity and Mechanical Ventilator. The record was reviewed on 06/28/2016 at 9:09 am. During the record review no evidence was found of the plan of care for restraint or seclusion
3. R.R. #29 is a 65 years old male who is admitted to on 12/29/15 with a diagnosis of Gastrointestinal Hemorrhage, Diverticulitis, Hepatic Failure and Alcohol Dependence. The record was reviewed on 06/28/2016 at 9:57 am. During the record review no evidence was found of the plan of care for restraint or seclusion
4. R.R. #28 is a 72 years old male who is admitted on 03/20/16 with a diagnosis of Sepsis, Acute Kidney Failure, Diabetes type II Alzheimer, Dementia and Bed Confinement. The record was reviewed on 06/28/2016 at 11:20 am. During the record review no evidence was found of the plan of care for restraint or seclusion
5. R.R. #31 is an 80 years old female who is admitted on 12/19/16 with a diagnosis of Acute appendicitis, Atelectasis and Pleural Effusion. The record was reviewed on 06/28/16 at 11:35 am. During the record review no evidence was found of the plan of care for restraint or seclusion
On 6/28/16 at 11:45 am during the restrictions protocol review it was identified that the facility restriction protocol did not have a plan of care.
On 6/28/16 at 11:46 am on interview employee #9 state " the facility did not have develop a restriction plan of care " .
a. The facility failed to include a written plan of care for restraint.

Based on sixty eight records reviewed (R.R), and the review of restraint policies and procedure it was determined that the facility failed to obtain the physician order (countersigning) immediately after the applications of restraint in 1 out of 68 records reviewed (RR) (RR. #29).

Findings include:

1.R.R. #29 is a 65 years old male who is admitted to on 12/29/15 with a diagnosis of Gastrointestinal Hemorrhage, Diverticulitis, Hepatic Failure and Alcohol Dependence. The record was reviewed on 06/28/2016 at 9:57 am. RR# 29 has a telephone restriction order dated on 12/29/2015. During the record review no evidence was found of the physician countersigning the restriction telephone order.
The facility fails to obtain the restraint order immediately after the applications of the restraint.

Based on sixty eight records reviewed (R.R), it was determined the facility fail to maintain patients free of restrictions orders as needed ( PRN) in 1 out of 68 records reviewed (RR) (RR. #28).
Findings include:

1.R.R. #28 is a 72 years old male who is admitted on 03/20/16 with a diagnosis of Sepsis, Acute Kidney Failure, Diabetes type II Alzheimer, Dementia and Bed Confinement. The record was reviewed on 06/28/2016 at 11:20 am. During the record review it was found evidence of a telephone order on 03/01/2016 of restriction on both superior extremities with soft restraint PRN if patient is agitated.
The facility fail to maintain patients free of restrictions orders PRN

Based on sixty eight records reviewed (R.R), it was determined that the facility failed to re-evaluate restraint patients by a physician after 24 hours of the first restraint order in 5 out of 68 records reviewed (RR) (RR. #28, #29, #31, #32 and #33).

Findings include:

1. R.R. #32 is a 94 years old male who is admitted on 12/26/15 with a diagnostic of Acute Respiratory Failure, Acute Kidney Failure, Acute Myocardial Infarction, Left Ventricular Failure and Mechanical Ventilator. The record was review on 06/28/16 at 8:41 am. RR# 32 has a restriction order dated on 12/26/2015. During the record review no evidence was found of physician restriction order renovation, evaluations and assessments every 24 hours for maintain the patient on restraint or seclusion.
2. RR #33 is a 66 years old female who was admitted on 01/06/16 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Obesity and Mechanical Ventilator. The record was reviewed on 06/28/2016 at 9:09 am. RR# 33 has a restriction order dated on 1/08/2016. During the record review no evidence was found of physician restriction order renovation, evaluations and assessments every 24 hours for maintain the patient on restraint or seclusion.
3. R.R. #29 is a 65 years old male who is admitted to on 12/29/15 with a diagnosis of Gastrointestinal Hemorrhage, Diverticulitis, Hepatic Failure and Alcohol Dependence. The record was reviewed on 06/28/2016 at 9:57 am. RR# 29 has a telephone restriction order dated on 12/29/2015. During the record review no evidence was found of physician restriction order renovation, evaluations and assessments every 24 hours for maintain the patient on restraint or seclusion.
4. R.R. #28 is a 72 years old male who is admitted on 03/20/16 with a diagnosis of Sepsis, Acute Kidney Failure, Diabetes type II Alzheimer, Dementia and Bed Confinement. The record was reviewed on 06/28/2016 at 11:20 am. RR# 28 has a restriction order dated on 03/01/2016. During the record review no evidence was found of physician restriction order renovation, evaluations and assessments every 24 hours for maintain the patient on restraint or seclusion.
5. R.R. #31 is an 80 years old female who is admitted on 12/19/16 with a diagnosis of Acute appendicitis, Atelectasis and Pleural Effusion. The record was reviewed on 06/28/16 at 11:35 am. RR# 31 has a restriction order dated on 12/21/2015. During the record review no evidence was found of physician restriction order renovation, evaluations and assessments every 24 hours for maintain the patient on restraint or seclusion.
6. The facility failed to re-evaluate restraint patients by a physician after 24 hours of the first restraint.

Based on the review of documents and policies and procedure it was determined that the facility failed to ensure that protocols for the use of physical restraint on patients comply with CMS Regional Office death reporting requirements.

Findings include:

1. A mechanism to ensure that facility develop and implement physical restraints protocols, policies and procedures accordingly with accepted standards of practice as well as CMS requirements were not performed, not followed accordingly with the following findings:

a. The Facility ' s policies and procedures did not include provisions to ensure that deaths associated with the use of physical restriction are reported to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient's death

b. Facility ' s policies and procedures did not include provisions to ensure that each death that occurs while a patient is in restraint that occurs within 24 hours after the patient has been removed from restraint are reported to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient's death

c. Facility ' s policies and procedures did not include provisions to ensure that each death that occurs within 1 week after restraint where it is reasonable to assume that use of restraint contributed directly or indirectly to a patient's death, are reported to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient's death

d. Facility ' s policies and procedures did not include provisions to ensure that staff must document in the patient's medical record the date and time the death of a patient who was on restriction was reported to CMS.

Based on review of the Quality Improvement Program, and Interview with the Quality Coordinator (employee #9), it was determined that the facility failed to maintain an active Quality Assessment Committee that use the data collected to identify opportunities for improvement and changes that will lead to improvement, discusses and take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained.

Findings include:

1. During Interview with the Quality Coordinator (employee#9) on 6/29/16 at 8:50 am she stated that "The Program of Quality Improvement is located at the end of organizational chart "organigrama" of the Hospital since 2010. I have much determination that the hospital comes forward. I was able to reestablish communication with supervisors. On February 2014, I was appointed as Director of Institutional and Risk Management Program. On 2015 the administration removed me of this charge and from Risk Management and assigned me as Quality Coordinator. At the three months I have manage the Risk Management but not appointed in this position. The program does not flow as it should. There is no currently established Quality committee, I have asked on several occasions at meetings, in the report to executive medical faculty. It belongs in several Committees as Infection Control, Utilization, Information Management, Transfusion, Emergency Room, Pharmacy and Therapeutics, Executive Cabinet. I provided to the Medical Faculty quality report, if discussed or not, I do not know, I do not receive a feedback or a Plan of Action and the next indicator out the same or worse. There are several departments that do not give me the report of the indicators and whether deliver after two or three months. Example: Emergency Room does not give me reports since December 2015, Medical Faculty Emergency Room not reports the indicator inform since March 2015. Pediatrics in March had to deliver the report was delivered in May 2016. Anesthesia, do not deliver the report of April and May, was delivered in June 2016. Pathology which is a service contract the January inform was reported on April 2016, February was provided on May 2016 and March report was provided on June 2016, the report from April and May 2016 was not reported. Respiratory Care report not given to me so far in 2016. Management Information May report has not delivered. Operating Room in June handed me the monthly report from January to May. I gave them to submit reports to the 15th of the following month. For example, the May report has until June 15 to deliver " .

2. Review of the Institutional Programs Organizational Performance Improvement and Risk Management Manual (Manual Programas institucionales Mejoramiento del desemño Organizacional y Manejo de Riesgo) on 6/6/29/16 at 8:40 am provide evidence that the manual was approved, by the Administrator, the Medical Director and the Chairman of the Governing Board on August 2014 and it was determined the line of communication, security, authority, the establishment of a Committee and responsibility of the Administrator, Medical Director and Governing Body to the Quality Program and establish the following:

a. In Part VII. Communication: communication of issues of interest to all staff of the institution is essential. The Governing Board, the Medical College and Hospital Administration recognize the benefit of maintaining effective lines of communication and ensure a coordinated and comprehensive program.
b. In Part VIII. Security: It is the responsibility of all hospital employees keep a watch to ensure that each individual to do his duty.
c. In Part IX. Authority: The Governing Board is responsible for establishing, supporting, and maintains a Program Improvement flexible, comprehensive and integrated Organizational Performance. It is delegated to the administrator and the Medical Faculty development and implementation thereof, which is coordinated by the Coordinating Improvement Program Organizational Performance.
d. In Part X. Monitoring Committee continuously Quality: continuous monitoring is established through a Quality Committee in order to provide the integration of the program with the entire hospital system; Committee participants are: Administrator, Medical Director, Quality Program Coordinator, Director of Nursing, Human Resources Director, Infection Control, Director of Pharmacy and others. The Medical Director has the responsibility to be involved in the committee and preside over it.
e. In Part XII. Release of Liability the Governing Body acknowledging its legal responsibility and moral medical services to ensure the highest quality to the community it serves, for this. Section 5. Analyze and take action regarding the quarterly reports presented by the Medical Faculty and Administration to improve service quality and patient satisfaction.

f. In Part XIII. Manager Responsibility: Provide the necessary support for the Improvement Program Organizational Performance effective. It will provide support for the Improvement Program Organizational Performance.
g. Part XIV. Responsibility Medical Director: Work with the Program Coordinator Organizational Performance Improvement.
h. The Quality Manual describes the purpose of the committee, its composition; responsibilities of the committee, the meetings will be least every 2 months.
3. However the facility governing body failed to establish a Quality Committee in accordance to the facility Quality Manual and failed to designate their members and establish meeting schedule.

Based on review of the Quality Assessment Program, and interview with the Quality Coordinator (employee #9), it was determined that the facility governing body, medical staff, and administrative officials failed to be responsible and accountable to the Quality Assessment Program.

Findings include:

During interview with the Quality Coordinator (employee#9) on 6/29/16 at 8:50 am state that "The Program of Quality Assessment is located at the end of organizational chart of the Hospital since 2010. I have much determination that the hospital comes forward. I was able to reestablish communication with supervisors. On February 2014, I was appointed as Director of Institutional and Risk Management Program. On 2015 the administration removed me of this charge and from Risk Management and assigned me as Quality Coordinator. At the three months, I'll have manage the Risk Management but not be appointed in this position. The program does not flow as it should. There is no currently established Quality committee, I have asked on several occasions at meetings, in the report to executive medical faculty. I repot to the Medical Faculty quality inform, if discussed or not, I do not know, I do not receive a feedback or a Plan of Action and the next month when apply the indicator the result was the same or worse. There are several departments that do not give me the reports of the indicators and whether deliver after two or three months later. Example: Emergency Room does not give me reports since December 2015, Medical Faculty Emergency Room not reports the indicator inform since March 2015. Pediatrics in March had to deliver the report was delivered in May 2016. Anesthesia, do not deliver the report of April and May, was delivered in June 2016. Pathology which is a service contract the January inform was reported on April 2016, February was provided on May 2016 and March report was provided on June 2016, the report from April and May 2016 not was repotted. Even Respiratory Care report not givento me so far in 2016. Management Information May report has not delivered. Operating Room in June handed me the monthly report from January to May. I give them to submit reports to the 15th of the following month. For example, the May report has until June 15 to deliver".

2. During the review of the Quality Assessment Program, Activities, Manual it was determined that the facility governing body failed to be responsible to support and maintain effective communication and maintain quality program integrated. Due to all services did not report their indicator according to Quality Assessment Program schedule.

Based on the review of thirty-four medical staff credential files, it was determined that the facility failed to examine the credential files (C.F) to ensure that medical staff have updated Hepatitis B vaccines and Influenza vaccines for 32 out of 34 medical staff's C.Fs (C.F.#3,#4,#5,#6,#7,#9,#10,#11,#12,#13,#14,#15,#16,#17,#20,#21,#22#23,#24,#28,#29,#30,#31,#32,#33 and #34).

Findings include:

1. During the review of thirty-four medical staff credential files on 6/29/16 from 10:26 am until 3:45 pm the following was found:

a. Thirteen out of thirty-four medical staff's credential files did not have evidence of their hepatitis profiles or responsibility exoneration. (CFs#3, #4, #5, #14, #15, #21, #22, #24, #30, #31, #32, #33 and #34).

b. Twenty-six out of thirty-four medical staff's credential files did not have evidence of their Influenza profiles or responsibility exoneration (C.F#3,#4,#6,#7,#9,#10,#11,#12,#13,#14,#15,#16,#17,#20#21,#22,#23,#24,#26,#28,#29#30,#31,#32,#33 and #34).

Based on administrative documents review and interviews with the Acting Nurse Director (employee #12) on 06/28/16 through 06/30/16, it was determined that the facility failed to have a Director of Nursing assigned to ensure a organize nursing services with a plan of administrative authority and delineation of responsibilities for patient care, developing a legible nursing job schedule according to the professional standards of practice and according the hospital rules and regulations.

Findings include:

1. During review of the hospital nursing job schedules performed by the Acting Nurse Director (employee # 12) it was found on 06/28/16 at 10:00 am through 6/30/16 the following was found:

a. The facility Acting Nurse Director provided evidence of the Nursing Department Organizational chart but on this chart is not updated, the facility did not have a nurse director on as off today because the prior nurse director resigned on March 30 of 2016 and the administrator resigned on September 3 of 2015.

b. The Acting Nurse Director (employee #12) was interview on 6/28/16 at 8:25 a. m. and she stated: '' I have the position of acting nurse director until April 1 of 2016 because the director of the nurse department resigned on March 30 of 2016 and the nursing department did not have a director. At the time when the DON resigned my position was a Surgery department supervisor and the DON employment was vacant and I request the nurse director position and the facility administration assigned me as the Acting Nurse Director on April 1, 2016 per the first 30 days and then May till September of 2016. The surgery department was left without a supervisor until April 1 of 2016 and at this moment the nurse supervisor of the medicine department is the supervisor of the two departments. Until now the surgery department lacks of nurse supervisor, however the medicine department was closed until May of 2016 and the patients was moved to the surgery department. AS of today the nurse nursing department does not have a supervisor for the surgery department, and the surgery and medicine department have a same supervisor but did not have head nurse and the census was maintain between 22 to 24 patients. The other department that does not have a head nurse is the pediatric department. The Nursery department, Delivery Room department and Intensive Pediatric Unit were closed.''

c. The nursing Department as per the Acting Nurse Director (employee #12) up to now I have a total of 41 Associate Degree Nurses (ADN) and twenty three (23) Bachelor Degree Nurses (BSN) assigned to different departments of the hospital as follow: '' Administrative are of the Nursing Department : 2 ADN designated for Infection Control Nurse and Skin Care Nurse, Surgery Department seven (7) ADN Nurses and three (3) Register Nurse B.S.N., Intensive Unit seven (7) ADN and four (4) Register Nurse B.S.N., Operating Room two (2) ADN and four (4) Register Nurse B.S.N., Medicine Department six (6) ADN and two (2) Register Nurse B.S.N., Pediatric Department seven (7) ADN and four (2) Register Nurse B.S.N., Emergency Room ten (10) ADN and four (7) Register Nurse B.S.N. and two Register Nurse B.S.N. under contract for Professionals Services at shifts 3:00 p. m. to 11:00 p. m. and 11:00 p. m. to 7:00 a. m. as general supervisors.
According with the Law Number 254 of December 31 of year 2015 '' To Create the new law to regulate and adjust the nursing practice to the actual world at the " Estado Libre Asociado de Puerto Rico; establish the new Board of Nursing Examination " Junta Examinadora de Enfermería " ; regulate everything related to the license or certification; to establish penalties; provide the operational funds of the Professional Board; and derogate the Law Núm. 9 of October 11, 1987, as amended.'' Eposes on page 13 ( f ) Associate Degree Nurse (ADN) can provide services under contract with agencies or persons only if she function under the direction and supervision of the generalist nurse (BSN) or advance practice nurse MSN.
The Pediatric Nurse Supervisor (employee #25) was interviewed on 6/30/16 at 9:40 a. m. a she stated: '' I have only two R.N. B.S.N.,6 A.D.N and 2 licensed practical nurse, I do not have head nurses. The categorization of patients ' is done by the B.S.N. R.N. from 7:00 a. m. till 3:00 p. m and the assignment is done by me. I do rounds in the morning to each patient ' s rooms. During the 3:00 p. m. till 11:00 p. m. y 11:00 p. m. till 7:00 a. m shifts the general supervisor does the assignment. I always assign a BSN in each shift as leader. The majority of the shifts are cover by the two R.N. B.S.N. but one shift is run by one A.D.N. because I only have only two R.N.B.S.N " .
d. The facility failed to comply with the requirement establish under the Law Number 254 of December 31 of year 2015, which regulates the nursing practice in Puerto Rico.
e. The Medicine and Surgery nurse department supervisor (employee # 8) was interview on 6/28/16 at 9:05 a.m during survey tour performed to evaluated this department she stated: '' The acting nurse director delegated the supervision of the two departments medicine and surgery to me. Today I have five (5) register nurse and one (1) licensed practical nurse (LPN), today two LPN's were absent and only one covered but I designated two of the five register nurses to assist the LPN (employee #19).'' Related to the functions of the nurse supervisor patient's categorization and the nurse assignments she stated: '' I performed the categorization of all of the patient's and the assignment of the first shift and for the shift to 3:00 p. m. till 11:00 p. m and shift to 11:00 p. m. till 7:00 a. m. I designated a bachelor ' s register nurse the responsibility to do the assignment. During my vacations or on my absent I delegated the responsibility to the bachelors register nurse we have a lot experience. ''

f. During the review of the patient's classification ' s and the assignment on 6/28/16 at 9:15 a. m. till 10:15 a. m. with the nurse supervisor and the acting nurse director the following was reveled:

On 4/27/16 the designated nurse on shift 7:00 a. m. till 3:00 p. m. (employee #8) did not performed the patient's classification.

On 5/15/16 and 5/16/16 the department has 25 patients ' the second and the third classification form lack of the date and the department.

On 5/17/16, 5/22/16 and 5/29/16 no evidence of patient ' s classification.

On 6/5/16 the designated nurse on shift 7:00 a. m. till 3:00 p. m. (employee #20) did not performed the patient's classification.

On 6/7/16 the designated nurse on shift 7:00 a. m. till 3:00 p. m. (employee #21) did not performed the patient's classification.

On 6/10/16 the designated nurse on shift 7:00 a. m. till 3:00 p. m. (employee #20) did not performed the patient's classification.

On 6/12/16, 6/16/16, 6/23/16, 6/25/16 and 6/26/6 on shift 7:00 a. m. till 3:00 p. m. did not performed the patient's classification.

On 6/23/16 the department has sixteen (16) patients ' however eleven patient's (11) were classified and patient #12 of the classification list with Sepsis diagnosis and not classified.

On 6/24/16 the department has fifteen (15) patients ' however 10 patients ' (10) were classified and five patients ' (5) were not classified.

On 6/25/16 the department have fifteen (15) patient's however nine patient's (9) ware classified and six patient's (6) did not classified.

On 6/26/16 the department has fifteen (15) patients ' however twelve patients ' (12) were classified and three patients ' (3) were not classified.

On 6/27/16 the department increase census to twenty two (22) twenty one (21) patients were classified and one patient (1) was not classified.

On 6/28/16 the department has fifteen (15) patients ' however 10 patients ' (10) was classified and five patient's (5) are not classified.

g. The nursing assignment on 6/11/16 on shift 3:00 p. m. till 11:00 p. m. lacks of the name of the nurse supervisor, patient census and lacks of specifics task.

h. The nursing assignment on 6/11/16 on shift 11:00 p. m. till 7:00 a. m. lacks of the name of the nurse supervisor and patient census.

i. The nursing assignment on 6/12/16 on shift 7:00 a. m. till 3:00 p. m. lacks of the name of the three registered nurses, lacks of the individually designated patients for the three nurses, the hour when the nurse go to have a meal, the name of the two licensed practical nurses, the designated patient's for the LPN nurses and the hour when the nurse go to have a meal.

j. On 6/15/16 on shift 11:00 p. m. till 7:00 p. m. lacks of the name of the designated LPN nurses personnel omit the patients distribution.

k. On 6/16/16 on shift 3:00 p. m. till 11:00 p. m. lacks of the supervisor name and the two LPN nurses designated for the shift and on shift 7:00 a. m. till 3:00 p.m. lacks of the date, the supervisor name and the census.

l. On 6/17/16 on shift 3:00 p. m. till 11:00 p. m. the designated register nurses lacks of specifies task.

m. On 6/18/16 and 6/23/16 on shift 11:00 p. m. till 7:00 a. m. and on 6/21/16 on shift 3:00 p. m. till 11:00 p. m. no evidence of nurses assignment.

n. On 6/25/16 on the shifts 7:00 a. m. till 3:00 p.m., 3:00 p. m. till 11:00 p. m. and 11:00 p. m. till 7:00 a. m. no evidence of nurses assignment.

o. On 6/26/16 on the shifts 7:00 a. m. till 3:00 p.m. and 3:00 p. m. till 11:00 p. m. no evidence of nurses assignment.

p. On 6/27/16 on the shifts 11:00 p. m. till 7:00 a. m. no evidence of nurses assignment.

q. The Medicine and Surgery nurse department supervisor (employee # 8) was interview on 6/28/16 at 10:35 a. m. and she stated: '' I was on vacations during May and I return on June 22, 2016 I performed the nursing assignment for shift 7:00 a. m. till 3:00 p. m. during the shifts 3:00 p. m. till 11:00 p. m. and 11:00 p. m. till 7:00 a. m. the assignment was performed by the bachiller register nurse (BSN) of the shift. I delegated the responsibility on the BSN nurse of each shift. The patient's classification during the weekends and on holidays the nurses determined who was performed. ''

r. According of the Administrative Nurse Manual on the designated area of ' ' Work Assignment '' (Asignacion de Trabajo) reviewed on 6/29/16 at 3:00 p.m. with the Acting Nurse Director the facility utilized the plan of care as base to elaborated the assignment and they have a patient categorization, specials activities of patient, specials assignments for nurses and patients distribution for each nurse. The assignment was performed with a guide for nursing personnel for the three shifts of the week.

s. During the survey process to observe and evaluated the medicine and surgery department on 6/28/16 from 9:05 a. m. till 2: 00 p. m. and on 6/29/16 from 9:00 a. m. till 11:00 a. m. it was found that the supervisor nurse performs multiples functions.

Based on administrative documents review and interviews with the Acting Nurse Director (employee #12) on 06/28/16 through 06/30/16, it was determined that the facility failed to have a Nursing Supervisor for each depatment assigned to ensure when needed the immediate availability of a register nurse for bedside care of any patient.

Findings include:

1. The Acting Nurse Director (employee #12) was interview on 6/28/16 at 8:25 a. m. and she stated: '' I have the position of acting nurse director until April 1 of 2016 because the director of the nurse department resigned on March 30 of 2016 and the nursing department did not have a director. At the time when the DON resigned my position was a Surgery department supervisor and the DON employment was vacant and I request the nurse director position and the facility administration assigned me as the Acting Nurse Director on April 1, 2016 per the first 30 days and then May till September of 2016. The surgery department was left without a supervisor until April 1 of 2016 and at this moment the nurse supervisor of the medicine department is the supervisor of the two departments. Until now the surgery department lacks of nurse supervisor, however the medicine department was closed until May of 2016 and the patients was moved to the surgery department. AS of today the nurse nursing department does not have a supervisor for the surgery department, and the surgery and medicine department have a same supervisor but did not have head nurse and the census was maintain between 22 to 24 patients. The other department that does not have a head nurse is the pediatric department. The Nursery department, Delivery Room department and Intensive Pediatric Unit were closed.''

2. During the review of the patient's classification ' s and the assignment on 6/28/16 at 9:15 a. m. till 10:15 a. m. with the nurse supervisor and the acting nurse director the following was reveled:

On 4/27/16 the designated nurse on shift 7:00 a. m. till 3:00 p. m. (employee #8) did not performed the patient's classification.

On 5/15/16 and 5/16/16 the department has 25 patients ' the second and the third classification form lack of the date and the department.

On 5/17/16, 5/22/16 and 5/29/16 no evidence of patient ' s classification.

On 6/5/16 the designated nurse on shift 7:00 a. m. till 3:00 p. m. (employee #20) did not performed the patient's classification.

On 6/7/16 the designated nurse on shift 7:00 a. m. till 3:00 p. m. (employee #21) did not performed the patient's classification.

On 6/10/16 the designated nurse on shift 7:00 a. m. till 3:00 p. m. (employee #20) did not performed the patient's classification.

On 6/12/16, 6/16/16, 6/23/16, 6/25/16 and 6/26/6 on shift 7:00 a. m. till 3:00 p. m. did not performed the patient's classification.

On 6/23/16 the department has sixteen (16) patients ' however eleven patient's (11) were classified and patient #12 of the classification list with Sepsis diagnosis and not classified.

On 6/24/16 the department has fifteen (15) patients ' however 10 patients ' (10) were classified and five patients ' (5) were not classified.

On 6/25/16 the department have fifteen (15) patient's however nine patient's (9) ware classified and six patient's (6) did not classified.

On 6/26/16 the department has fifteen (15) patients ' however twelve patients ' (12) were classified and three patients ' (3) were not classified.

On 6/27/16 the department increase census to twenty two (22) twenty one (21) patients were classified and one patient (1) was not classified.

On 6/28/16 the department has fifteen (15) patients ' however 10 patients ' (10) was classified and five patient's (5) are not classified.

3. The nursing assignment on 6/11/16 on shift 3:00 p. m. till 11:00 p. m. lacks of the name of the nurse supervisor, patient census and lacks of specifics task.

4. The nursing assignment on 6/11/16 on shift 11:00 p. m. till 7:00 a. m. lacks of the name of the nurse supervisor and patient census.

5. The nursing assignment on 6/12/16 on shift 7:00 a. m. till 3:00 p. m. lacks of the name of the three registered nurses, lacks of the individually designated patients for the three nurses, the hour when the nurse go to have a meal, the name of the two licensed practical nurses, the designated patient's for the LPN nurses and the hour when the nurse go to have a meal.

6. On 6/15/16 on shift 11:00 p. m. till 7:00 p. m. lacks of the name of the designated LPN nurses personnel omit the patients distribution.

7. On 6/16/16 on shift 3:00 p. m. till 11:00 p. m. lacks of the supervisor name and the two LPN nurses designated for the shift and on shift 7:00 a. m. till 3:00 p.m. lacks of the date, the supervisor name and the census.

8. On 6/17/16 on shift 3:00 p. m. till 11:00 p. m. the designated register nurses lacks of specifies task.

9. On 6/18/16 and 6/23/16 on shift 11:00 p. m. till 7:00 a. m. and on 6/21/16 on shift 3:00 p. m. till 11:00 p. m. no evidence of nurses assignment.

10. On 6/25/16 on the shifts 7:00 a. m. till 3:00 p.m., 3:00 p. m. till 11:00 p. m. and 11:00 p. m. till 7:00 a. m. no evidence of nurses assignment.

11. On 6/26/16 on the shifts 7:00 a. m. till 3:00 p.m. and 3:00 p. m. till 11:00 p. m. no evidence of nurses assignment.

12. On 6/27/16 on the shifts 11:00 p. m. till 7:00 a. m. no evidence of nurses assignment.

13. The Medicine and Surgery nurse department supervisor (employee # 8) was interview on 6/28/16 at 10:35 a. m. and she stated: '' I was on vacations during May and I return on June 22, 2016 I performed the nursing assignment for shift 7:00 a. m. till 3:00 p. m. during the shifts 3:00 p. m. till 11:00 p. m. and 11:00 p. m. till 7:00 a. m. the assignment was performed by the bachelor register nurse (BSN) of the shift. I delegated the responsibility on the BSN nurse of each shift. The patient's classification during the weekends and on holidays the nurses determined who will was perform it. ''

14. According of the Administrative Nurse Manual on the designated area of ' ' Work Assignment '' (Asignacion de Trabajo) reviewed on 6/29/16 at 3:00 p.m. with the Acting Nurse Director the facility utilized the plan of care as base to elaborated the assignment and they have a patient categorization, specials activities of patient, specials assignments for nurses and patients distribution for each nurse. The assignment was performed with a guide for nursing personnel for the three shifts 7:00 a. m. till 3:00 p. m., 3:00 p.m. till 11:00 p. m. and 11:00 p. m. till 7:00 a. m. during seven days of the week. The responsibility of the assignment was performed by the nurse supervisor of each department or the professional designated of the unit and the supervisor is the responsible before and after the shift to evaluate if all of the personnel performed and complied of the assignment.

15. During the survey process to observe and evaluated the medicine and surgery department on 6/28/16 from 9:05 a. m. till 2: 00 p. m. and on 6/29/16 from 9:00 a. m. till 11:00 a. m. it was found that the supervisor nurse performs multiples functions such as supervisor, head nurse, staff nurse and others functions. However, according of the daily assignment evaluation and the daily patient classification documents the nurse supervisor failed to evaluate if the staff personnel provide and complied of patient care needs. The following was revealed during the active patient's records evaluation on 6/28/16 at 11:00 a. m. till 12:00 p. m. and 1:00 p. m. till 2:20 p.m.:

a.R.R #59 is a 77 years old female admitted on 6/26/16 with primary diagnosis of Cellulitis of Left Lower Limb and Diabetes Mellitus. According to the review of medical record performed on 6/28/16 at 11:00 a.m. with the nurse supervisor (employee #8) the physician ordered local care daily with Saline Solution .9% and apply Kaltostac daily however the nurses notes did not provide evidence of local care. The facility have a associated nurse exclusive to provide the patient a local care however the patient record did not provide evidence of this care.
The physician order provide evidence that the patient was maintain N.P.O. after breakfast tomorrow and on call to operating room tomorrow in p. m. the physician order lacks of documented what kind of procedure was to be performed. The patient was going to operating room on 6/27/16 and received Zozyn 3.375 grams intravenous every 6 hours then came out of the OR and goes to recovery room at 3:00 p. m. and then to surgery ward.
The physician ordered local care with saline solution 0.9% and apply " the order was not clearly and legible. When the surveyor requests the nurse supervisor to read it she could not read what the order the physician wrote. The physician documentation was not legible including the orders.
The nurses notes did not provide evidence if the patient received the local care.
The employee #8 state that the nurse designated to provide the care provided it, however no evidence on the patient record on 6/27/16 and on 6/28/16.
b. The nurse supervisor (employee #8) failed to reviewed the patient record to assure if the patient received the local care according with the physician orders and failed to assure what kind of procedure was performed by the surgeon, what kind of local medication the skin nurse utilized to provide local care because the physician order was not legible and assure that when the patient received the local care intervention place the documentation on the patient record.
c. On 6/28/16 at 3:10 p. m. the skin care nurse (employee #18) was interviewed related to her functions and he stated: '' I worked at this facility for 13 years and a half as license practical nurse (LPN) until 2006 when I completed my associate degree up to now.
I am the skin care nurse since March 2010. I took a course of skin care of 12 hours at the en Veterans Hospital. Related to my Job description when a case is refer to me for skin care I interview the patient and ask for authorization to take pictures, is the patient cannot sign because of ant other condition a family member is the one that sign when authorized. The consent is always sign when the patient/family authorize. Before we use a camera, now we use a tablet that the hospital provides to take the pictures. Only the affected area is taken not the face, and is identified with a label and general information and another label for the anatomical area and who took it signs it. I am the only and exclusive person to manage the photo and is located at my office. ''
During the credentials file evaluation of the skin nurse it did not provide evidence of a Specialist Skin Care Nurse, it only provide evidence of a '' Certificate of Completion educational activity for 12.0 contact hours taken on September 15 of 2009.
According to the Associated Nurse, he respond directly to the Nursing Service Director. No evidence of indicators to evaluate and supervise the procedures performed by the skin care nurse, nor who is the immediate supervisor to evaluate his skills.
d. The patient record provides evidence that the physician ordered on 6/26/16 at 8:41 a. m. destrostix ( a quick test to measure glucose in blood) every 6 hours and covered with Regular Insulin mild scale. The patient record destrostix register was reviewed on 6/28/16 at 11:00 a. m. and reveled that on 6/27/16 at 4:15 p. m. according of the nurse note the patient was received at the surgery ward, and reveled that at 4:00 p. m. they performed a destrostix sample and has 54 mgs/dl however at this time the patient stay on recovery room, the nurse note on 6/27/16 on shift 3 -11 did not provided evidence related to the destrostix and no evidence of nurse intervention.
e. The multidisciplinary plan of care was initiated by the nurse on 6/26/16 and revealed that the patient was not evaluated by the nutritionist, this patient has diabetes, hypertension and was admitted do to left foot infected puncture wound.

f. The form used for '' reconciliacion of medications '' Medication reconciliation performed by the nurse on 6/26/16 at 8:00 p. m. lacks of education related to medications used by the patient.

g. The form used at the nursing department 'check list preparation of patient to operating room '' lacks of patient name, record number and other important information of the patient when received intervention procedure and lacks of the nurse signature who prepared the patient. The form did not provide to write the date and the hour when the nurse performed the intervention.

h. The general consent form performed on 6/26/16 at 3:30 p. m. lacks of what department the patient came from, the name of the physician, the name of the patient, the date and the hour when she signed the consent.

i. The educational plan for patient performed by the nurse (employee #23) on 6/26/16 at 8:00 p. m. lacks of patient name, age, education level and did individualized the patient objectives, what kind of information the patient or care giver received.

16. R.R #60 is a 48 years old male admitted on 6/27/16 at 8:00 a. m. with primary diagnosis of Acute Ischemic Heart Disease Unspecified. According to the review of medical record performed on 6/28/16 at 10:50 a.m. with the nurse supervisor (employee #8) the physician ordered on 6/27/16 at 6:00 p. m. consult for cardiology evaluation patient with ASC Bradicardia.

On 6/27/16 a physician ordered EKG on a.m. of 6/28/16. On 6/28/16 at 11:24 a. m. the nurse staff was interview related to if the EKG was performed to the patient a she said no, she stated: '' The EKG was pending because the nurse supervisor delegated it to the nurse (employee #24) to performed the EKG and at this time was not performed. "

The consent form for patient treatment performed on 6/27/16 lacks of the hour when was taken.

Base on fifty one nursing credential files reviewed it was determined that the facility failed to ensure that nursing personnel maintain annual evaluation, influenza vaccine, hepatitis vaccine, " antecedentes penales " criminal records and appointment for 7 out of 51 one credential files (C.F.'s #3, #12, #21, 27, #47, #48 and #51).

Findings include:

1. During the review of nursing credential files with human recourse personnel on 6/29/16 at 1:30 p. m. till 4:00 p. m. the following was found:

a. C. F. #3 did not provide evidence of appointment and criminal record.

b. C. F. #12 did not provide evidence of annual evaluation from 5/15 through 5/16. The last evaluation was performed from 9/20/14 through 5/31/15.

c. C. F. #21 did not provide evidence of annual evaluation from 5/31/15 through 5/31/16. The last evaluation was performed from 6/01/14 through 5/31/15.

d. C. F. #27 did not provide evidence of annual evaluation from 5/31/15 through 5/31/16. The last evaluation was performed from 6/01/14 through 5/31/15.

e. C. F. 's #47, #48 and #51 did not provide evidence of Influenza Vaccine

f. C. F. #49 did not provide evidence of Influenza Vaccine and Hepatitis Vaccine.

Based on sixty-eight medical record review with the Director of Nursing (DON) (employee #12) it was determined that the facility failed to ensure that the nursing staff develops, and keeps current, nursing care plans for each patient for 2 out of 68 record review. (RR #30 and #68)

Findings include:

1. R.R #30 is an 87 years old male admitted on 6/3/16 with a diagnosis of Intestinal Obstruction. Accordance to the review of medical record performed on 6/28/16 at 3:30 pm with the discharge planer employee #11 it was found the following:
a. Accordance to the Transfer note between departments, the patient was transfer from intensive unit to medicine unit on 6/21/16. The nurses documented that patient has a Foley catheter #18. However, during the stay in medicine ward from 6/21/16 thru 6/28/16, no evidence was found that nursing staff develops and keeps current the nursing care plan to the problem with the urinary system.
2. R.R #68 is an 88 years old male admitted on 6/4/16 with a diagnosis of Acute Cholelithiasis, Alzheimer, Atrial Fibrillation and Diabetes Mellitus. Accordance to the review of medical record performed on 6/28/16 at 11:50 am with the DON employee #12 it was found the following:

a. On 6/12/16 at 5:00 am the physician ordered Foley Catheter #16. The nurse documented on 6/12/16 that foley catheter #16 was inserted by the shift supervisor. Evidence was found that patient continue with foley catheter from 6/12/16 thru 6/27/16. However, no evidence was found that nursing staff develops and keeps current the nursing care plan to the problem with the urinary system.

Based on the observational tour of the medical record department with the Medical Record Assistant (employee #13), it was determined that the facility failed to ensure that the inactive and active medical record are protected.

Findings include:

1. During the observational tour of the inactive and active medical record department located inside of the hospital on the first floor with the medical record assistant (employee #13) on 6/27/16 at 2:07 pm the following was identified:

a. It was found a microwave and a small refrigerator was located at a corner of the medical record room. The area was found full of records for review and stored, and the microwave and refrigerator are fire hazards due to their close proximity and lack of separation.

b. It was found a shelve with food in the same corner that the microwave and the small refrigerator are located.

c. The medical record personnel use non fire retardant material shelves to place the close medical records.

d. There were two boxes on the top of the close medical record shelves that touched the ceiling.

e. One of the two air conditioning units in the main clinical record area; was turned off causing a high temperature, humidity and strong odor.

f. The air conditioning unit of the incomplete medical records room was turned off.

g. There was no fire extinguisher in the incomplete medical records room.

Based on sixty-eight (68) medical record reviewed (R.R) it was determined that the facility failed to ensure that al medical record be legible, complete, dated, timed, and authenticated in written by the person responsible for providing or evaluating the service provided for 3 out of 68 record review (R.R.#27, #28 and #30)

Findings include:

1. R.R #27 is a 44 years old male admitted on 6/18/16 with a diagnosis of Back Abscess and Diabetes Mellitus. Accordance to the review of medical record performed on 6/28/16 at 10:15 am with the Discharge Planning employee #11. The employee #11 state that patient was a readmission due to he was receiving wound care in his home with Vac Therapy he need an recertification to continue with the treatment and the insurance medical plan delayed the authorization for the treatment and no care was provided about 3 days and the patient decide to came to the Emergency Room, then be admitted. During the record review it was found the following:
a. The Nurses History provide evidence that patient was admitted with a Negative Pressure System (Vac Therapy) placed on the back abscess and the left leg drain purulent secretion. However, no evidence was found that the nurse staff identified Discharge Planning needs, related to wound care after discharge.
b. No evidence was found that the nurse notified the physician to know the amount of negative pressure need the Vac therapy System on 6/18/16 and on 6/19/16 that patient continue with the Vac Therapy.
c. The physician failed to ordered wound care at the admission.
d. The nurses progress note performed from 6/18/6 to 6/27/16, the nurse documented in the integumentary system that the wound care, bandage change and wound appearance not Apply (N/A).
e. No evidence was found of care provided to patient wound on 6/18/16 an on 6/19/16.
f. On 6/20/16 at 8:45 am till 2:00 pm the patient goes to operation room for and Incision and drained (I+D) of the abscess of the back and left leg.
g. On 6/21/16 at 9:30 the physician ordered Wound Care Aquasell AG by employee #18. However the physician failed to write a complete order due to lack to write each time to provide the wound care and the area to apply the Aquasell AG.
h. The nurse in charge of wound care employee #18 documented the wound care performed on 6/21/16, on 6/23/16, on 6/24/16 and 6/27/16, however the letter was illegible.
i. On 6/22/16 the nurse of the 7-3 shift documented that wound care was provide by license Practice Nurse (LPN). However did not document the characteristic of the wound.
j. On 6/23/16 the nurse ' s note from 7-3 shift was illegible and the ulcer care nurse ' s progress note was illegible.
k. On 6/24/16 the nurse on chart note 7-3 shift document local care provided by the employee #18, however did not documented characteristic of the wound. The wound care nurse note was illegible.
l. On 6/25/16 the 7-3 shift nurses note documented that the surgeon evaluate and provide care to the wound, however the nurses did not documented the characteristic of the wound, what treatment was provide to the wound.
m. On 6/26/16 the 7-3 shift document that the bandage of the wound was clean and dry, no evidence was found related to the wound care and characteristic of the wound.
n. On 6/27/16, the nurse on chart note 7-3 shift document local care provided by the employee #18, however did not documented characteristic of the wound. The wound care nurse note was illegible.
o. On 6/21/16 the employee #18 performed the initial evaluation of the ulcer and documented the measure; however on 6/27/16 that started the next week, no evidence was found related to ulcer measure.
p. On 6/28/16, at 11:00 am the employee 18 was interview related to illegible letter in his documentation, and to interpreter this letter, he state at that time 11:00 am that "today the patient started on Vac Therapy (negative pressure system), the physician give me an telephonic order to start in Vac Therapy, and I provide the ulcer care and stared on Vac Therapy. I have not written the telephonic order yet.
However, no evidence was found at 11:05 am related to physician telephonic order.
During interview 6/28/16, at 11:30 am with the acting DON (employee #12) state that telephonic order is to be written in the medical record immediately the physician gives it.
Accordance to the facility policy and procedure related to Telephonic physician order review on 6/28/16 at 11:30 am on the item #2 state "Documented the telephonic order immediately and certify the same with the physician, reading that written and very if is the same as dictated.
However, the facility nursing staff failed to write telephonic physician order according to facility policy and procedure. The telephonic physician order to start on VAC Therapy was written after 12:00 pm.
2. R.R #68 is an 88 years old male admitted on 6/4/16 with a diagnosis of Acute Cholelithiasis, Alzheimer, Atrial Fibrillation and Diabetes Mellitus. Accordance to the review of medical record performed on 6/28/16 at 11:50 am with the DON employee #12 it was found the following:
a. On 6/5/16 at 1:00 am the physician ordered an Indwelling catheter, the nurses takes the order at 2:00 pm, however the physician failed to documented a completed Foley order that included: the size of the catheter, and when should be changed and the reason for the foley.

The Nurses failed to document in the nursing note the perianal care before foley insertion, the insertion of the foley, the size and the technique use for the insertion, the amount and characteristic of the urine after place the catheter.

b. On 6/12/16 at 5:00 am the physician ordered Foley Catheter #16. The nurse documented on 6/12/16 that foley catheter #16 was inserted by the shift supervisor. However the nursing staff failed to document the perianal care previous to foley insertion, the amount and characteristic of the urine after insertion and the activation of the plan of care for the problem of foley need. The physician failed to write a complete physician order due to the order lack of when to change the foley and the reason for the foley.

c. From 6/12/16 thru 6/27/16 the patient continue with the foley catheter; however no evidence was found that the nurse documented the foley size, the care provide to the perianal area, the patient or relative orientation and the activation of the urinary system plan of care.

d. No evidence was found of the nurses documented the nurse note on 6/18/16 at 11-7 shift, on 6/25/16 at 3-11 shift, on 6/26/16 at 3-11 shift.

e. On 6/27/16 at 8:00 pm, the physician ordered Discontinue (D/C) the intravenous fluids (IVF'S) and discharge home, however the physician failed to document the Remove of Foley Catheter. No evidence was found that the nursing staff removes or not the foley catheter after discharge home to the patient. No evidence was found if patient continuous with spontaneous urine after the foley catheter removed.

3. R.R #30 is an 87 years old male admitted on 6/3/16 with a diagnosis of Intestinal Obstruction. Accordance to the review of medical record performed on 6/28/16 at 3:30 pm with the discharge planer employee #11 it was found the following:
a. Accordance to the Transfer note between departments, the patient was transfer from intensive unit to medicine unit on 6/21/16. The nurses documented that patient has a Foley catheter #18. However, during the stay in medicine ward from 6/21/16 thru 6/28/16 no evidence was found that the nurse activate the plan of care for the urinary system problem due to need of a Foley Catheter.
b. On 6/28/16 at 8:30 am the physician ordered Discharge to Casa de Salud. On 6/28/16 the 7-3 shifts the nurse ' s note no evidence was found related to the foley catheter number. The care provide to the meatus, the nurse documented that the foley catheter was drain an patent, at 8:30 am the nurse documented that patient was evaluate by the physician and ordered Discharge with transfer to Casa de Salud of Ryder Hospital, at 12:11 pm the patient was transfer in ambulance in company of family in stretcher alert without concern. However no evidence was found related if patient was transferred with the foley catheter or not.

Based on policies and procedures (p&p's), 30 clinical records review performed on 06/27/16 - 06/29/16 and interview with the Clinical Record Assistant (employee #13), 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 2 out of 30 records review. (RR #42 and #46).

Findings include:

1. During RR performed on 06/27/16 - 06/29/16 1:00 pm it was identified incomplete physician's orders:

According to interview with Clinical Record Assistant (employee #13) performed on 06/28/15 at 1:30 pm, she stated: "The incomplete physician's orders is a concern that we identified and establish quality indicators for surveillance of incomplete records. It has been difficult to deal with the situation but we still are working incomplete records, we send letters, emails and telephone calls in an effort to notify the staff of the incomplete records".

2. During RR #42 performed on 06/28/16 at 1:30 pm, an 84 years old female who was admitted on 02/01/16 due to a diagnose of Acute Diverticulitis, it was found:

a. Order from 02/05/16 12:45 pm- Benadryl 25 mg (milligrams) IV (intravenous) x1 dose, Solumedrol 60 mg IV x1 dose. There is no evidence of the physician signature on the telephone order.

3. During RR #46 performed on 06/28/16 at 2:00 pm, an 68 years old female who was admitted on 05/05/16 due to a diagnose of Diverticulitis Sigmoid Colon, it was found:

a. Order from 02/05/16 6:50 pm- Complete Blood Count (CBC) stat, 0.9% 500 milliliters (ml) full drip. There is no evidence of the physician signature on the telephone order.

b. Order from 02/05/16 8:40 pm- Basic Metabolic Panel (BMP) in am. There is no evidence of the physician signature on the telephone order.

3. During P& Ps' review provided by Clinical record assistant (employee #13) on 06/28/16 at 3:00 pm, the Policy of medical electronic record documentation (EHR) created on 06/15/16 states on item 4. Medical Orders of treatment or Diagnostic. (7) The telephone and oral orders must be documented with date, time and signature of the physician that dictates it, within the first twenty-four hours (24 hours) of issued the order. (Regulation 117 Chapter XXII Management Services Health Information, Orders Section 6.2.a Medical treatment or diagnosis).

4.The verbal orders and the orders made by telephone should be written with date, hour and physician's signature, the one who dictated the order, during the 24 hours that the order was issue. The falicity failed to comply with federal requirements and State Law Rules and Regulations Number 117 of December 1 of 2004, Chapter 12, Article 6, Section 6, step 2a.

2. R.R #27 is a 44 years old male admitted on 6/18/16 with a diagnosis of Back Abscess and Diabetes Mellitus. Accordance to the review of medical record performed on 6/28/16 at 10:15 am with the Discharge Planning employee #11. The employee #11 state that patient was an readmission due he was receiving wound care at his home with Vac Therapy he need a recertification to continue with the treatment and the insurance medical plan delayed the authorization for the treatment and no care was provided about 3 days and the patient decide to came to the Emergency Room , then be admitted. During the record review it was found the following:
a. The Nurses History provide evidence that patient was admitted with a Negative Pressure System (Vac Therapy) placed on the back abscess and the left leg drain purulent secretion. However, no evidence was found that the nurse staff identified Discharge Planning need, related to wound care after discharge.
b. No evidence was found that the nurse notified the physician to know the amount of negative pressure need the Vac therapy System on 6/18/16 and on 6/19/16 that patient continue with the Vac Therapy.
c. The physician failed to ordered wound care on the admission.
d. The nurse ' s progress note performed from 6/18/6 to 6/27/16, the nurse documented in the integumentary system that the wound care, bandage change and wound appearance no Apply (N/A).
e. No evidence was found of care provided to patient wound on 6/18/16 an on 6/19/16.
f. On 6/20/16 at 8:45 am till 2:00 pm the patient go to operation room for and Incision and drained (I+D) of the abscess of the back and left leg.
g. On 6/21/16 at 9:30 the physician ordered Wound Care Aquasell AG by employee #18. However the physician failed to write a complete order due to lack to write each time to provide the wound care and the area to apply the Aquasell AG.
h. The nurse on charge of wound care employee #18 documented the wound care performed on 6/21/16, on 6/23/16, on 6/24/16 and 6/27/16, however the letter was illegible.
i. On 6/22/16 the nurse of the 7-3 shift documented that wound care was provide by license Practice Nurse (LPN). However did not document the characteristic of the wound.
j. On 6/23/16 the nurse ' s note from 7-3 shift was illegible and the ulcer care nurses progress note was illegible.
k. On 6/24/16 the nurse on chart note 7-3 shift document local care provided by the employee #18, however did not documented characteristic of the wound. The wound care nurse note was illegible.
l. On 6/25/16 the 7-3 shift nurses note documented that the surgeon evaluate and provide care to the wound, however the nurses did not documented the characteristic of the wound, what treatment was provide to the wound.
m. On 6/26/16 the 7-3 shift document that the bandage of the wound was clean and dry, no evidence was found related to the wound care and characteristic of the wound.
n. On 6/27/16, the nurse on chart note 7-3 shift document local care provided by the employee #18, however did not documented characteristic of the wound. The wound care nurse note was illegible.
o. On 6/21/16 the employee #18 performed the initial evaluation of the ulcer and documented the measure; however on 6/27/16 that started the next week, no evidence was found related to ulcer measure.
p. On 6/28/16, at 11:00 am the employee 18 was interview related to illegible letter in his documentation, and to interpreter this letter, he state at that time 11:00 am that "today the patient started on Vac Therapy (negative pressure system), the physician give me a telephonic order to start in Vac Therapy, and I provide the ulcer care and stared on Vac Therapy. I do not write the telephonic order yet.
However, no evidence was found at 11:05 am related to physician telephonic order. During interview with the acting DON (employee #12) state that telephonic order is to be written in the medical record immediately the physician gives.
Accordance to the facility policy and procedure related to Telephonic physician order review on 6/28/16 at 11:30 am on the item #2 state "Documented the telephonic order immediately and certificate the same with the physician, reading that written and verify if is the same as dictated.
However, the facility nursing staff failed to write a telephonic physician order according to facility policy and procedure. The telephonic physician order to start on VAC Therapy was written after 12:00 pm.
3. R.R #30 is an 87 years old male admitted on 6/3/16 with a diagnosis of Intestinal Obstruction. Accordance to the review of medical record performed on 6/28/16 at 3:30 pm with the discharge planer employee #11 it was found the following:
a. Accordance to the Transfer note between departments, the patient was transfer from intensive unit to medicine unit on 6/21/16. The nurses documented that patient has a Foley catheter #18. However, during the stay in medicine ward from 6/21/16 thru 6/28/16 no evidence was found that the nurse activate the plan of care for the urinary system problem due to need of a Foley Catheter.
b. On 6/28/16 at 8:30 am the physician ordered Discharge to Casa de Salud. On 6/28/16 the 7-3 shifts the nurse ' s note no evidence was found related to the foley catheter number. The care provide to the meatus, the nurse documented that the foley catheter was drain an patent, at 8:30 am the nurse documented that patient was evaluate by the physician and ordered Discharge with transfer to Casa de Salud of Ryder Hospital, at 12:11 pm the patient was transfer in ambulance in company of family in stretcher alert without concern. However no evidence was found related if patient was transferred with the foley catheter or not.
4. R.R #68 is an 88 years old male admitted on 6/4/16 with a diagnosis of Acute Cholelithiasis, Alzheimer, Atrial Fibrillation and Diabetes Mellitus. Accordance to the review of medical record performed on 6/28/16 at 11:50 am with the DON employee #12 it was found the following:

a. On 6/5/16 at 1":00 am the physician ordered an Indwelling catheter, the Nurses take the order at 2:00 pm; however the physician failed to document a completed Foley order that included: the size of the catheter, and every wish time to be changed and the reason for the foley. The Nurses failed to document in the nursing note the perianal care before foley insertion, the insertion of the foley, the size and the technique user for the insertion. the amount and characteristic of the urine after place the catheter.

b. On 6/12/16 at 5:00 am the physician ordered Foley Catheter #16. The nurse documented on 6/12/16 that foley catheter #16 was inserted by the shift supervisor. However the nursing staff failed to document the perianal care previous to foley insertion, the amount and characteristic of the urine after insertion and the activation of the plan of care for the problem of foley need. The physician failed to write a complete physician order due to the order lack of each time to be changed the foley and the reason for the foley.

c. From 6/12/16 thru 6/27/16 the patient continue with the foley catheter; however no evidence was found that the nurse documented the foley size. the care provide to the perianal area, the patient or relative orientation and the activation of the urinary system plan of care.

d. No evidence was found of the nurses documented the nurse note on 6/18/16 at 11-7 shift, On 6/25/16 at 3-11 shift, on 6/26/16 at 3-11 shift.

e. On 6/27/16 at 8:00 pm, the physician ordered Discontinue (D/C) the intravenous fluids (IVF'S) a discharge home, however the physician failed to documented the Remove of Foley Catheter. No evidence was found that the nursing staff removes or not the foley catheter after discharge home the patient. No evidence was found if patient continuous with spontaneous urine after the foley catheter removed.


36632


Based on fifty records reviewed (R.R) with the Clinical Record assistant (employee #13), it was determined that the facility failed to ensure that clinical records have complete documentation related to admission and final diagnosis, discharge planning, discharge note, nursing history, nurse's notes, physician's progress notes, triage and consent of blood and products transfusion for 20 out of 30 records reviewed (R.R #8, #27, #30, #39, #42, #43, #44, #45, #46, #47, #49, #50, #51, #52, #53, #54, #56, #57, #58 and #68).

Findings include:

1. During the review of 30 close clinical records (C.C.R.) on 06/27/16 - 06/29/16, 8:47 am with the Clinical Record assistant (employee #13), the following was determined:

a. In one out of thirty medical record evaluated it was identified that facility personnel failed document the time on the discharge note that the patient was officially allowed to leave the hospital. (C.C.R #51).

b. In five out of thirty medical record evaluated it was identified that facility personnel failed to complete discharge planning form. (C.C.R #39, #43, #49, #54 and #56).

c. In three out of thirty medical record evaluated it was identified that facility Registered Nurse (RN) did not document the signature on the triage form of the emergency room department. (C.C.R #44, #45 and #57).

d. In three out of thirty medical record evaluated it was identified that facility did not showed evidence of the signature of the patient on the triage form of the emergency room department. (C.C.R #44, #45 and #57).

e. In one out of thirty medical record evaluated it was identified that facility personnel did not document the date and the time that the informed consent of transfusion of blood and products was signed. (C.C.R #53).

f. In three out of thirty medical record evaluated it was identified that facility personnel did not include patient signature on the discharge summary form. (C.C.R. #52, #54 and #58).

g. In one out of thirty medical record evaluated it was identified that the physician did not document the signature on the discharge summary form. (C.C.R #47).

h. In one out of thirty medical record evaluated it was identified that facility personnel did not document the reason for hospitalization (principal diagnosis) on the discharge summary form. (C.C.R #47).

i. In two of thirty medical record evaluated it was identified that facility personnel did not document the discharge diagnosis on the discharge summary form. (C.C.R #8, and #47).

j. In one out of thirty medical record evaluated it was identified that facility RN failed to document the signature on the patient flow sheet note. (C.C.R #54).

k. In one out of thirty medical record evaluated it was identified that facility RN failed to document the signature on the patient history and admission note for intensive unit care form. (C.C.R #54).

l. In two out of thirty medical record evaluated it was identified that facility personnel failed to signed medical telephone orders (C.C.R. #42 and #46).

m. In one out of thirty medical record evaluated it was identified that facility personnel failed to document in the physician progress notes date and time (C.C.R. #50).

Based on thirty clinical records review performed on 06/27/16 - 06/29/16 and interview with the Clinical Record Assistant (employee #13), it was determined that the facility failed to ensure that clinical records contain the final diagnosis within 30 days following discharge or outpatient care for 2 out of 30 records reviewed (R.R # 8 and #47).

Findings include:

1. During RR #8 performed on 06/27/16 2:35 pm, 54 years old male who was admitted on 04/08/16 due to a diagnose of Multiples Adhesions, it was found that facility personnel did not document the final diagnosis on the discharge summary.

2. During RR #47 performed on 06/29/16 2:15 pm, 54 years old male who was admitted on 02/22/16 due to a diagnose of Myocardial Infarct, it was found that facility personnel did not document the final diagnosis on the discharge summary.

Based on thirty clinical record reviewed (R.R), with Clinical Record Assistant (employee #13), it was determined that facility failed to ensure that clinical records are complete within 30 days following discharge or outpatient care for 17 of 30 records reviewed. (R.R #8, #39, #42, #43, #44, #45, #46, #47, #49, #50, #51, #52, #53, #54, #56, #57 and #58).

Findings include:

1. During the review of thirty clinical records from 06/27/16 - 06/29/16 at 3:30 pm with Clinical Record Assistant (employee #13), it was identified on 17 clinical records with incomplete documentation within 30 days following discharge. (R.R #8, #39, #42, #43, #44, #45, #46, #47, #49, #50, #51, #52, #53, #54, #56, #57 and #58).
a. The "Delinquent Clinical Records Report of 2016" revealed that there are 1,500 incomplete clinical records by the medical staff from January to May 31, 2016. There is an average of 92 to 438 monthly incomplete medical records.

c. On 6/27/16 at 9:06, the Radiology Services Department was visit with the Radiology Supervisor (Employee #10) and in the Fluoroscopy and Radiology unit #2, it was found in a cabinet approximated 9 container of contrast without lock, accessible to non authorized personnel.
d. On 6//27/16 at 10:30 am, the Radiology Services Department was visit with the Radiology Supervisor (Employee #10) and in the Radiology unit #1, it was found at the right side of the room in a wood shelf without lock, a small open basket identified as Emergency Tray with the following medication: 5 vial of 10 milliliter (ml) of Sterile Water, 5 vial of Solumedrol 40 milligram (mg) /ml, 5 ampule of Epinephrine 1:1000, 1 vial of 20 ml of Lidocaine 1% 10 mg/ml, 1 vial of 20 ml of Lidocaine 2% 100 mg/ 5 ml, 5 vial of 10 ml of Benadryl 50 mg/ml, 1 vial of 20 ml of Atropine 8 mg/20 ml and 2 vial of 10 ml of Aminophilline 250 mg/10 ml., accessible to non authorized personnel.


34043


Based on observations, controlled substance count, emergency carts check, medications carts verifications, medications storage check and interviews, it was determined that the facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel.

Findings include:

1. On 6/29/16 at 10:12 am a tour was perform with the Pharmacy Director (Employee #6) for the verification of proper storage of the drugs and biological

a. During the Emergency Room medications storage check on 6/29/16 at 10:51 accompany with employee #6 and with the emergency room supervisor RN #7 it was found the Emergency room medications storage door unsecured, medications cabinet unlocked and medications refrigerator unlocked. The facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel.
b. On 6/29/16 at 1:40 pm on the 3rd floor medical surgical ward accompany with employee #6 it was found the medications carts unsecured. On 6/29/2016 at 1:46 pm during interview with the RN Supervisor (Employee #7) state that the two medications carts did not have keys for secure them. 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 spot check of the emergency cart on the medicine and surgery ward with the Pharmacy Director (employee #6) it was determined that the facility failed to ensure that Outdated, mislabeled, or unusable drugs and biological are not available for patient use.

Findings included:

During the spot check of the emergency cart on the medicine and surgery ward on 06/29/16 at 1:46 pm with the Pharmacy Director (employee #6) the following was found:

1. On 06/29/16 at 1:46 am it was found in the emergency cart Epinephrine 1:1000 1mq/1ml with an expiration date 06/01/16 available to patient use.

The facility failed to ensure that Outdated, mislabeled, or unusable drugs and biological are not available for patient.

Based on observation of the Radiology service and interview with the Radiology supervisor (employee #10), it was determined that the facility failed to ensure that diagnostic and therapeutic services meet the standard for safety and be free from hazards for patients for 2 out of 2 radiology units.

Findings included:

During the observation tour of the Radiology Department with Radiology Supervisor (employee #10), on 6/27/16 from 8/50 am thru 1:30 pm, it was found that he Radiology service has two unit of Radiology, in Radiology Unit #1 they performed diagnostic X-ray, and in the Radiology Unit #2 they performed the Fluoroscopy.

1. During Interview with the Radiology services Supervisor (employee #10) on 6/27/16 at 10:30 am state that the Radiology Department did not have a crash cart. If an emergency occur they transfer the patient to the Emergency Room. When they going to performed and study in the radiology unit #2 and Fluoroscopy, the nurse carries the emergency tray and the emergency medication basket from the radiology Unit #1.
2. Evidence was provided that the Radiology department has an Emergency tray in the Radiology unit #1 with medical equipment for intubation over the counter in the left side of the room. In the right side of the room near the radiology aprons it was observed the manual resuscitator bag and in the right side of the room in a wood shelf without lock, it was found a small open basket identified as Emergency tray with 5 vial of 10 milliliter (ml) of Sterile Water, 5 vial of Solumedrol 40 milligram (mg) /ml, 5 ampule of Epinephrine 1:1000, 1 vial of of 20 ml of Lidocaine 1% 10 mg/ml, 1 vial of of 20 ml of Lidocaine 2% 100 mg/ 5 ml, 5 vial of 10 ml of Benadryl 50 mg/ml, 1 vial of 20 ml of Atropine 8 mg/20 ml and 2 vial of 10 ml of Aminophilline 250 mg/10 ml.
3. According to the employee #10 the average of patient attendance by month was between 1144 to 1345. The distance from the Radiology department and the emergency room was approximated 50 lineal feet's.
4. The facility Radiology services failed to maintain a secure crash cart that contains all necessary equipment in one place including a cardiorespiratory monitor with defibrillator to promote free from hazards and secure for patients.

Based on personnel records review and laboratory general supervisor interview at 11:00 a.m. on 6/28/16, it was determined that the laboratory failed to follow the established schedule for clinical consultant evaluation.

The findings include:

1. The laboratory schedule for clinical consultant competence evaluation showed that it must be performed every year.

2. The laboratory did not perform the clinical consultant competence evaluations since 1/2015.

3. The laboratory general supervisor confirmed that the competence evaluations were not performed as established.

Based on blood gases quality control records review and laboratory testing personnel interview at 12:40 p.m. on 6/28/16, it was determined that the laboratory failed to perform and document the required daily preventive maintenance of the Cobas b 221 system instrument.
The findings include:
1. The laboratory uses Cobas b 221 system to perform the blood gases samples tests.
2. The manufacturer manual instructed the laboratory to perform and document the following daily preventive maintenance: Check fill levels and Check printer paper.
3. From 10/2015 to 6/2016, the records showed that the laboratory did not perform nor document the daily preventive maintenance 61 days out of 244 days.
4. The laboratory processed and reported one hundred eighty three (183) blood gases patient ' s samples test those days.
Based on blood gases quality control records review and laboratory testing personnel interview at 12:40 p.m. on 6/28/16, it was determined that the laboratory failed to review and evaluate calculated blood gases ratio results (BE, HCO3a, tCO2, O2 Sat).

The finding includes:

1. The laboratory testing personnel confirmed that the laboratory failed to review and evaluate the instrument calculated blood gases ratios using an alternative method since November 2014.

Based on kitchen observational tour, review of policies/procedures and interviews, it was determined that the facility failed to ensure that food and dietetic services organization requirements are met, related with lack of hot water on one of the stations for hand washing and detergents, sanitizers and cleaners are storage without lock.

Findings include:

1. During the kitchen observational tour performed with the administrative dietitian (employee #3) from 6//28/19 through 6/29/16, the following was observed:

a. Hand washing sink located in front of the area were the ice machine is located does not had hot water. Facility failed to promote that kitchen equipment comply with required fixtures to promote appropriate hand washing procedures as required by Chapter 2 2013 of the food code.

b. The kitchen area where detergents, sanitizers and cleaners are storage does not had a device to lock the doors. Facility failed to comply with requirements established in the Chapter 7; 2013 of the food code for the storage of chemical products in the kitchen.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Physical Plant Director (employee #XX), 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. During the observational tour performed on Emergency Room (E.R) on 6/27/16 from 9:00 am until 12:10 pm the following was found:
a. Waiting room area:
1. The water fountain in the waiting room do not functioned.
2. The restroom for man and women on the waiting area does not have exhaust fan.
3. The man restroom door was observed with graffiti.
b. Respiratory Therapy Area:
1. Cubicle #1: it was observed with lounge chair cover broken in the area of the back, buttock and arm rests.
2. Cubicle #2: it was observed the lounge chair broken and with the cover peeled on the arm rest and lot of mold. The cubicle curtain was observed with blood stain on it.
3. Cubicle #3: it was observed the cubicle curtain with stains and the lounge chair with mold stain and the cover ripped.
c. Triage Area
1. The counter where the baby scale is located was observed with broken Formica.
2. The sampling blood area has no sink. The staff nursing had to go wash their hands in a medical exam room. At 9:10 am it was observed a stretcher blocking the lavatory where register nurse (RN) employee #Keyla Marcano shows where she washed her hands. There lavatory was observed dirty. Also this area does not provide privacy when nurse is taking blood sample to a patient.
3. The sampling blood area also had a stretcher for pediatric patients. This stretcher it was observed over a wooden base. The wood was observed all ripped. In this area RN placed intravenous infusions and take blood samples from pediatric patients.
4. The door of the triage area is clear and does not provided privacy to the patient.
d. Janitor room:
1. The door of the janitor room in the receiving ambulance area it was observed on 6/27/16 at 9:15 am with the lock broken and it was covered with duct tape.
2. Two ceiling tiles were removed and two broomsticks were observed touching the ceiling.
e. Observation #1 area:
1. The call system box in the bathroom was observed with rust.
2. It was observed not treated wooden shelves with surgical medical equipment.
3. The medication room was observed at 9:20 am with the door unlocked. the cabinet for controlled drugs unlocked.
4. The intravenous fluid storage is made with untreated wood.
5. The counter where the suture material is located was observed unlocked and one of the locks is broken.
6. It was observed a wooden table at the cardio room. Employee #XX indicates at 9:48 am that the wooden piece it is use to put behind the patient backs at the event of a CPR. The wooden piece was observed deteriorated and ripped and without pieces of wood.
f. Observation #2 area
1. The lock for the restroom was broken from the outside and does not have key to open it
2. On cubicle #5 was observed ceiling tiles out of place.
3. Cubicle #12 and #14 was observed with peeling off painting on the walls and the cubicle curtains with stains.
4. The surgical medical supply storage was observed at 9:55 am with: two untreated wooded cabinets without lock, office material inside the surgical medical storage. The entrance of the storage had untreated porous wooden frame and wooden door.
5. Cubicle #10: The gypsum board wall was observed with a hole, peeling off pain t and porous untreated wooden molding. Ceiling tiles out of place.
6. Cubicle #7: The walls were observed with humidity bumps. The mattress of the crib was broken.
7. Cubicle #8: The mattress of the crib was peeled.
8. The bathroom does not have exhaust fan
g. Intensive care Unit
1. Ceiling tile in front of the nursing station broken.
2. All the nursing station chairs are covered with cloth and it were observed dirty.
3. The dirty utility room does not have exhaust fan.
4. The surgical medical storage are untreated wooden material and the storage have a strong odor of humidity.
5. The patient rest restroom: it was observed a commode with rust and under the lavatory sink it was observed cleaning detergent without lock.
6. The isolation room: Ceiling tiles with mold, missing rubber base in front of the restroom. The restroom has three sweaters hanging from the shower pole. The night table was observed broken and the base from the dinner table was observed with rust. The night light cover was observed broken.
7. There not near lavatory for the nursing staff wash their hands.
h. Kitchen:
1. It was observed one wooden wall with Termites residues on the floor.
2. The fridge floor entrance was observed with rust.
i. Pharmacy:
1. It was observed on 6/27/16 at 10:35 am the medication storage with wooden pallets on the floor.
2. All the cabinets are wooden.
3. Ceiling tiles with humidity stain (mold).
4. The bathroom does not have exhaust fan.
j. The security Camera room:
1. All ceiling tiles out of place. A lot of cables crossing the ceiling without straps.
k. Radiologic Area:
l. The fluoroscopy room was observed with ceiling tiles with mold stains. The restroom in this area was observed the ceiling tiles with mold. The call system does not have the cord.
m. Morgue (Cold room)
1. It was observed a lot of mold around the main entrance door.
2. It was observed that the walls are covered with a material (Insulation) that not permitted a proper sanitization and disinfection of the room.
3. It was observed the room without clean.
4. It was observed a lot of condensation inside the room.
5. No temperature, humidity and cleaning log report was provided.
n. Procedure room:
1. The restroom door with termite.
2. The telephone box improperly installed.
3. The wall was observed with 6 missing tiles.
4. Ceiling tiles with mold.
5. Stretcher with rust.
6. Table with endoscopy equipment with rust.
7. Wall tiles with mold.
8. The floor with old stains.
o. The emergency room were visited on 6/27/16 from 9:00 am until 11:00 am and on 6/28/16 from 9:00 am until 9:45 am and provided evidence that patient's bathrooms can be locked from the inside, however personnel did not have a device with them to open the doors when the system was activated during bathroom call systems testing. Personnel arrived at the bathrooms without a device that was supplied to them by the physical plant department and valuable time was lost when they went back to the nurse's counter to look for the device. All personnel must receive in-service training related to carrying this device with them for all shifts along with periodic testing for compliance.
p. The hospital's laundry was visited on 6/28/16 at 11:20 am and provided evidence that the flow of dirty linen to the washer machine, to the dryer and then to the clean linen folding table does not move in one direction (from dirty to clean). The dirty linen cart enters past the clean linen folding table and stops in front of the washer, after the linen are washed they go towards the back of the room to the dryer and when they finish drying they pass by the dirty linen cart and washer to get to the clean linen folding table near the main entrance. This procedure increases the risk of cross contamination of the clean linen with the dirty linen.
q. The biohazard waste storage room was observed on 6/28/16 at 11:15 am the air conditioner was observed that was recently turned on.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Physical Plant Director, it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed from 6/28/18 from 9:00 am until 4:00 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form ( K0048, K0050 and K0130).

Based on observations made during the survey for the physical environment with the facility's Physical Plant Director, it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality for 2 out of 2 defibrillators..

Findings include:
1.The Emergency room has two defibrillator that is located near the nursing station during the observational tour on 6/27/16 at 9:40 am a test was performed with and without electrical power only battery power. The battery allows the tests.
Evidence was found that the biomedical technician verified the battery during his last inspection. However no evidence was found about tests performed by nursing staff with electrical power and without electrical power on 6/24/16 (shift 3:00 pm to 11:00 pm) on defibrillator #1. Defibrillator #2 no evidence was found on 6/9/16 (3:00 pm-11:00 pm written note indicating " No function " , 11:00 pm - 7:00am " Do not print " ),6/11/16 (11:00 pm-7:00 am), 6/12/16(3:00 pm- 11:00pm),6/14/16(3:00pm -11:00pm), 6/20/16, 6/21/16(3:00pm- 11:00pm),6/23/16 (11:00pm-7:00am), 6/24/16(3:00 pm-11:00pm) and 6?26/16(3:00 pm-11:00pm).
2. The facility failed to ensure staff kept evidence of the tests performed daily.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Physical Plant Director and interview, 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. The pull cords of the emergency call systems in the bathrooms of the surgery ward (rooms #302 through #315), medicine ward (rooms #101 through #109) were observed on 6/27/16 from 11:30 am until 3:00 pm and on 6/28/16 from 9:00 am until 10:00 am. It was found that the showers have pull cords positioned to allow patients to activate them if needed, however patients in the toilet area do not have a pull cord close to them to summon for help and the pull cords of the shower are not accessible from the toilet or if they fall to the ground near the toilet.
2. The emergency room was visited on 6/27/16 from 9:00 am until 11:45 am and the triage area was observed. The triage room has two openings to gain access to this area, one has a sliding metal door with plexi-glass and the other opening is uncovered. The sliding door is extremely difficult to open and close and was found in the opened position and the opening without anything is located near the main entrance to access the emergency room. These openings do not protect the patients during interviews and physical evaluations from auditory and visual privacy. Doors that can be easily opened and closed and provide visual and conversational privacy are required.
3. The operating room department was visited on 1/28/16 from 10:15 am until 11:15 am and provided evidence of the following:
a. The pre-induction lounge chair area (seven lounge chairs) is located in a non-restricted hallway used by staff to access the dressing rooms.
b. The phase II area contains three lounge chairs. These chairs must be separated by curtains and there needs to be at least four feet between each chair and the seats should be placed to avoid visual contact from patient to patient.
4. The operating department does not have a designated preoperative patient holding area as described in "The Guidelines for Design and Construction of Health Care Facilities" 2010 edition chapter 2.1 sections 5.3.3.1.

Based on the observations tour with the infection control officer and interviews, it was determined that the facility failed to promote a sanitary and safe care through its infection control program in the emergency room, medical/surgical ward, endoscopic procedure room and laundry department related to improper infection control procedures and failed to follow infection control standards of practice.

Findings include:

1. Facility did not promote or operationalize procedures consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable diseases. The following was observed during survey procedures on 6/27/16 through 6/13/16 from 9:00 am till 3:30 pm related to infection control procedures:

a. In the emergency room department in the area was mid-acuity ambulatory patients received respiratory treatment it was observed three traditional living room recliner chairs. Those chairs of leather or similar material are observed in bad condition with ripped upholstery. The areas were the material is peeled does not permit a complete disinfection between patients use.

b. Acid acetic and water were found rebottle in a spray container of dermal wound cleanser.
No label indicates percent of dilution or date when the solution is prepared.

Emergency room nursing supervisor (employee #7) stated on interview on 6/29/16 at 9:13 am that this solution is used to provide local care to patients who visit emergency room with history of pressure ulcers.

c. Housekeeping room/storage located in the emergency room department was observed with the device to lock the door broken. Patients and employees may see into this restricted space as they are passing by. Accordingly with information provided by housekeeping supervisor (employee # 4) 6/28/16 at 10:35 am, housekeeping room/storage doors must always be kept locked for safety.
d. In the facility laundry area there is no clear separation of soiled laundry space from clean laundry areas and soiled laundry who maintain negative pressure.

e. In the medical/surgical ward doors of room # 301,# 302,# 303,# 304, # 305 and # 306 were observed in bad condition with Formica chipped and broken, this does not permit complete cleaning, encourage the growth of bacteria and may harm patient skin if contact with those areas.

f. Cadavers cold storage room used for the storage of human corpses were observed in need of cleaning, two stretchers with blankets were observed located inside the room and one dead cockroach in the floor.
Infection control officer (employee # 2) ,stated on interview on 6/29/16 at 11:59 am that she does not have keys of the cold storage room, that only maintenance and environmental personnel had access to this place. Policies for infection control at the cold storage room were not available for review.


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h. During the round to observe and evaluated the Operating Room Department on 6/29/16 at 9:00 a. m. in the main entrance of the operating room was observed a traditional living room recliner chair designated to sit the ambulatory patient's, this is and opening area used by the nurse to identified the patient and oriented related to the area designated to change the clothes and then the nurse accompanied the patient to the pre-anesthesia area.

The area designated for this procedure receiving and orienting patients was located near the area designated and sign reads " Area de Almacenamiento de desperdicios biomedicos personal autorizado solamente '' Area to store biomedical waste personal authorized only, in this area it was observed a small refrigerator and the nurse supervisor (employee #26 ) stated that the area was used also to place biomedical waste and the refrigerator for pathologies. ''

" Utility Room '' inside of this utility room the following was observed: one stair, one oxygen tank, a regular trash can without lid, an open biohazard trash can, five mops, one used for lunch area, one for recovery room, one for waiting room, corridors, office and one for contaminated areas. In the same room it was observed one gallon of water and 2 ounces of Marzan dissolve, one gallon of water dissolve with 10 ml of Clorox and the material safety data sheet manual.

On the main corridor of the operating room area was observed at left side shelf con crystal doors where lens are placed and medications for eye surgery. In front of the shelf on the same corridor a wood doors was observed and on the interior of this storage was observed sterile trays used on the deferent surgeries. A clock was observed in the interior of this storage and the humidity was on 62 % and the temperature was on 67.1 grades Fahrenheit at 9:16 a. m.

Two bottles of Marzan dissolved were observed on the housekeeping car around the bottles adhesive bandage was used as label to label the bottle used on Room #1.

The operating room number two was observed with the temperature at 9:35 a. m. stay on 64.2 grades Fahrenheit and Humidity was on 60 percent (%). The clock did not mark the real hour it showed 10:45 a.m.

The designated area for intravenous fluids '' Almacen de liquidos Intravenosos '' provides evidence of the daily log for temperature and humidity for year 2016 the log provide evidence of following:

January 4 temperature 19.9 grades centigrades
February 11 and 12 temperature 19.4 grades centigrade, 2/16/16 temperature 19.1 grades centigrade, 2/17/16 temperature 19.3 grades centigrade, 2/18/16 temperature 19.4 grades centigrade, 2/19/16 temperature 19.2 grades centigrade, 2/22/16 temperature 19.3 grades centigrade, 2/23/16 temperature 19.2 grades centigrade, 2/24/16 temperature 19.4 grades centigrade, 2/25/16 temperature 19.3 grades centigrade, 2/26/16 temperature 18.4 grades centigrade and Humidity was on 48 % and on 2/29/16 temperature 19.3 grades centigrade.

March 1, 2, 8, 9, 17 and 18 the temperature was 18 º grades centigrade, on March 3 and 24 the temperature was on 18.5 grades centigrade, on March 4 the temperature was on 19.4 grades centigrade, on March 7 the temperature was on 14.1 grades centigrade, on March 10 the temperature was on 17.4 grades centigrade, on March 11 the temperature was on 17.5 grades centigrade, on March 14 and 25 the temperature was on 19.0 grades centigrade, on March 15 and 31 the temperature was on 19.1 grades centigrade, on March 16 temperature 19.2 grades centigrade, on March 18 the temperature was on 18.3 grades centigrade, on March 21 the temperature was on 19.0 grades centigrade, on March 22, 23 and 30 the temperature was on 19.3 grades centigrade and on March 29 the temperature was on 18.7 grades centigrade. Humidity was on 48 % and on 2/29/16 temperature 19.3 grades centigrade.

March 1, 2, 8 and 11 the humidity was on 49 %, on March 3, 9, 10 and 24 the humidity was on 47 %, on March 4, 7, 14, 15, 16, 21, 25 29 and 31 the humidity was on 51 %, on March 17, 22, 23, 28 and 30 the humidity was on 50 % and on March 18 the humidity was on 45 %.

April 1 of 2016 the temperature was 19 grades centigrade, on April 4, 7, 11, 14 and 20 the temperature was on 19.3 grades centigrade, on April 5, 12 and 19 the temperature was on 19.1 grades centigrade, on April 6 the temperature was on 19.4 grades centigrade, on April 8 the temperature was on 18.1 grades centigrade, on April 13 and 21 the temperature was on 19.5 grades centigrade, on April 15 and 25 the temperature was on 19.8 grades centigrade, on April 18 the temperature was on 19.9 grades centigrade, on April 22 temperature was on 19.7 grades centigrade.

April 14 and 15 the humidity was on 49 %.

May 9, 20 and 25 of 2016 the temperature was 19.9 grades centigrade, on May 26 the temperature was on 19.8 grades centigrade and on May 27 and 30 the daily temperature log provide evidence that the daily temperature was not taken by the personnel.

On May 3 the humidity was on 49 % and on May 27 and 30 the daily humidity log provide evidence that the daily humidity was not taken by the personnel.

According of the daily log for temperature and humidity for year 2016 for this area designated for '' Storage for Intravenous Fluids '' the acceptable temperatures was maintain enter 20 to 26 grades centigrade and the Humidity acceptable parameters was maintain between 50 % to 70 %. The document provides evidence that when changes are detected on temperature and humidity notify to physical plant. According of this document on February 12 of 2016 at 1:45 p.m. was notify at Physical Plant to notified the person on charge related to this situation however no documentation evidence when the personnel resolved the situation.

The log designated for '' Limpieza Diaria De Suministros Esteriles'' Daily cleaning of Sterile Supplies, was reviewed and according to the information written in the document the daily cleaning is performed by technician of environmental control, for the assign equipment and Marzan Solution,' the log was reviewed on 6/29/16 at 10:30 a. m. and provide evidence that on March 25, May 30 and June 2 of 2016 the daily cleaning was not performed.

The log designated for ''Limpieza diaria de Sala de Operaciones Room #1 and Room #2 '' Daily Cleaning of Operating Rooms was reviewed and according of the information on May 18 and 30, did not performed the daily cleaning on both operating rooms. The document provide evidence that on May 18 it is written the letter '' A'' on both logs and on May 30 the space was maintain in blank.

The log designated for ''Registro de limpieza General Mensual Sala de Operaciones year 2016 '' Monthly Register of General Cleaning of Operating Rooms year 2016, did not provide evidence of monthly cleaning of the ' ' Equipment Room and Anesthesiology Office '' on January 15/16 and on May 6/16 for the walls of the Lounge, both of the spaces was observed in blank.

i. On the Anesthesia room the following was observed:

On the interior of the wash station (lavamano) it was observed three boxes of red wipes, three gallons of Metrzyme, two boxes of Cavi wipes, one gallon of Cydex OPA and one black box of tools.

On the top of the counter a blue large canister was observed and has a label and read: Cydex prepared on 6/20/16 expired on 7/4/16 and signed by the anesthetist nurse.

The nurse supervisor of anesthesia (employee #27) was interview related to the disposition of the Zydex solution and she stated that the material was discard on the same wash stand (fregadero ) this room did not have extractor and was management by the Central Supply employees.

'' The Advanced Sterilization Products ' ' ASP ' ' on page number 3 section number 8 " Controls for the Exposition / PersonalProtection '' on the second section established on technical controls '' Utilicese en una zona bien ventilada '' use on a ventilated area, however the two areas available to place this product was on the Anesthesia Office and on the Central Supply '' the two area are closed areas and none have an adequate ventilated area.

j. The Skin Care and Wound Manual was reviewed on 6/30/16 at 11:35 a. m. and lacks of the date when was approved, date of revision and the next date of revision. On the first page reading '' Guides for Management of Ulcers and Wounds '' approved by Surgery Director, Nurse Service Director and Medical Director. They provided evidence Acting Nurse Director was interviewed related to the Skin Care facility program.

The second page reading '' Guides for Management of Ulcers and Wounds '' approved by Skin Care Coordinator, Nurse Service Director, Surgery Director and Medical Director. Reviewed on September of 2012 next revision on September 2014.

The third page reading '' Skin Care Program Management of Ulcers and Wounds '' performed by Nurse Director R.N.B.S.N. approved by Medical Director and Surgery Medical Director reviewed on August 2014 next revision on August 2016. The page is not signed by the Surgery Director and the nurse director revoke on March of 2016.

On 6/30/16 at 1:15 p. m. the binder designated to ' ' Guides and Nursing Protocols '' was reviewed and lacks of ulcers and wounds management. The Acting Nurse Director (employee #12) was interviewed related to if the facility has an active program for patients to management the skin care ulcers and wounds. She stated: '' As of today the facility designated a Associated nurse to provide care to all of the patient's admitted at the facility, we have ulcers and wounds. He provided care from Monday through Friday from 8:00 a. m. till 4:00 p. m. As of today the facility initiated a committee of '' Skin Care '' and only has performed two meetings one on December 2 of 2015 and the second on April 27, 2016. According to the Acting Nurse Director the physician committee president (employee #28) is taking the course about skin care/ management to then offer it at the facility " .


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g. During the initial tour of the radiology department with the employee #10 on 6/27/16 at 8:50 am it was observed in the record storage room and portable x-ray machine with a tape holding an marker pen to identified the left and right side of the radiology. This tape not provide for the complete disinfestations of the x-ray machine. At 9:05 am in the Sonography room it was observe 3 boxes and a cushion under the stretcher directly on the floor.


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k. On 06/28/2016 at 1:49 pm during a tour with the respiratory therapist (employee #29) it was identified on the third floor a room where the mechanicals ventilators were storage. The storage area was found unlock and observed unorganized and the following was found:

In the same room that clean and disinfected mechanic ventilators were store it was found on the left side of the room multiples medical equipment and on the right side of the storage is a table with chairs, a bed, a television, telephone, unsecure sharp container on the floor and a red trash can with Biohazard trash.

The facility fails to maintain the storage area secure for the prevention of non-authorized access.
The facility fails to properly maintain the area to limit infection control risks and possible cross contamination.

l. On 6/28/2016 at 2:00 pm during a visit on the respiratory therapy department with employee#29 it was found a bi-pap with the stand rust and moldy this does not permit complete cleaning and encourage the bacterial grow.

Based on review of five records reviewed (R.R), policies/procedures review and interview with the Discharge Planning and Social Worker Director (employee #11) on 6/27/16 from 1:45 pm thru 4:00 pm and 6/28/16 from 9:35 am thru 4:30 pm, it was determined that the facility failed to reassess the patient's discharge plan to identify and address factors that may affect continuity of care accordingly with patient needs, for 1 out of 5 records review (RR #66).

Findings include:

1. During Interview with the Discharge Planning/Social Worker Director on 6/27/16 at 2:00 pm related to the discharge planner process she stated that "I'm on charge to perform all discharge planning process, only one personnel for this process. The Discharge planning starts on admission we provide a screaming sheet that the same patient identified need that they had. Within 48-72 hour of the admission I take the patient census and evaluate and sign all screening sheet and identified the patient that need follow for discharge planning. This patient that I identified that need a discharge planning I reassess their need or if any change in their condition. I evaluate an average census by month of 60 patients in this hospital. Same time one patient takes me all day to their discharge pacification. I was the only social worker to evaluate all social problem of the patient in the hospital. Some time It does not give me the time to serve all them.

2. During the review of 5 medical records for discharge Planning Services with the employee #11 the following it was found:

a. R.R #66 is a 77 years old male admitted on 6/1/16 with a diagnosis of Congestive Obstructive Pulmonary Disease (COPD), Respiratory Failure, Congestive Heart Failure (CHF) and Diabetes Mellitus. The record review was performed on 6/28/16 at 9:35 am with the employee #11. The record provides evidence that the discharge planning employee #11 evaluated the screening sheet on 6/3/16 and performed the initials evaluation for discharge planning. and identified need for Home Health Services and Medical equipment.

The reassessment for change on their need or condition was performed on 6/13/16, 6/20/16 no change was identified. The facility failed to reassess patient need each 72 hour according to facility policies and procedure for Discharge planning reassessment. Then the discharge planning continue their intervention every 2-3 days with the medical insurance plan to approve the medical equipment As positioning bed, Air Mattress, wheel chair, walker, Bi-PAP, Respiratory Therapy, Oxygen, and Home Care.

Based on observations made of the surgical department, interview and review of policies/procedures with the Operation Room Nurse Supervisor (employee #26), it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice and patients' care.

Findings include:

1. During the observation round to evaluated the Operating Room Department on 6/29/16 at 9:00 a. m. in the main entrance of the operating room was observed a traditional living room recliner chair designated to seat the ambulatory patient's, this is and opening area used per the nurse to identified the patient and oriented related to the area designated to change the clothing and then the nurse accompanied the patient to the pre-anesthesia area. The area designated for this procedure receiving and oriented patients was located near the area designated and label read: " Area de Almacenamiento de desperdicios biomedicos personal autorizado solamente '' Area of storage of biomedical waste only authorize personnel, in this area was observed a small refrigerator and the nurse supervisor (employee #26) stated that the area was used also that the area was used also to place biomedical waste and the refrigerator for pathologies.

a. " Utility Room '' inside of this utility room the following were observed: one stair, one oxygen tank, a regular trash can without lid, an open biohazard trash can, five mops one used for lunch area, one for recovery room, one for waiting room, corridors, office and one for contaminated areas. In the same room was observed one gallon of water and 2 ounces of Marzan dissolved, one gallon of water dissolved with 10 ml. of Clorox and the material safety data sheet manual.

b. On the main corridor of the operating room area was observed at left side shelf with glass doors where lens are places\d and medications used for eyes surgeries. In front of the shelf on the same corridor a wood door was observed and on the interior of this storage was observed sterile trays used on the different surgeries. A clock was observed on the interior of this storage and the humidity was on 62 percent (%) and the temperature was on 67.1º grades Fahrenheit at 9:16 a. m.

c. Two bottles of Marzan dissolved was observed on the housekeeping car around the bottles adhesive bandage was used as label to label the bottle used on Room #1.

d. The operating room number two was observed the temperature at 9:35 a. m. stay on 64.2 grade Fahrenheit and Humidity was on 60 %. The clock did not mark the real hour indicated 10:45 a.m.

e. The designated area for intravenous fluids '' Almacen de liquidos Intravenosos '' provovides evidence of the daily log for temperature and humidity for year 2016 the log provide evidence of following:

January 4 temperature 19.9 grades centigrade

February 11 and 12 temperature 19.4 grades centigrade, 2/16/16 temperature 19.1 grades centigrade, on 2/17/16 temperature 19.3 grades centigrade, on 2/18/16 temperature 19.4 grades centigrade, on 2/19/16 temperature 19.2 grades centigrade, on 2/22/16 temperature 19.3 grades centigrade, on 2/23/16 temperature 19.2 grades centigrade, on 2/24/16 temperature 19.4 grades centigrade, on 2/25/16 temperature 19.3 grades centigrade, on 2/26/16 temperature 18.4 grades centigrade and Humidity was on 48 % and on 2/29/16 temperature 19.3 grades centigrade.

March 1, 2, 8, 9, 17 and 18 the temperature was 18 grades centigrade, on March 3 and 24 the temperature was on 18.5 grades centigrade, on March 4 the temperature was on 19.4 grades centigrade, on March 7 the temperature was on 14.1 grades centigrade, on March 10 the temperature was on 17.4 grades centigrade, on March 11 the temperature was on 17.5 grades centigrade, on March 14 and 25 the temperature was on 19.0 grades centigrade, on March 15 and 31 the temperature was on 19.1 grades centigrade, on March 16 temperature 19.2 grades centigrade, on March 18 the temperature was on 18.3 grades centigrade, on March 21 the temperature was on 19.0 grades centigrade, on March 22, 23 and 30 the temperature was on 19.3 grades centigrade and on March 29 the temperature was on 18.7 grades centigrade. Humidity was on 48 % and on 2/29/16 temperature 19.3 grades centigrade.

March 1, 2, 8 and 11 the humidity was on 49 %, on March 3, 9, 10 and 24 the humidity was on 47 %, on March 4, 7, 14, 15, 16, 21, 25 29 and 31 the humidity was on 51 %, on March 17, 22, 23, 28 and 30 the humidity was on 50 % and on March 18 the humidity was on 45 %.

April 1 of 2016 the temperature was 19 grades centigrade, on April 4, 7, 11, 14 and 20 the temperature was on 19.3 grades centigrade, on April 5, 12 and 19 the temperature was on 19.1 grades centigrade, on April 6 the temperature was on 19.4 grades centigrade, on April 8 the temperature was on 18.1 grades centigrade, on April 13 and 21 the temperature was on 19.5 grades centigrade, on April 15 and 25 the temperature was on 19.8 grades centigrade, on April 18 the temperature was on 19.9 grades centigrade, on April 22 temperature was on 19.7 grades centigrade.

April 14 and 15 the humidity was on 49 %.

May 9, 20 and 25 of 2016 the temperature was 19.9 grades centigrade, on May 26 the temperature was on 19.8 grades centigrade and on May 27 and 30 the daily temperature log provide evidence that the daily temperature was not taken by the personnel.

On May 3 the humidity was on 49 % and on May 27 and 30 the daily humidity log provide evidence that the daily humidity was not taken by the personnel.

f. According of the daily log for temperature and humidity for year 2016 for this area designated for '' Storage for Intravenous Fluids '' the acceptable temperatures was maintain enter 20 to 26 grades centigrade and the Humidity acceptable parameters was maintain enter 50 % to 70 %. The document provides evidence that when was a detected change on temperature and humidity notify to environment employee. According of this document on February 12 of 2016 at 1:45 p.m notify the Physical Environmental person in charge related to this situation, however no documentation evidence when the personnel resolved the situation.

g. The log designated for '' Limpieza Diaria De Suministros Esteriles '' Daily cleaning of sterile supplies was reviewed and according of the information written in the document the daily cleaning was performed by technician of environment control with the assigned equipment and '' Marzan Solution '' the log was reviewed on 6/29/16 at 10:30 a. m. and provide evidence that on March 25, May 30 and June 2 of 2016 the daily cleaning is not performed.

h. The log designated for ''Limpieza diaria de Sala de Operaciones " Daily cleaning of Operating rooms, Room #1 and Room #2 '' was reviewed and according of the information on May 18 and 30 did not performed the daily cleaning on both operating rooms. The document provide evidence that on May 18 a written letter '' A'' on both logs and on May 30 the space was maintain in blank.

i. The log designated for ''Registro de limpieza General Mensual Sala de Operaciones year 2016 '' Monthly General Register to Clean Operating Rooms 2016 did not provide evidence of monthly cleaning of the '' Equipment Room and Anesthesiology Office '' on January 15/16 and on May 6/16 for the walls of the Lounge, both of the spaces were observed in blank.

2. On the Anesthesia Room the following was observed:

a. On the interior of the wash stand (lavamano) was observed three boxes of red wipes, three gallons of Metrzyme, two boxes of Cavi wipes, one gallon of Cydex OPA and one black box of tools.

b. On the top of the counter a blue large canister was observed and has a label and read: Cydex prepared on 6/20/16 expired on 7/4/16 and signed by the anesthetist nurse.
The nurse supervisor of anesthesia (employee #27) was interview related to the disposition of the Zydex solution and she stated that the material was discard on the same wash stand (fregadero ) this room did not have extractor and was management by the Central Supply employees.
'' The Advanced Sterilization Products ''ASP '' on page number 3 section number 8 " Controles De Exposition/ Protecsión Personal " Controls of exposition/personal protection on the second section established on technical controls ''Manufacturers' recommendations suggests that the solution is used in a well-ventilated area and stored in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. However the two areas available to place this product was on the Anesthesia Office and on the Central Supply '' the two area s are closed areas, none have adequate ventilation " .