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Based on complaint investigation survey Acts Intake PR00000588 & PR00000592, performed on 04/10/17 thru 04/11/17 and administrative documents reviewed (admission package) performed on 4/10/17 at 2:00 pm, it was determined that the facility failed to provide an actualized phone directory where patients can call to place a grievance.

Findings include:

1. Brochure that is given to the patient and/or representative during admission process was review on 4/10/17 at 2:00 pm. During review it was identified include information related with the management of grievances by facility with some telephone numbers of certain agencies. However, some of these phone call numbers are not updated such as: State Law 101, Livanta, Medicare direct phone number, Medicare Toll Free phone number and the TTY phone number.

Based on complaint investigation survey Acts Intake PR00000588 & PR00000592, observations of the fifth floor and interview, it was determined that the facility failed to treat patients with the full recognition of their individuality and personal needs related to a written sign posted on the wall behind patient head indicating patient blindness condition in an effective and dignified manner.

Findings include:

A mechanism to ensure that patient receive services in a manner that maintains the patients' dignity admitted to receive services were not promoted not followed accordingly with the following findings identified during complaint investigation survey procedures on 4/10/17 through 4/11/17:

1. During the observational initial tour performed on the 5th floor on 4/10/17 at 11:25 am on room # 507-A it was observed a written sign posted on the wall behind the patients head indicating " Paciente No Vidente " (Blind Patient).

During interview with the Nurse Supervisor (employee#4) on 4/10/17 at 11: 26 am revealed that the facility does not had sign with symbols for the identification of patient with disabilities.

During interview with Director of Nursing (employee #1) stated: "I started working in this hospital on January. I'm still working in some processes that the personnel needs to improve. I'm going to send someone to remove the sign immediately".

2. The facility failed to ensure that the nursing staff follows standards of practice for patients ' privacy and dignity in an effective and dignified manner.

Based on complaint investigation survey Acts Intake PR00000588 & PR00000592, performed on 04/10/17 through 04/11/17 and 31 record review and review of policies and procedures (P&P) related to the restraint protocol and fifth floor tour, it was determined that the facility failed to ensure that all patients can freely exit the bed related to side rails on up position for 2 out of 32 records review.

Finding includes:

1. On 4/10/2017 at 2:30 pm during RR#19 the following was identified:

a. RR#19 it is a 46 years old female patient, admitted on 03/04/2017 and discharge on 03/08/2017 with a diagnosis of diverticulitis. In the nursing progress notes dated 3/06/2017 at 7:00 am and 03/07/2017 at 7:00 am it is written that the patient is with the side rails up and nurse call accessible for her security. On the electronic record in the nursing physical assessment the patient is identified as a minimum assistance patient for ambulating and toileting. The use of side rails to prevent patient from falls are not considered as a restraint by the facility as written in the restriction protocol.

The facility failed to ensure that all patients can freely and voluntarily exit the bed without any restriction.


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2. Supplementary Sample Patient #1 is a 63 years old male patient, admitted on 04/4/2017 with a diagnosis of Left Periorbital Cellulitis. On 04/11/2017 at 8:43 am during fifth floor tour the patient was observed in room 522A in the company of a family and with the four segmented side rails up.

During interview with patient sample #1 on 4/11/17 at 8:45 am, he state: "I can walk, but short distances because I get tired, but if I get tired I have my wheelchair and I used it. The nurses say that is for my safety".

During interview with Interim Nursing Supervisor of the fifth floor (Employee #4) on 4/11/17 at 1:30 pm, she stated: " The patient Clinical History must be documented by the physician writhing the first 24 hours that the patient is admitted. The bed side rails must be documented to be "Bed side rails in upward position for safety precautions". If the patient is able to ambulate, the one of the four bed side rails is left down and if the patient can not ambulate the four side rails are kept up. The reason for the position of the bed side rails must be documented. It is for safety measures."

Based on complaint investigation survey Acts Intake PR00000588 & PR00000592, performed on 04/10/17 through 04/11/17 and 31(R.R), records reviewed it was determined that the facility failed to include physician order for restraint in 2 out of 32 records reviewed (R.R #21 , R.R. #31).

Findings include:

1. R.R. #21 is an 89 years old female who is admitted on 002/16/2017 and discharge on 2/22/2017 with a diagnosis of Infected Sacral Ulcer, Bedridden, Scabies and Senile Dementia. The record was review on 04/10/17 at 3:00 pm. During the record review it was identified a telephone order for restriction on superior extremities from the MD
(employee #11) dated on 02/16/2017 at 9:50 am was without the MD signature for authentication.

2.R.R. #31 is a 72 years old female who is admitted on 04/08/2017 with a diagnosis of Pneumonia, Large Left Pleural Effusion Recurrent and Severe Constipation. The record was review on 04/10/17 at 9:00 am. During the record review it was identified a Doctor's Order Sheet Restraint Orders dated on 4/08/17. The order have a written statement of No telephone or verbal orders are accepted. On 4/08/17 at 5:40 pm a telephone order for soft restraint is written by the RN. The facility fail to maintain an accurately documented medical records.

a. The facility failed to use the restraint in accordance with the order of a physician.

Based on complaint investigation survey Acts Intake PR00000588 & PR00000592, performed on 04/10/17 through 04/11/17 and 31 (R.R) records reviewed it was determined that the facility failed to include physician order for restraint in 1 out of 32 records reviewed (R.R #21 ).

Findings include:

1. R.R. #21 is an 89 years old female who is admitted on 02/16/2017 and discharge on 2/22/2017 with a diagnosis of Infected Sacral ulcer, Bedridden, scabies and Senile Dementia. The record was review on 04/10/17 at 3:00 pm. During the record review it was identified a telephone order for restriction on superior extremities from the MD (employee # 11) dated on 02/16/2017 at 9:50 am was without the MD signature for authentication. The 24 hours restraint re-order was not found.

a. The facility failed to include the physicians re-order every 24 hours.

Based on complaint investigation survey Acts Intake PR00000588 & PR00000592, observations perform on the 5th floor, discussion with Director of Nursing (employee #1), and interview with patients it was determined that the facility failed to ensure nursing care and services as provided to patients as needed.

Findings include:

1. A mechanism to assure that there are supervisory and staff personnel for each nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient were not promoted. The following was identified during survey procedures 04/10/17 through 04/11/17 from 9:30 am through 3:30 pm:

a. On 4/10/17 at 9:54 am it was observed three register nurses documenting on the nurses station located on the fifth floor. It was observed that the nurses call system receive calls who are answering on the nurses station by the nurse. When the nurse answer to the patient via intercom "Digame en que puedo ayudar" Tell me how I can help you. Then refer the situation to the nurse for whom are assigned the patient, who was in charge of the area (room) were the patient made the call.

b. On 4/10/17 at 9:30 am thru 11:00 am it was observed IV pumps alarm and nurse call on rooms # 505 A, # 507-B, #517-A and # 528-B with the alarm activated. When surveyor and employee # 4 enter the room, she turn off the alarm.

c. On the monthly patient grievances from January/2017, February /2017 and March/2017, patients comments and related information evidence that them identify improvement needs and suggests that special attention are required to the services offered by nursing personnel. In many instances patients comments are related with the delay of attention to them when use the call system to request assistance. As observed on 4/10/17 at 9:54 am no supervisory rounds or evaluation are performed to assure immediate availability of a registered nurse for bedside care of any patient. Nurse responsiveness to the nurse call and IV pumps alarms how often patients or family visitors who had unmet needs and require assistance received; was not observed assessed.


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2. Patient #1 is a 72 years old female patient, admitted on 04/6/2017 with a diagnosis of Gastritis/ Diverticulitis. On 04/10/2017 at 11:50 am during 5th floor observational tour in room 524A was found the following:

a. The patient's IV pump was giving an alert sound. It was observed redness and tightness in the puncture area. The skin looks tense and with a large amount of liquid extravasates between the tissues.

During interview with patient on 4/10/17 at 11:50 am, she state: "My right arm is hurting since they connected me to the intravenous lines. The IV pump has been with the alert sound all night and I called the nurse desk but they did not come. I think it is leaking fluid because I am all wet and it hurts."

During the patient's interview the nursing staff assesses the patient's intravenous lines and she stated: "Yes, the IV line is leaking."

The facility failed to ensure nursing care and services are provided to patients as needed.

Based on a compliant investigation ACTS Intake PR00000592, review of clinical records and policies/procedures, it was found that the facility failed to ensure that 1 out of 32 records reviewed R. R (R.R. #8) have developed updated and implemented nursing care plans.

Findings include:

1. One out of thirty two records reviewed for care plans development and implementation for patients according to the patient's needs provided evidence that care plans do not have written evidence of developed, updated, revisions and are implemented during the patients' hospital stay related to their needs:

a. R.R #8 is a 77 years old female who was admitted on 03/03/16 with a diagnosis of Altered Mental Status, Acute Colitis and Infected Sacral Ulcer stage II. During the record review performed on 4/11/17 at 9:00 am no evidence was found that the registered nurse developed and implemented the plan of care for the patient according to the patient's needs of neurological system, urinary system.

Based on complaint investigation survey Acts Intake PR00000588 & PR00000592, records reviewed (R.R.), policies and procedures (P&P's), interviews, and the observational tour of the medical records department through the central file storage area with the Medical Record Coordinator, it was determined that the facility failed to have a medical record system that allows the medical record of any patient be easily retrieved and readily accessible, ensure that all medical records accurately and completely document within a period of no more than thirty (30) days after discharge, be properly stored in secure locations where they are protected from fire, water damage and other threats for 3 out of 32 R.R. (R.R. # 10, #16 and #25).

Finding includes:

1. During the entrance conference on 4/10/17 at 8:34 am the facility was informed that the surveyor would need individual log in access to the electronic medical record system. The patient roster sample selection was selected and notified to the facility at 9:30 am. The facility failed to provide access to the electronic medical record system to the surveyor on 4/10/17. However the facility provided the close records that they print once the patient is discharge on 4/10/17 at 2:00 pm. The facility caused a time delay for the evaluation of the active electronic records from 4/10/17 until 4/11/17 at 11:38 am that the log in access was provided.

During interview with the administrator (Employee #9) on 4/10/17 at 2:40 am, he state:

"I consulted with my joint commissioner officer about granting individual access to our electronic medical record system and they told me that it would violate the HIPAA Law. They explained me that if we had private medical health insurance patient that did not wanted that the surveyors have access to their record we could be involve in legal action or sued. The access to our system to see only the sample patient roster is going to be for tomorrow, because I have to communicate with the electronic record department. That is going to take time."

2. Patient #25 is a 52 years old female patient, admitted on 03/6/2017 with a diagnosis of Rectal Bleeding; and discharge on 3/9/17, close record review. On 04/10/2017 at 3:15 pm during R.R. it was found the following:

a. The Discharge Summary Form of 3/9/17 does not provides evidence of the disposition of the patient. The document of discharge summary gives disposition options (walking, wheelchair, stretcher, or other) to be selected by the nursing staff; however the nursing staff did not select any choice.

During facility's Content and documentation of the clinical record P&P's review related to General Rules of Documentation on 4/11/17 11:30 am, it was found on item #4: "The inpatient clinical file must be completed within a period of no more than thirty (30) days after discharge from the patient."

3. Patient #16 is a 58 years old male patient, admitted on 03/2/2017 with a diagnosis of Upper Gastrointestinal Bleeding; and discharge on 3/6/17, close record review. On 04/11/2017 at 10:10 am during R.R. it was found the following:

a. The Patient Internal Transfer "Hand Off" Form of 3/6/17 does not provides evidence of when the department that transferred the patient documented the form, the vital signs were left in blank, and there is no information provided for pending procedures or significant events, however the patient was being transferred to the operation room (OR).

b. The Checklist sheet for surgery (Hoja de Cotejo para Cirugia) states on the bottom of the page: "Verify that the documents be signed, dated, and timed"; however there is no evidence of the date, time, and name and signature of the person who documented on the Checklist for Surgery.

During facility's Content and documentation of the clinical record P&P's review related to General Rules of Documentation on 4/11/17 11:30 am, it was found on item #4: "The inpatient clinical file must be completed within a period of no more than thirty (30) days after discharge from the patient." In item #9 was found: "All entries in the medical file must always have the date, time and signature."

4. During the observational tour of the medical records department through the central file storage area with the Medical Record Coordinator on 11:10 am, it was observe orange colored water stains from the ceiling to the wall and electrical cables that were not covered were observed near the medical records.

During interview with the Medical Record Coordinator (employee #6) on 4/11/17 at 10:40 am, she state:

"It was established that the discharge summary must be completely documented. Even though we document the discharge summary on the electronic record, the paper form for discharge summary must be signed by the patient. The patients will not sign a discharge summary that is in blank, for that reason we document both the electronic and the paper discharge document. Those were the instructions. If the report of consult is not signed, dated, and timed by the physician that requested the consult, that form is incomplete. Those incomplete reports of consults are not in compliance, because you cannot determine if they were answer in the 24 hour timeframe.

The regulation establishes that the documentation must be clear and legible. Even the coders have had problems with the illegible documentation. We have been working with the medical staff and are confident that with the implementation of the electronic record hospital wide that problem is going to be resolve. We are expecting to be hospital wide with the electronic record for September of this year.The medical and nursing staff comes weekly to the medical record department to complete any incomplete record.

We do not have a temperature and humidity registry in the medical record storage area because the thermometers have not been calibrated and installed on the walls by the biomedical staff."

During interview with the Medical Record Custodian (employee #8) on 4/11/17 at 11:15 am, he state:

"The water marks on the ceiling are old; I have never seen water dripping from the ceiling to the walls. I do not know why those cables are expose and not cover."


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5. Patient #10 is a 93 years old female patient, admitted on 01/10/2017 with a diagnosis of Pneumonia, as review on the closed record. On 04/11/2017 at 11:30 am during R.R. it was found the following:

a. The Discharge Summary Form of 3/9/17 does not provides evidence of the disposition of the patient. The document of discharge summary gives disposition options (walking, wheelchair, stretcher, or other) to be selected by the nursing staff; however the nursing staff did not select any choice.

During facility's Content and documentation of the clinical record P&P's review related to General Rules of Documentation on 4/11/17 11:30 am, it was found on item #4: "The inpatient clinical file must be completed within a period of no more than thirty (30) days after discharge from the patient."

Based on complaint investigation survey Acts Intake PR00000588 & PR00000592, review of closed and active clinical records reviewed (R.R), Policies and Procedures (P&P's), and interviews, it was determined that the facility failed to ensure that medical staff, nursing personal or other entries in the medical record maintain legible, complete, dated, timed entries, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided for 14 out of 32 records reviewed (R.R #5, #6, #9, #10, #12, #13, #16, #21, #22, #23, #25, #26, #29, and #31).

Findings include:

Thirty clinical records reviewed from 4/10/17 through 4/11/17 from 8:30 am till 5:00 pm.

1. Patient #26 is a 85 years old male patient, admitted on 03/8/2017 with a diagnosis of Crohn's Disease; and discharge on 3/10/17, close record review. On 04/10/2017 at 9:55 am during R.R. it was found the following:

a. There is evidence that on 3/5/17 5:00 pm and 3/18/17 (the hour is not legible) the physician progress notes are not legible.

b. There is evidence that on 3/11/17 (the date and hour are not legible) the physician's order is not legible.

2. Patient #25 is a 52 years old female patient, admitted on 03/6/2017 with a diagnosis of Rectal Bleeding; and discharge on 3/9/17, close record review. On 04/10/2017 at 3:15 pm during R.R. it was found the following:

a. The Discharge Summary Form of 3/9/17 does not provides evidence of the disposition of the patient. The document of discharge summary provide disposition options (walking, wheelchair, stretcher, or other) to be selected by the nursing staff; however the nursing staff did not select any choice.

3. Patient #16 is a 58 years old male patient, admitted on 03/2/2017 with a diagnosis of Upper Gastrointestinal Bleeding; and discharge on 3/6/17, close record review. On 04/11/2017 at 10:10 am during R.R. it was found the following:

a. The Patient Internal Transfer "Hand Off" Form of 3/6/17 does not provides evidence of when the department that transferred the patient documented the form, the vital signs were left in blank, and there is no information provided for pending procedures or significant events, however the patient was being transferred to the operation room (OR).

b. The Checklist sheet for surgery (Hoja de Cotejo para Cirugia) states on the bottom of the page: "Verify that the documents be signed, dated, and timed"; however there is no evidence of the date, time, and name and signature of the person who documented on the Checklist for Surgery.

During facility's Content and documentation of the clinical record P&P's review related to General Rules of Documentation on 4/11/17 11:30 am, it was found on item #9 was found: "All entries in the medical file must always have the date, time and signature."

c. The Report of Consult is requested on 3/2/17 at 11:00 pm, notified at 3/3/17 at 9:09 am and answered on 3/4/17 at 2:55 pm. The facility failed to ensure that the consult was answered within the twenty four hours from the request.

During facility's Content and Documentation of the Clinical Record P&P's review related to Informs and requisition of Consults on 4/11/17 11:30 am, it was found under Specific Rules on item #2: "Must be answered within the 24 hours of being requested."

4. Patient #29 is a 59 years old female patient, admitted on 04/8/2017 with a diagnosis of Right Thigh Cellulitis. On 04/11/2017 at 11:30 am during R.R. it was found the following:

a. The Report of Consult does not provide evidence of the signature of the requesting physician, date and time that the consult was requested and evidence of notification. However it is documented in hand writing: "Personally notified to he by MD. Reyes."

During facility's Content and Documentation of the Clinical Record P&P's review related to Informs and requisition of Consults on 4/11/17 11:30 am, it was found on item 1:

a. Information of the patient identification
b. Information of the request
c. Physician that request the consult
d. Physician that is requested the consult
e. Evidence that it was notified (name, date, and time)
f. Brief history or description of the patient's condition
g. Date, time, and signature of the physician that requested the consult
h. Information to be documented by the consultant (who answers the consult)
i. Consultant's written opinion. Must reflect when pertinent:

ii. Findings report and recommendations to the primary physician
iii. Diagnostic impression
iv. Date, time, and signature

However the facility failed to ensure that the consult was completed according to facility's P&P's.

b. There is evidence that the physician signed, dated, and timed telephone and verbal orders with the same date and time that the nursing staff wrote the order.

i: Telephone order written by the nurse on 4/9/17 at 9:52 am is signed by the physician on 4/9/17 at 9:52 am
ii: Telephone order written by the nurse on 4/9/17 at 10:42 am is signed by the physician on 4/9/17 at 10:42 am
iii: Telephone order written by the nurse on 4/9/17 at 11:40 am is signed by the physician on 4/9/17 at 11:52 am

During facility's Content and documentation of the clinical record P&P's review related to Verbal and Telephone Orders on 4/11/17 11:30 am, it was found on item #3 and #4 was found:

5. The statutes of the Medical Faculty shall identify by title and category the personnel authorized to accept and transcribe verbal and telephone orders of doctors with privileges in the facility. Telephone and verbal orders must be documented with date, time and signature of the doctor who dictates it, within twenty-four (24) hours of the issuance of the order.

6. Verbal orders are only used in emergency situations."

c. There is evidence that a verbal medical order from 4/9/17 10:07 am is not signed by the physician.

During facility's Content and documentation of the clinical record P&P's review related to General Rules of Documentation on 4/11/17 11:30 am, it was found on item #9 was found: "All entries in the medical file must always have the date, time and signature."

During interview with the Medical Record Coordinator (employee #6) on 4/11/17 at 10:40 am, she state:

"It was established that the discharge summary must be completely documented. Even though we document the discharge summary on the electronic record, the paper form for discharge summary must be signed by the patient. The patients will not sign a discharge summary that is in blank, for that reason we document both the electronic and the paper discharge document. Those were the instructions.

If the report of consult is not signed, dated, and timed by the physician that requested the consult, that form is incomplete. Those incomplete reports of consults are not in compliance, because you cannot determine if they were answer in the 24 hour timeframe.

The regulation establishes that the documentation must be clear and legible. Even the coders have had problems with the illegible documentation. We have been working with the medical staff and are confident that with the implementation of the electronic record hospital wide that problem is going to be resolve. We are expecting to be hospital wide with the electronic record for September of this year.

The medical and nursing staff comes weekly to the medical record department to complete any incomplete record."

7. Patient #9 Complaint record is a 71 years old male patient, admitted on 01/25/2017 with a diagnosis of Acute Abdominal Pain; and discharge on 1/30/17, close record review. On 04/11/2017 during R.R. it was found the following:

a. Two Report of Consult does not provide evidence of the date and time that the consult was request and the physician who request the consult signature.

b. There is evidence that a telephone medical order from 1/28/17 at 8:39 pm is not signed by the physician.

c. Important message of Medicare unsigned by patient or caregiver.


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8. R.R. #21 is an 89 years old female who is admitted on 02/16/2017 and discharge on 2/22/2017 with a diagnosis of Infected Sacral ulcer, Bedridden, Scabies and Senile Dementia. The record was review on 04/10/17 at 3:00 pm. During the record review it was identified a telephone order for restriction on superior extremities from the MD ( employee # 11 ) dated on 02/16/2017 at 9:50 am was without the MD signature for authentication. The MD Progress notes dated on 02/16/2017, 02/19/2017, 02/17/17, 02/18/17, 02/20/17, 02/21/17 and 02/22/17 are illegible. The facility DON was ask to identify the MD signature but the DON cannot identified the signature as requested.

The facility fail to maintain a legible and accurately documented medical records.

9. R.R. #23 is a 52 years old male who is admitted on 02/25/2017 with a diagnosis of Right Foot Infected Ulcer with Cellulitis. The record was review on 04/10/17 at 9:50 am. During the record review it was identified a consult report answer on 2/25/17 with the dated on the physician request with a number written on the top of another number.

The facility fail to maintain an accurately documented medical records.

10. R.R. #31 is a 72 years old female who is admitted on 04/08/2017 with a diagnosis of Pneumonia, Large Left Pleural Effusion Recurrent and Severe Constipation. The record was review on 04/10/17 at 9:00 am. During the record review it was identified a Doctor's Order Sheet Restraint Orders dated on 4/08/17. The order have a written statement of No telephone or verbal orders are accepted. On 4/08/17 at 5:40 pm a telephone order for soft restraint is written by the RN.

The facility fail to maintain an accurately documented medical records.

11. R.R. #13 is a 57 years old female who is admitted on 01/24/2017 and discharge on 01/31/2017 with a diagnosis of Extensive Infected Sacral ulcer. The record was review on 04/10/17 at 10:00 am. During the record review it was identified the MD Progress notes dated on 01/26/2017, 0/28/2017, 01/29/17, 01/30/17 and 01/31/17 are illegible. The facility DON was ask to identify the MD signature but the DON cannot identified the signature as requested.

The facility fail to maintain a legible and accurately documented medical records.


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12. Patient #5 is an 89 years old male patient, admitted on 04/01/2017 with a diagnosis of Lobar Pneumonia. . On 04/11/2017 at 11:30 am during R.R. it was found the following:

a. The Report of Consult does not provide evidence of the time that the consult was answered.
During facility's Content and documentation of the clinical record P&P's review related to Informs and requisition of Consults on 4/11/17 11:30 am, it was found on item 1:

a. Information of the patient identification
b. Information of the request
c. Physician that request the consult
d. Physician that is requested the consult
e. Evidence that it was notified (name, date, and time)
f. Brief history or description of the patient's condition
g. Date, time, and signature of the physician that requested the consult
h. Information to be documented by the consultant (who answers the consult)

i. Consultant's written opinion. Must reflect when pertinent:
ii. Findings report and recommendations to the primary physician
iii. Diagnostic impression
iv. Date, time, and signature"

13. Patient #10 is a 93 years old female patient, admitted on 01/10/2017 with a diagnosis of Pneumonia and discharged 1/20/17, close record. On 04/11/2017 at 11:30 am during R.R. it was found the following:
a. There is evidence that a telephone medical order from 1/10/17 at 1:15 pm, 1/11/17 at 7:37 pm, 1/14/17 at 12:00 pm and 1/17/17 at 3:15 pm is not signed by the physician.

14. Patient #12 is a 40 years old male patient, admitted on 1/23/2017 with a diagnosis of Right Foot Cellulitis with Ulcer; and discharge on 1/30/17, close record review. On 04/10/2017 at 3:55 pm during R.R. it was found the following:

a. The form of exoneration of responsibility to refuse (Exoneracion de Responsabilidad por Rehusar) of the 1/28/17 does not indicated the reasons that why the patient want to exonerate the change of his IV Line.
b. There is evidence that the physician signed, dated, and timed telephone and verbal orders with the same date and time that the nursing staff wrote the order.

i: Telephone order written by the nurse on 1/26/17 at 12:15 pm is signed by the physician on 1/26/17 at 12:15 pm
ii: Telephone order written by the nurse on 1/26/17 at 3:30 am is signed by the physician on 1/26/17 at 3:30 am
iii: Telephone order written by the nurse on 1/29/17 at 8:44 am is signed by the physician on 1/29/17 at 8:44 am
iv. Telephone order written by the nurse on 1/29/17 at 3:23 pm is signed by the physician on 1/29/17 at 3:23 pm

During facility's Content and documentation of the clinical record P&P's review related to Verbal and Telephone Orders on 4/11/17 11:30 am, it was found on item #3 and #4 was found:

"3. The statutes of the Medical Faculty shall identify by title and category the personnel authorized to accept and transcribe verbal and telephone orders of doctors with privileges in the facility. Telephone and verbal orders must be documented with date, time and signature of the doctor who dictates it, within twenty-four (24) hours of the issuance of the order.

4. Verbal orders are only used in emergency situations."
c. There was found a form (Vacuna Contra La Influenza) signed by the patient indicating that he want to be vaccinated and no evidence was found that the facility provide the vaccination.

15. Patient #22 is a 64 years old male patient, admitted on 03/05/2017 with a diagnosis of Infected Sacral Ulcer; and discharge on 3/10/17, close record review. On 04/10/2017 at 3:25 pm during R.R. it was found the following:

a. There is evidence that on 3/4/17 11:00pm and 3/10/17 4:30 pm the adult medical history the physician notes are not legible.
b. The Report of Consult does not provide evidence of the date and time that the consult was request and the physician who request the consult signature.
c. The Report of Consult does not provide evidence of to whom the consultation is request to, the reason of the consult, date that the consult was request to the general surgeon.

During facility's Content and documentation of the clinical record P&P's review related to Informs and requisition of Consults on 4/11/17 11:30 am, it was found on item 1:

1. Information of the patient identification
2. Information of the request
3. Physician that request the consult
4. Physician that is requested the consult
5. Evidence that it was notified (name, date, and time)
6. Brief history or description of the patient's condition
7. Date, time, and signature of the physician that requested the consult
8. Information to be documented by the consultant (who answers the consult)

i. Consultant's written opinion. Must reflect when pertinent:
ii. Findings report and recommendations to the primary physician
iii. Diagnostic impression
iv. Date, time, and signature"

d. The Patient Internal Transfer "Hand Off" Form of 3/7/17 does not provides evidence of time that transferred the patient documented the form, were left in blank. Patient was transferred to OR ward.

e. The Discharge Summary Form was found left in blank; just the patient signature. Does not provides evidence of the disposition of the patient. The document of discharge summary gives disposition options (walking, wheelchair, stretcher, or other) to be selected by the nursing staff; however the nursing staff did not select any choice.

16. Patient #6 is a 59 years old female patient, admitted on 04/6/2017 with a diagnosis of Right Foot Cangrena. On 04/11/2017 at 1:30 pm during R.R. it was found the following:

a. The Patient Internal Transfer "Hand Off" Form of 4/7/17 and 4/10/17 does not provides evidence of time that transferred the patient documented the form, the vital signs were left in blank, and there is no information provided for pending procedures or significant events. Patient was transferred to OR ward.

b. The Patient was admitted on 4/6/17 and the initial medical history was not completed by the physician at the time of the review of the file on 4/11/17.
According to policies and procedures of the facility revised on 4/11/17 at 1:30 pm this information must be obtained within the first 24 hours of patient admission.

c. The form of exoneration of responsibility to refuse (Exoneracion de Responsabilidad por Rehusar) of the 4/7/17 was found without signing by medical personnel; as they guided the patient about the risk of not performing the procedure.

d. There is evidence that a telephone medical order from 4/10/17 at 10:49 am indicating that patient need to be in isolation is not signed by the physician.

e. There is evidence that a telephone medical order from 4/6/17 at 3:40 pm is not signed by the physician.

Based on complaint investigation survey Acts Intake PR00000588 & PR00000592, tests performed on equipment , observations and interviews made during the survey for the physical environment with the facility's Director of Nursing (DON) (employee #1) on 4/10/17 through 4/11/17, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner.

Findings include:

1. The Clean utility room was visited on 4/10/17 at 11:15 am it was observed floor tile broken.

2. Patient's bathrooms on rooms #504, #507, #508 and # 527 the bathtub area was observed with yellow stains and walls tiles dirty.

3. Patient's bathrooms were observed with peeling off paint in wall tiles.

4. On patient's bathroom rooms # 507, #508 and #522 ceiling tiles out of place.

5. On room #527 the visitor chair cover was ripped.

6. Electrical room on the fifth floor was found unlocked and accessible to non-authorized persons.

7. On Machine room where the ice machine is locate under the ice machine was found two blue pads wet from the water that the machine is dripping and the wall and floor was observed with black mold.

8. The biohazard room of the fifth floor was found unlocked and it was observed without trash container. Two biohazard bag full with disposal waste was observed direct on the floor.

9. On room #507-B it was observed an intravenous machine pump plug on top of the patient's head board bed. The plug was observed touching the patient left side head.

The patient was interviewed on 4/10/17 at 11:25 am and she cited: "that plug has been on the bed since last night. Supposedly the machine does not work and they got me another one; but they left that other one there.

10. Room #532 was observed that is remodeling and the door does not had a sign indicating that the room is under construction, the door was unlocked and inside the room it was found a cart with tools on top.

11. Room #522-B was visited on 4/10/17 and it was found that the nurse call it is not functioning. However, at the moment of the finding DON employee #1 and nurse supervisor (employee #4) were present and they call immediately the biomedical company and they came the same day and repair the nurse call.

Interview to patient from 522-B on 4/10/17 at 11:55 am reveals that the nurse call system was not functioning since Friday of the last week.

Employee #4 was interviewed on 4/10/17 at 11:57 am and cited: "Every Monday the nurse calls system in every room are revised and every day the internal round is done. It is supposed to be informed if it was damaged".

12. On room #508 it was observed the hand sink with rust and black spots.

Based on complaint investigation survey Acts Intake PR00000588 & PR00000592 performed on 04/10/17, observations and interview made during the survey for the physical environment with the Director of Nursing (employee #1), 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.

Findings include:

1. Room #532 was observed that is remodeling and the door does not had a sign indicating that the room is under construction, the door was unlocked and inside the room it was found a cart with tools on top.

2. On room #507-B it was observed an intravenous machine pump plug on top of the patient's head board bed. The plug was observed touching the patient left side head.

The patient was interviewed on 4/10/17 at 11:25 am and she cited: "that plug has been on the bed since last night. Supposedly the machine does not work and they got me another one; but they left that other one there.2. Maintenance cart with one drill, two cans of paints and other tools was observed from 4/6/17 at 9:15 am beside a stretcher with one patient waiting for the physician evaluation.

3. Room #522-B was visited on 4/10/17 and it was found that the nurse call it is not functioning. However, at the moment of the finding employee #1 and nurse supervisor (employee #4) were present and they call immediately the biomedical company and they came the same day and repair the nurse call.

Interview to patient from 522-B on 4/10/17 at 11:55 am reveals that the nurse call system was not functioning since Friday of the last week.

Employee #4 was interviewed on 4/10/17 at 11:57 am and cited: "Every Monday the nurse calls system in every room are revised and every day the internal round is done. It is supposed to be informed if it was damaged".

Based on complaint investigation survey Acts Intake PR00000588 & PR00000592 performed on 04/10/17 through 04/11/17, it was determined that the facility failed to promote sanitary and safe environment through its infection control program as evidenced by lot of dust in patient's room hand sink with rust, mold on wall and floor in the ice machine room, biohazard waste bag direct on the floor, clean bed linen out of plastic bag, hand washing and glove inside the pockets.

Findings include:

1.On ice machine room where under the ice machine was found two blue pads wet from the water that the machine is dripping and the wall and floor was observed with black mold.

2.The biohazard room of the fifth floor was found unlocked and it was observed without trash container. Two biohazard bag full with disposal waste was observed direct on the floor.

3. Patient's bathrooms on rooms #504, #507, #508 and # 527 the bathtub area was observed with yellow stains and walls tiles dirty.

4. On room #508 it was observed the hand sink with rust and black spots.

5.On clean utility room it was found clean white linen over a table out of the plastic bag.

6.Because of the patient's rooms remodeling it was observed a lot of dust in different places.

Surveyor asked to DON ( employee # 1) on 4/10/17 at 12:10 pm if the facility had a Dust Control Plan and she indicates that the facility had the plan and they are implementing the plan because the floor still operating.

However, the plan was never provided.

7.On 4/10/17 at 2:25 pm in room 510-A the venipuncture procedure is observed. During the procedure the following is observed:

a. The register nurse (employee #5) goes outside the room where the supply cart is and a pair of gloves is placed in his pocket.

b. At the time of washing hands the stream of water that came out of the faucet was little. Supervisor tells him to open more the faucet; the supervisor increase the stream of water opening more the faucet. When he finishes washing his hands, he dries his hands, closes the faucet and with the napkin that he used to close the faucet, he puts it back in his hand and then throws it in the trash. He puts his hands in his pockets, took out the gloves and puts them on.

c. After two attempts to cannulate a vein of the patient. RN ( employee #5) asks to his supervisor to perform the procedure. Nurse Supervisor (employee #4) went to perform hand washing. During hand washing it was observed that it was performed for less than 30 seconds according to the recommendations of the CDC guidelines.