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Based on a complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol review of medical records, policies and procedures, documents, observations, and interviews from 7/21/16 through 7/22/16 from 8:30 am until 4:00 pm it was determined that facility failed to comply with State and Local Laws which make this condition not met. (Cross refer to Tag A021)

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol, review of medical records, policies and procedures, documents, observations, and interviews from 7/21/16 through 7/22/16 from 8:30 am until 4:00 pm it was determined that facility failed to demonstrate compliance with State and Local Laws.

Findings include:

1. A mechanism to ensure that the hospital comply with all applicable State and local law related to the health and safety of patients requirements are met were not followed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 1:57 pm:

a. The facility failed to comply with dispositions established by state Law # 35 of June 28, 1994, who require screening, stabilization and appropriate transfer procedures to patients who seek for care with mental health emergency conditions. (Cross refer Tags A142 & A144).
b. The facility failed to comply with dispositions established by Puerto Rico Government Health Care insurance (Reforma de Salud) who requires 23-hour crisis observations, evaluation, holding and stabilization (adult) area for each patient received to a mental health hospital before final disposition of each case. This level of care must provides up to 23 hours of care in a secure and protected, medically staffed, psychiatrically supervised treatment environment. The primary objective of this level of care is for prompt evaluation and stabilization of individuals presenting with acute psychiatric symptoms or distress. (Cross refer to Tag A347).
c. The facility failed to comply with Puerto Rico State Law 300 from September 2, 1999 who requires that medical staff personnel had evidence of the criminal background check. This is also a contract requirement for the Health Insurance Administration of Puerto Rico (ASES). (Cross refer to Tag A341).
d. The facility failed to comply with Commonwealth of Puerto Rico Department of Health Administrative Order # 172 of April 2, 2002 to establish and maintain mechanisms to protect patients from abuse and neglect. (Cross refer to Tag A142, A144 & A145).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol review of medical records, policies and procedures, documents, observations, and interviews from 7/21/16 through 7/22/16 from 8:30 am until 4:00 pm it was identified that Governing Body failed to carry out its responsibility for the operation and management of the hospital. The Governing Body failed to provide the necessary oversight and leadership as evidenced by the lack of compliance with: Compliance with Laws Condition (42 CFR 482.11), Governing Body Condition (42 CFR 482.12), Patients Rights Condition (42 CFR 482.13) and Medical Staff Condition (42 CFR 482.22).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol review of medical records, policies and procedures, documents, observations, and interviews from 7/21/16 through 7/22/16 from 8:30 am until 4:00 pm and interview with facility administrator (employee #1), it was determined that governing body failed to ensure that medical staff requirements are met.

Findings include:
1. A mechanism to ensure that medical staffs members comply with requirements established in the bylaws are not followed, not performed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:

a. During review of psychiastrist monthly schedule for coverage the 23-hour crisis observations, evaluation, holding and stabilization (adult) area it was identified that during the month of April 2016, May 2016 and June 2016 no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case during weekends.

b. During review of psychiatrist monthly schedule for coverage the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area it was identified that during the month of July 2016, no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case during weekdays, holidays and weekends.

c. Accordingly with information provided by the medical director on July 21, 2016 at 1:30 pm during April 2016, May 2016 and June 2016 weekends no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area because no psychiatrist are available to cover those shifts.

d. For the month of July 2016 in addition to the weekends some holidays and week days no psychiatrist are available to cover those shifts because the hospital salaried psychiatrist who cover week days are on vacation.

e. The Administration provides documentation on 7/21/16 at 3:30 pm, of the facility efforts to cover weekends schedule with psychiatrists for the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. During review of this documentation it was identified that an average of 22 requests were performed monthly to psychiatrists and they stated that they cannot cover on weekends.

f. The facility failed to ensure that and medical staff leadership maintains mechanisms by which the medical staff fulfills its responsibility to be accountable for the quality of medical care in the hospital.

g. Accordingly with information provided by the administrator on July 22, 2016 at 11:00 am Puerto Rico Government Health Care insurance (Reforma de Salud ) require 23-hour crisis observations, evaluation , holding and stabilization (adult ) area for each patient received to a mental health hospital before final disposition of each case. This level of care must provides up to 23 hours of care in a secure and protected, medically staffed, psychiatrically supervised treatment environment. The primary objective of this level of care is for prompt evaluation and stabilization of individuals presenting with acute psychiatric symptoms or distress.

h. To comply with requirements established by Puerto Rico Government Health Care insurance (Reforma de Salud) facility had developed a protocol for the 23-hour crisis observations, evaluation, holding and stabilization (adult) area function and management. Accordingly with this protocol once a patient came to the triage area a general medicine physician, a nurse and a social worker evaluates the patient and determines if the patient requires emergency or crisis intervention services. The general medicine physician consults the case with the psychiatrist for recommendations on the initial treatment. Then the patient is admitted to the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This case must be evaluated by a psychiatrist before 23 hours for the final disposition of the case.

i. In the cases were no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area and accordingly with information provided by administrator on July 22, 2016 at 11:30 am the instructions given by the administration is to admit the patients to the hospital. Once admitted to the hospital a psychiatrist performs the evaluation.

j. Accordingly with information provided by the medical director on July 21, 2016 at 1:55 pm this hospital only had 2 salaried physicians one psychiatrists and one internal medicine physician. The other physician ' s generalists and psychiatrists are employed by contract by the facility. Those contracted psychiatrists are the ones approached by the facility to cover weekend ' s shifts on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area but all of them refused to cover the shifts.

k. Accordingly with information provided by the president of medical faculty (employee #4) on 7/22/16 at 11:45 am had knowledge of the situation of non-coverage of weekend ' s shifts on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area and the fact that contracted psychiatrists stated that they cannot cover the shifts. He stated that medical faculty is working under the leadership of a new medical director and that some changes are going to be performed in the contracts of physicians after August 7, 2016.

l. Governing body failed to ensure to maintain under contract medical staff members that are accountable for the quality of medical care provided to the patients. Contracted medical staff members failed to demonstrates its accountability through its exercise of its duties required on the 23 -hour crisis observations, evaluation , holding and stabilization (adult ) area as required by Puerto Rico Government Health Care insurance (Reforma de Salud ).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care , review of incidents and complaints reports, review of facility abuse and neglect protocol review of medical records, policies and procedures, documents, observations, and interviews from 7/21/16 through 7/22/16 from 8:30 am until 4:00 pm and interview with facility administrator (employee #1), it was determined that governing body failed to ensure that medical staff is accountable to the governing body for the quality of care provided to patients.

Findings include:
1. Facility governing body failed to assure that contracted medical staff member is well organized and accountable for the quality of the medical care provided to the patients. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:

a. During review of psychiatrists monthly schedule for coverage the 23-hour crisis observations, evaluation, holding and stabilization (adult) area it was identified that during the month of April 2016, May 2016 and June 2016 no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case during weekends.

b. During review of psychiatrists monthly schedule for coverage the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area it was identified that during the month of July 2016, no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case during weekdays, holidays and weekends.

c. Accordingly with information provided by the medical director (employee # 3) on July 21, 2016 at 1:30 pm during April 2016, May 2016 and June 2016 weekends no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area because no psychiatrists are available to cover those shifts.

d. For the month of July 2016 in addition to the weekends some holidays and week days no psychiatrists are available to cover those shifts because the hospital salaried psychiatrists who cover week days are on vacation.

e. The Administration provide documentation on 7/21/16 at 3:30 pm , of the facility efforts to cover weekends schedule with psychiatrists for the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area. During review of this documentation it was identified that an average of 22 requests were performed monthly to psychiatrists and they stated that they cannot cover on weekends.

f. The facility failed to ensure that and medical staff leadership maintains mechanisms by which the medical staff fulfills its responsibility to be accountable for the quality of medical care in the hospital.

g. Accordingly with information provided by the administrator on July 22, 2016 at 11:00 am Puerto Rico Government Health Care insurance (Reforma de Salud ) require 23-hour crisis observations, evaluation , holding and stabilization (adult ) area for each patient received to a mental health hospital before final disposition of each case. This level of care must provides up to 23 hours of care in a secure and protected, medically staffed, psychiatrically supervised treatment environment. The primary objective of this level of care is for prompt evaluation and stabilization of individuals presenting with acute psychiatric symptoms or distress.

h. To comply with requirements established by Puerto Rico Government Health Care insurance (Reforma de Salud) facility had developed a protocol for the 23-hour crisis observations, evaluation, holding and stabilization (adult) area function and management. Accordingly with this protocol once a patient came to the triage area a general medicine physician, a nurse and a social worker evaluates the patient and determines if the patient requires emergency or crisis intervention services. The general medicine physician consults the case with the psychiatrists for recommendations on the initial treatment. Then the patient is admitted to the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This case must be evaluated by a psychiatrist before 23 hours for the final disposition of the case.

i. In the cases were no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area and accordingly with information provided by administrator on July 22, 2016 at 11:30 am the instructions given by the administration is to admit the patients to the hospital. Once admitted to the hospital a psychiatrist performs the evaluation.

j. Accordingly with information provided by the medical director (employee # 3) on July 21, 2016 at 1:55 pm this hospital only had 2 salaried physicians one psychiatrist and one internal medicine physician. The other physician ' s generalists and psychiatrists are employees by contract by the facility. Those contracted psychiatrists ' are the ones approached by the facility to cover weekend ' s shifts on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area but all of them refused to cover the shifts.

k. Accordingly with information provided by the president of medical faculty (employee #4) on 7/22/16 at 11:45 am had knowledge of the situation of non-coverage of weekends shifts on the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area and the fact that contracted psychiatrists ' stated that they cannot cover the shifts. He stated that medical faculty is working under the leadership of a new medical director and that some changes are going to be performed in the contracts of physicians after August 7, 2016.

l. Governing body failed to ensure maintain under contract medical staff members that are accountable for the quality of medical care provided to the patients. Contracted medical staff members failed to demonstrates its accountability through its exercise of its duties required on the 23 -hour crisis observations, evaluation , holding and stabilization (adult ) area as required by Puerto Rico Government Health Care insurance (Reforma de Salud ).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol and interview with facility administrator (employee # 1), it was determined that there are serious deficient practices identified that seriously threaten the patient right to receive appropriate services and to ensure psychological well being which makes this condition Not Met ( Cross refer to Tags: A142, A143, A144 and A145 ).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care , review of incidents and complaints reports, review of facility abuse and neglect protocol, review of medical records and interview with facility administrator (employee # 1), it was determined that the patient right to receive appropriate services where their privacy and safety are maintained were not ensured for 3 out of 37 cases reviewed (Case #22, #23 and # 29)
Findings include:
1. A mechanism to ensure that facility promotes privacy and safety requirements while patients are receiving treatment and continuity of care are needed were not followed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:
a. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated February 4, 2016 it was discussed with the administrator by the medical faculty president that facility is not complying with the Puerto Rico Government Health Care insurance (Reforma de Salud ) requirement of the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area for each patient received to a mental health hospital before final disposition of each case. Due to lack of psychiatrists ' to cover weekends shifts on the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area the cases are evaluated by the generalists physicians and their mental condition health treatment are delay for an unforeseen amount of time. This practice does not promote stabilizing treatment needed by the un-well mental health patients are provided without delay. Personnel who manage patients while waiting more than 23 hours for the evaluation of a psychiatrist are exposed to the risk of an exacerbation of patient behavior; safety of those patients and personnel could be endangered by the situation.
b. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated June 15, 2016 it was discussed with the administrator by the medical director that several weeks ago ambulance services transport 3 patients from First Hospital Panamericano main location at Cidra to the First Hospital Panamericano Psychiatric unit located at Ponce. No evidence was found documented of the investigation of this situation. Facility did not determine or investigate whether those 3 patient rights were violated and whether an act of neglect was involved during the situation. The facility did not determine or investigate whether those 3 patient rights were violated and whether an act of neglect was involved during the situation.
c. Accordingly with information provided during survey procedures and reviewed of facility incidents and accidents reports log. On May 20, 2016 ambulance services transport 6 patients from First Hospital Panamericano main location at Cidra to the First Hospital Panamericano Psychiatric unit located at San Juan. The transport of those 6 patients in one ambulance did not reflect facility regulations and procedures. The incident was investigated; however during investigation facility did not determine or investigate whether those 6 patient rights were violated and whether an act of neglect was involved during the situation.
During investigation admissions department personnel and nursing services personnel were involved, however physicians and ambulance services personnel were not involved or documented as involved in the investigation procedures. Admission services department and physicians were re-oriented after investigation of the facility policies and procedures related with transportation of patients from First Hospital Panamericano Psychiatric main Hospital location at Cidra to any one of First Hospital Panamericano Psychiatric Hospital unit ' s locations.
Circumstances were this situation occurs were not clearly investigated or documented as investigated after the incident. Identification of those 6 patients with diagnosis health status and condition during and after the transport was not included in the investigation. Situation appears to be managed from the perspective of administrative level incident; without consider patients health status, and the potential of harm psychological well being of any of those 6 patients during the transport. The entire process of transport a patient from First Hospital Panamericano main location to any one of First Hospital Panamericano Psychiatric Hospital ' s unit location were not assessed in order to determine deviation from facility policies, procedures and requirements.
Responsibility for not compliance were adjudicated to the admission services department however health care professionals who participate in those 6 patients assessment and care and contracted ambulance services were not considered responsible or involved in the process.
Review of the Policies and procedures of the 23-hour crisis observations, evaluation, holding and stabilization (adult) of facility, last reviewed on October /2015, establish that the interdisciplinary team members are responsible for the treatment and care of patients and the psychiatrist is the responsible for the final disposition of the case. Accordingly with information included in the plan of action for the management of cases transported to another hospital location (dated 05/25/16) a memo was sent to the chief of clinical physicians. However no participation of medical staff personnel were identified as involved in this plan of action.
d. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated June 15, 2016 it was discussed with the administrator by the medical faculty members that there is a delay on psychiatric evaluation of patients on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This due to lack of availability of psychiatrists' who perform patient ' s evaluation and be responsible for the treatment and care of patients until the final disposition of each case. This practice does not promote that patients receive services in a secure and protected, medically staffed, psychiatrically supervised treatment environment to patients.

e. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated June 15, 2016 it was discussed with the administrator by the medical faculty members that sometimes several patients are transported to another of the facility locations without psychiatric evaluation of patients on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This due to lack of availability of psychiatrists who performs patient ' s evaluation and be responsible for the treatment and care of patients until the final disposition of each case. The facility did not determine or investigate whether those patient rights were violated and whether an act of neglect was involved during the situation. This practice does not promote that patients who requires emergency or crisis intervention services before being transported to another location are provided by the services; to stabilize their conditions. Personnel who transport those patients to another location are exposed to the risk of an exacerbation of patient behavior during transport. Personnel who receive those patients are exposed to the risk of an exacerbation of patient behavior when they receive them in their location.

f. Accordingly with information reviewed by facility director of nursing (employee #2) on 7/21/16 thought 7/22/16 on thirty seven medical records of patients who receive services in the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area it was identified that facility failed to comply with state Law # 35 of June 28,1994. On three out of thirty seven cases reviewed (case #22,#23 and # 29 ) of patients transferred to another location of the hospital, no information were included on the medical record related with circumstances were the intra hospital transfer occur.

Accordingly with Article 4 of the state Law # 35 of June 28, 1994 the transfer must be performed under appropriate circumstances (information of patient condition must be included and appropriate transport must be used).

g. Accordingly with information provided by the administrator (employee #1) during interview on 07/22/16 at 2:45 pm facility administration had been managing the situation and establish changes to deal or mitigate with the lack of availability of psychiatrists to comply with the evaluation of patients on the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area. He also stated that administration had a compromise to avoid the practice to transport more than one patient from First Hospital Panamericano ' s main location of Cidra to anyone First Hospital Panamericano Psychiatric units locations.

Based on the complaint investigation PR00000558, observations made during the physical environment and patients assessment with the Director of Nursing, it was determined that the facility failed to ensure that patients receive personal privacy during initial and admission assessment for treatment for 1 out of 1 random observation.

Findings include:

During the observational tour performed on 07/22/16 at 9:00 am, the nurse from the triage area was observed performing a patient initial assessment without providing privacy. The front door of the triage room and the medical examination room does not have a (dark plastic film) to provide visual privacy to the patient.

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care , review of incidents and complaints reports, review of facility abuse and neglect protocol and interview with facility administrator (employee #1), it was determined that the patient right to receive care in a safe setting were not ensured.
Findings include:
1. A mechanism to ensure that facility promote that each patient receives care in a safe environment were not followed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:
a. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated February 4, 2016 it was discussed with the administrator by the medical faculty president that facility are not complying with the Puerto Rico Government Health Care insurance (Reforma de Salud ) requirement of the 23-hour crisis observations, evaluation, holding and stabilization (adult ) area for each patient received to a mental health hospital before final disposition of each case. Due to lack of psychiatrists ' to cover weekends shifts on the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area the cases are evaluated by the generalists physicians and their mental condition health treatment are delay for an unforeseen amount of time. Personnel who manage patients while waiting more than 23 hours for the evaluation of psychiatrists are exposed to the risk of an exacerbation of patient behavior; safety of those patients and personnel could be endangered by the situation. The facility failed to protect vulnerable patients, and to provide protection for the patient's emotional health and safety as well as his/her physical safety.

b. Accordingly with information reviewed of facility incidents and accidents reports log. On May 20, 2016 ambulance services transport 6 patients from First Hospital Panamericano Psychiatric Hospital main location of Cidra to the First Hospital Panamericano Psychiatric Hospital unit location of San Juan. The transport of those 6 patients in one ambulance did not reflect facility regulations and procedures. Facility failed to perform supervisory oversight to promote that acutely un-well mental health patients receive transport in a safe environment. Facility failed to protect vulnerable patients, respect, dignity and comfort are not maintained promoting an emotionally safe environment; elements that could affect patient physical safety during transport to another hospital location. While reviewing incident and accident reports it was identified that a similar situation occurs on March 2016; this constituted a pattern of non-compliance concerning a safe environment during patient ' s transportation by ambulance to another hospital location.

c. Accordingly with information provided during survey procedures and reviewed of facility incidents and accidents reports log. On May 20, 2016 ambulance services transport 6 patients from First Hospital Panamericano Psychiatric hospitals ' main location of Cidra to the First Hospital Panamericano Psychiatric hospitals ' unit location of San Juan. The transport of those 6 patients in one ambulance did not reflect facility regulations and procedures. The incident was investigated; however during investigation facility did not determine or investigate whether those 6 patient rights were violated and whether an act of neglect was involved during the situation.
During investigation admissions department personnel and nursing services personnel were involved, however physicians and ambulance services personnel were not involved or documented as involved in the investigation procedures. Admission services department and physicians were re-oriented after investigation of the facility policies and procedures related with transportation of patients from First Hospital Panamericano main location to any one of First Hospital Panamericano Psychiatric Hospital unit locations.
Circumstances were this situation occurs were not clearly investigated or documented as investigated after the incident. Identification of those 6 patients with diagnosis health status and condition during and after the transport was not included in the investigation. Situation appears to be managed from the perspective of administrative level incident; without consider patients health status, and the potential of harm psychological well being of any of those 6 patients during the transport.
The entire process to transport a patient from First Hospital Panamericano Psychiatric Hospital main location at Cidra to any one of First Hospital Panamericano Psychiatric Hospital unit location were not assessed in order to determine deviation from facility policies, procedures and requirements. Responsibility for non compliance were adjudicated to the admission services department however health care professionals who participate in those 6 patients assessment and care and contracted ambulance services were not considered responsible or involved in the process.
Review of the policies and procedures of the 23-hour crisis observations, evaluation, holding and stabilization (adult) of facility, last reviewed on October /2015, establish that the interdisciplinary team members are responsible for the treatment and care of patients and the psychiatrist is the responsible for the final disposition of the case.
Accordingly with information included in the plan of action for the management of cases transported to another hospital location (dated 05/25/16) a memo was sent to the chief of clinical physicians. However no participation of medical staff personnel were identified as involved in this plan of action.
d. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated June 15, 2016 it was discussed with the administrator by the medical faculty members that there is a delay on psychiatric evaluation of patients on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This due to lack of availability of psychiatrists who performs patient ' s evaluation and are responsible for the treatment and care of patients until the final disposition of each case. This practice does not promote that patients receive services in a secure and protected, medically staffed, psychiatrically supervised treatment environment to patients.

e. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated June 15, 2016 it was discussed with the administrator by the medical faculty members that sometimes several patients are transported to another of the facility locations without psychiatric evaluation of patients on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This due to lack of availability of psychiatrists who performs patient ' s evaluation and be responsible for the treatment and care of patients until the final disposition of each case. Facility did not determine or investigate whether those patient rights were violated and whether an act of neglect was involved during the situation.
This practice does not promote that patients who requires emergency or crisis intervention services before being transported to another location are provided by the services; to stabilize their conditions. Personnel who transport those patients to another location are exposed to the risk of an exacerbation of patient behavior during transport. Personnel who receive those patients are exposed to the risk of an exacerbation of patient behavior when they receive in their location.
The facility failed ensure that the hospital protects vulnerable patients, and to provide protection for the patient's emotional health and safety as well as his/her physical safety.

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol and interview with facility administrator (employee #1), it was determined that facility failed to act upon situations where employees are involved on incidents of fight and verbal abuse while performing duties at the facility and providing care and services to patients for 3 out of 3 incidents reports (IR). (IR. #1, #2 and #3)
Findings include:
1. A mechanism to ensure that facility maintain a proactive approach to identify events and occurrences that may contribute abuse and neglect incidents and represent a potential risk for patients were not followed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:


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2. During survey it was identified that the facility did not promote approaches and implement policies and procedures to investigate and manage complaints filed by staff. Information related with complaints filed by staff for February 2016 and April 2016 reviewed on 07/21/16 at 3:00 pm evidence that rather than investigate and response using systematic proactive approach the concerns referred by staff, facility react but does not investigate through feedback from the individuals in order to determine if it has similar concerns or is an isolated event.
The following information was provided during survey procedures on 07/21/16 through 07/22/16. This information is related with incidents reported during year 2016:
a. Incident # 1 is a register nurse writes an incident report against a facility psychiatrist (employee #5 ) and explain that the psychiatrist call her on 2/16/16 at the facility and she answer the telephone but did not hear the person talking at the telephone and she proceed to hang up the telephone. Few minutes later the psychiatrist calls again and starts screaming to the nurse with insults and bad words in an offensive manner.
b. Incident # 2 on 2/20/16 a facility nurse supervisor arrives at the unit and employee # 5 becomes aggressive against him. The psychiatrist starts claiming that the supervisor pressures the register nurse to make the incident report against him. Another doctor intervenes in the incident because the psychiatrist was approaching the nurse supervisor in a challenging form.
c. Incident # 3 on 4/21/2016 a facility primary therapist write a incident report against employee # 5 and explain that she went to the psychiatrist office and ask him about a medication information for a patient and employee # 5 answers her, " no and look in doctor Google " . The therapist asks the pharmacist for the information. When the therapist arrives at the unit the psychiatrist gives her the information and she told him that she has the information from pharmacy and he told her a bad word.

d. Formal instructions performed in order to protect employee were not found documented or established. Facility did not institute measures for the protection of patients receiving services and staff as means of preventing the re-occurrence or continuation of incidents of verbal abuse.
e. On all those incidents (# 1 # 2 and # 3) previously presented involves facility psychiatrist (employee # 5) behavior. Those incidents were referred to the medical staff for investigation. However no information were provided to the governing body of the circumstances were those incidents happen, interviews of personnel involved in the situations and the potential involvement of patients during events. If an internal investigation were performed results were not informed to the governing body as informed by the administrator on 7/22/16 at 11:15 am.
On 02/23/2016 multiples interviews were perform about the incidents #1, #2 and #3 by the DON (employee #2) and Human Resources Director (employee #6) however no corrective actions by the facility were identified. Facility failed to ensure that a similar act were verbal abuse occur is repeated. The potential of similar behavior from this employee to other employees or to patients are not considered neither forms the medical staff leadership or governing body.
3. A mechanism to ensure that facility comply with state requirements on the employment screening of staff were not followed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:

During the review of fourteen medical staff credential files on 7/21/16 from 1:30 pm until 3:00 pm the following was found:
a. Ten out of fourteen medical staff credential file did not have evidence of the criminal background check (Puerto Rico Law 300 from September 2, 1999) (C.F.#2,#3,#4,#6,#7,#8,#9,#10,#11,#14).
This is a contract requirement for The Health Insurance Administration of Puerto Rico (ASES) Puerto Rico Government Health Care insurance (Reforma de Salud ).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care , review of incidents and complaints reports, review of facility abuse and neglect protocol and interview with facility administrator (employee # 1), medical director (employee #3) and president of medical faculty(employee #4) it was determined that the hospital failed to have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital, which makes this condition Not Met. (Cross refer to Tags A341 and A347).

Based on a complaint investigation ACTS Intake PR00000558, review of fourteen medical staff credential files and review of policies and procedures it was determined that the facility failed to examine the credential files (C.F) to ensure that medical staff have updated Hepatitis B vaccine, updated Influenza vaccines and Criminal Background check for 11 out of 14 medical staff's C.Fs (C.F.#1, #2, #3, #4, #6, #7, #8, #9, #10, #11 and #14)
Findings include:

1. During the review of fourteen medical staff credential files on 7/21/16 from 1:30 pm until 3:00 pm the following was found:

a. One out of fourteen medical staff's credential files did not have evidence of their hepatitis b profiles, hepatitis b antibody HBsAg (Anti-HBs) or hepatitis b responsibility exoneration. (CF #6).

b. Six out of fourteen medical staff' credential files did not have evidence of their Influenza profiles or responsibility exoneration (C.F.#1,#2,#3,#9,#10,#11)
c. Ten out of fourteen medical staff credential file did not have evidence of the criminal background check (Puerto Rico Law 300 from September 2, 1999) (C.F. #2, #3, #4, #6, #7, #8, #9, #10, #11, and #14). This is a contract requirement for The Health Insurance Administration of Puerto Rico (ASES). Accordingly with facility policy and procedure dated October 2015 reviewed every facility employee must provide evidence of the criminal background check Puerto Rico Law 300 from September 2, 1999 every two years.

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol and interview with facility administrator (employee #1), medical director (employee #3) and president of medical faculty (employee #4) it was determined that facility failed to ensure that contracted medical staff member are well organized and accountable to the governing body for the quality of the medical care provided to the patients.

Findings include:
1. A mechanism to ensure that facility maintain a system of checks and balances within an overall framework of collaboration between the governing body and the medical staff (and, to a certain degree, also between an individual practitioner and the hospital's medical staff and governing body) were not followed not promoted.
a. Review of psychiatrist ' s monthly schedule for coverage the 23-hour crisis observations, evaluation, holding and stabilization (adult) area the following was identified:

On the month of April 2016 on Sunday April 3, 2016 , Saturday April 9, 2016,Sunday April 17, 2016 and Saturday April 23, 2016 no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case.

On the month of May 2016 on Sunday May 1st 2016, Saturday May 7, 2016 Sunday May 8, 2016, Saturday May 14, 2016, Saturday May 21, 2016, Sunday May 22, 2016 and Sunday May 29, 2016 no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case.

On the month of June 2016 on Saturday June 4, 2016, Sunday June 5, 2016, Saturday June 11, 2016, Saturday June 18, 2016, Sunday June 19, 2016, Saturday June 25, 2016 and Sunday June 26, 2016 no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case.

On the month of July 2016 on Saturday July 2, 2016, Sunday July 3, 2016, Monday (holiday) July 4, 2016,Tuesday July 5, 2016, Thursday July 7, 2016, Friday July 8, 2016, Saturday July 9, 2016, Sunday July 10, 2016, Monday July 11, 2016,Tuesday July 12, 2016,Thursday July 14, 2016, Friday July 15, 2016, Saturday July 16, 2016, Sunday July 17, 2016, Monday July 18, 2016 ,Tuesday July 19, 2016, Saturday July 23, 2016, Sunday July 24, 2016 , Saturday July 30, 2016 and Sunday July 31,2016 no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case.

Accordingly with information provided by the administrator on July 22, 2016 at 11:00 am Puerto Rico Government Health Care Insurance (Reforma de Salud ) require 23-hour crisis observations, evaluation , holding and stabilization (adult ) area for each patient received to a mental health hospital before final disposition of each case. This level of care must provides up to 23 hours of care in a secure and protected, medically staffed, psychiatrically supervised treatment environment. The primary objective of this level of care is for prompt evaluation and stabilization of individuals presenting with acute psychiatric symptoms or distress. To comply with Government Health Plan; members must evidence of the participation in the stabilization unit prior admission to inpatient treatment.

To comply with requirements established by Puerto Rico Government Health Care insurance " Reforma de Salud " , the facility had developed a protocol for the 23-hour crisis observations, evaluation, holding and stabilization (adult) area function and management. Accordingly with this protocol once a patient came to the triage area a general medicine physician, a nurse and a social worker evaluates the patient and determines if the patient requires emergency or crisis intervention services. The general medicine physicians consult the case with the psychiatrist for recommendations on the initial treatment. Then the patient is admitted to the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This case must be evaluated by a psychiatrist before 23 hours for the final disposition of the case.

In the cases were no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area and accordingly with information provided by administrator on July 22, 2016 at 11:30 am, the instructions given by the administration is to admit the patients to the hospital. Once admitted to the hospital a psychiatrist performs the evaluation.

Accordingly with information provided by the medical director (employee # 3) on July 21, 2016 at 1:30 pm during April 2016, May 2016 and June 2016 weekends no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area because no psychiatrist are available to cover those shifts.

For the month of July 2016 in addition to the weekends some holidays and week days no psychiatrist are available to cover those shifts because the hospital salaried psychiatrist who cover week days were on vacation.

Accordingly with information provided by the medical director on July 21, 2016 at 1:55 pm this hospital only has 2 salaried physicians ' one psychiatrist and one internal medicine physician. The other physician ' s generalists and psychiatrists ' are employee by contract by the facility. Those contracted psychiatrists ' are the ones approached by the facility to cover weekend ' s shifts on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area, but all of them refused to cover the shifts.

Accordingly with information provided by the president of medical faculty (employee #4) on 7/22/16 at 11:45 am had knowledge of the situation of non-coverage of weekends shifts on the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area and the fact that contracted psychiatrists ' stated that they cannot cover the shifts. He stated that medical faculty is work under the leadership of a new medical director and that some changes are going to be performed in the contracts of physicians after August 7, 2016.

Administration provides documentation on 7/21/16 at 3:30 pm, of the facility efforts to cover weekends schedule with psychiastrists for the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. During review of this documentation it was identified that an average of 22 requests were performed monthly to psychiatrists ' and they stated that they cannot cover on weekends.

2. Facility failed to ensure that medical staff leadership maintains mechanisms by which the medical staff fulfills its responsibility to be accountable for the quality of medical care in the hospital.

Contracted medical staff members failed to demonstrates its accountability through its exercise of its duties required on the 23 -hour crisis observations, evaluation, holding and stabilization (adult) area as required by Puerto Rico Government Health Care insurance " Reforma de Salud " .

Based on a complaint investigation ACTS Intake PR00000558, observations made during the survey for the physical environment with Director of Nursing (employee #2) on 7/22/16 at 9:00 am until 10:45 am, it was determined that the holding area and the stabilization area SEC ( " Sala Establizadora " ) failed to ensure staff provide care in a safe manner, ensuring the well-being of patients receiving services.
Findings include:
1. The holding area was observed on 7/22/16 at 9:55 am. It lacks sufficient space for patients waiting to be admitted. The area has 6 lounge chairs and the separation between them is less than 4 lineal feet and 80 sq. ft. per area.
2. The stabilization room was observed on 7/22/16 at 9:30 am and it was found that the room has 9 lounge chairs and 1 isolation room (quiet room) with the door opened one patient in bed. The bed is observed without linen. The 9 chairs were occupied. It was observed that between chairs their less than 4 linear feet of separation.

Based on a complaint investigation ACTS Intake PR00000558, observations made during the survey for the physical environment with the facility's Director of Nursing (employee #2) , it was determined that the physical structure and care areas of the emergency rooms' waiting area and triage area failed to provide proper ventilation with an air disinfection system.

Findings include:

The Admission area was visited on 7/22/16 from 9:00 am until 10:30 am and provided evidence that the waiting area and triage area are not equipped with an air disinfection system (for example: Ultraviolet lights).
According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) the triage area is the point of entry of undiagnosed and untreated airborne infections and should be designed and ventilated to reduce exposure of staff, patients and families to airborne infectious diseases.
Through the facility's infection control program, determinations must be made related to general ventilation and air disinfection similar to inpatient requirements for airborne infection isolation rooms according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". The waiting area is another area to provide protection with an air disinfection system due to the concentration of patients and space.

Based on a complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol review of medical records, policies and procedures, documents, observations, and interviews from 7/21/16 through 7/22/16 from 8:30 am until 4:00 pm it was determined that facility failed to comply with State and Local Laws which make this condition not met. (Cross refer to Tag A021)

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol, review of medical records, policies and procedures, documents, observations, and interviews from 7/21/16 through 7/22/16 from 8:30 am until 4:00 pm it was determined that facility failed to demonstrate compliance with State and Local Laws.

Findings include:

1. A mechanism to ensure that the hospital comply with all applicable State and local law related to the health and safety of patients requirements are met were not followed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 1:57 pm:

a. The facility failed to comply with dispositions established by state Law # 35 of June 28, 1994, who require screening, stabilization and appropriate transfer procedures to patients who seek for care with mental health emergency conditions. (Cross refer Tags A142 & A144).
b. The facility failed to comply with dispositions established by Puerto Rico Government Health Care insurance (Reforma de Salud) who requires 23-hour crisis observations, evaluation, holding and stabilization (adult) area for each patient received to a mental health hospital before final disposition of each case. This level of care must provides up to 23 hours of care in a secure and protected, medically staffed, psychiatrically supervised treatment environment. The primary objective of this level of care is for prompt evaluation and stabilization of individuals presenting with acute psychiatric symptoms or distress. (Cross refer to Tag A347).
c. The facility failed to comply with Puerto Rico State Law 300 from September 2, 1999 who requires that medical staff personnel had evidence of the criminal background check. This is also a contract requirement for the Health Insurance Administration of Puerto Rico (ASES). (Cross refer to Tag A341).
d. The facility failed to comply with Commonwealth of Puerto Rico Department of Health Administrative Order # 172 of April 2, 2002 to establish and maintain mechanisms to protect patients from abuse and neglect. (Cross refer to Tag A142, A144 & A145).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol review of medical records, policies and procedures, documents, observations, and interviews from 7/21/16 through 7/22/16 from 8:30 am until 4:00 pm it was identified that Governing Body failed to carry out its responsibility for the operation and management of the hospital. The Governing Body failed to provide the necessary oversight and leadership as evidenced by the lack of compliance with: Compliance with Laws Condition (42 CFR 482.11), Governing Body Condition (42 CFR 482.12), Patients Rights Condition (42 CFR 482.13) and Medical Staff Condition (42 CFR 482.22).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol review of medical records, policies and procedures, documents, observations, and interviews from 7/21/16 through 7/22/16 from 8:30 am until 4:00 pm and interview with facility administrator (employee #1), it was determined that governing body failed to ensure that medical staff requirements are met.

Findings include:
1. A mechanism to ensure that medical staffs members comply with requirements established in the bylaws are not followed, not performed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:

a. During review of psychiastrist monthly schedule for coverage the 23-hour crisis observations, evaluation, holding and stabilization (adult) area it was identified that during the month of April 2016, May 2016 and June 2016 no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case during weekends.

b. During review of psychiatrist monthly schedule for coverage the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area it was identified that during the month of July 2016, no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case during weekdays, holidays and weekends.

c. Accordingly with information provided by the medical director on July 21, 2016 at 1:30 pm during April 2016, May 2016 and June 2016 weekends no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area because no psychiatrist are available to cover those shifts.

d. For the month of July 2016 in addition to the weekends some holidays and week days no psychiatrist are available to cover those shifts because the hospital salaried psychiatrist who cover week days are on vacation.

e. The Administration provides documentation on 7/21/16 at 3:30 pm, of the facility efforts to cover weekends schedule with psychiatrists for the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. During review of this documentation it was identified that an average of 22 requests were performed monthly to psychiatrists and they stated that they cannot cover on weekends.

f. The facility failed to ensure that and medical staff leadership maintains mechanisms by which the medical staff fulfills its responsibility to be accountable for the quality of medical care in the hospital.

g. Accordingly with information provided by the administrator on July 22, 2016 at 11:00 am Puerto Rico Government Health Care insurance (Reforma de Salud ) require 23-hour crisis observations, evaluation , holding and stabilization (adult ) area for each patient received to a mental health hospital before final disposition of each case. This level of care must provides up to 23 hours of care in a secure and protected, medically staffed, psychiatrically supervised treatment environment. The primary objective of this level of care is for prompt evaluation and stabilization of individuals presenting with acute psychiatric symptoms or distress.

h. To comply with requirements established by Puerto Rico Government Health Care insurance (Reforma de Salud) facility had developed a protocol for the 23-hour crisis observations, evaluation, holding and stabilization (adult) area function and management. Accordingly with this protocol once a patient came to the triage area a general medicine physician, a nurse and a social worker evaluates the patient and determines if the patient requires emergency or crisis intervention services. The general medicine physician consults the case with the psychiatrist for recommendations on the initial treatment. Then the patient is admitted to the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This case must be evaluated by a psychiatrist before 23 hours for the final disposition of the case.

i. In the cases were no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area and accordingly with information provided by administrator on July 22, 2016 at 11:30 am the instructions given by the administration is to admit the patients to the hospital. Once admitted to the hospital a psychiatrist performs the evaluation.

j. Accordingly with information provided by the medical director on July 21, 2016 at 1:55 pm this hospital only had 2 salaried physicians one psychiatrists and one internal medicine physician. The other physician ' s generalists and psychiatrists are employed by contract by the facility. Those contracted psychiatrists are the ones approached by the facility to cover weekend ' s shifts on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area but all of them refused to cover the shifts.

k. Accordingly with information provided by the president of medical faculty (employee #4) on 7/22/16 at 11:45 am had knowledge of the situation of non-coverage of weekend ' s shifts on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area and the fact that contracted psychiatrists stated that they cannot cover the shifts. He stated that medical faculty is working under the leadership of a new medical director and that some changes are going to be performed in the contracts of physicians after August 7, 2016.

l. Governing body failed to ensure to maintain under contract medical staff members that are accountable for the quality of medical care provided to the patients. Contracted medical staff members failed to demonstrates its accountability through its exercise of its duties required on the 23 -hour crisis observations, evaluation , holding and stabilization (adult ) area as required by Puerto Rico Government Health Care insurance (Reforma de Salud ).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care , review of incidents and complaints reports, review of facility abuse and neglect protocol review of medical records, policies and procedures, documents, observations, and interviews from 7/21/16 through 7/22/16 from 8:30 am until 4:00 pm and interview with facility administrator (employee #1), it was determined that governing body failed to ensure that medical staff is accountable to the governing body for the quality of care provided to patients.

Findings include:
1. Facility governing body failed to assure that contracted medical staff member is well organized and accountable for the quality of the medical care provided to the patients. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:

a. During review of psychiatrists monthly schedule for coverage the 23-hour crisis observations, evaluation, holding and stabilization (adult) area it was identified that during the month of April 2016, May 2016 and June 2016 no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case during weekends.

b. During review of psychiatrists monthly schedule for coverage the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area it was identified that during the month of July 2016, no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case during weekdays, holidays and weekends.

c. Accordingly with information provided by the medical director (employee # 3) on July 21, 2016 at 1:30 pm during April 2016, May 2016 and June 2016 weekends no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area because no psychiatrists are available to cover those shifts.

d. For the month of July 2016 in addition to the weekends some holidays and week days no psychiatrists are available to cover those shifts because the hospital salaried psychiatrists who cover week days are on vacation.

e. The Administration provide documentation on 7/21/16 at 3:30 pm , of the facility efforts to cover weekends schedule with psychiatrists for the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area. During review of this documentation it was identified that an average of 22 requests were performed monthly to psychiatrists and they stated that they cannot cover on weekends.

f. The facility failed to ensure that and medical staff leadership maintains mechanisms by which the medical staff fulfills its responsibility to be accountable for the quality of medical care in the hospital.

g. Accordingly with information provided by the administrator on July 22, 2016 at 11:00 am Puerto Rico Government Health Care insurance (Reforma de Salud ) require 23-hour crisis observations, evaluation , holding and stabilization (adult ) area for each patient received to a mental health hospital before final disposition of each case. This level of care must provides up to 23 hours of care in a secure and protected, medically staffed, psychiatrically supervised treatment environment. The primary objective of this level of care is for prompt evaluation and stabilization of individuals presenting with acute psychiatric symptoms or distress.

h. To comply with requirements established by Puerto Rico Government Health Care insurance (Reforma de Salud) facility had developed a protocol for the 23-hour crisis observations, evaluation, holding and stabilization (adult) area function and management. Accordingly with this protocol once a patient came to the triage area a general medicine physician, a nurse and a social worker evaluates the patient and determines if the patient requires emergency or crisis intervention services. The general medicine physician consults the case with the psychiatrists for recommendations on the initial treatment. Then the patient is admitted to the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This case must be evaluated by a psychiatrist before 23 hours for the final disposition of the case.

i. In the cases were no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area and accordingly with information provided by administrator on July 22, 2016 at 11:30 am the instructions given by the administration is to admit the patients to the hospital. Once admitted to the hospital a psychiatrist performs the evaluation.

j. Accordingly with information provided by the medical director (employee # 3) on July 21, 2016 at 1:55 pm this hospital only had 2 salaried physicians one psychiatrist and one internal medicine physician. The other physician ' s generalists and psychiatrists are employees by contract by the facility. Those contracted psychiatrists ' are the ones approached by the facility to cover weekend ' s shifts on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area but all of them refused to cover the shifts.

k. Accordingly with information provided by the president of medical faculty (employee #4) on 7/22/16 at 11:45 am had knowledge of the situation of non-coverage of weekends shifts on the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area and the fact that contracted psychiatrists ' stated that they cannot cover the shifts. He stated that medical faculty is working under the leadership of a new medical director and that some changes are going to be performed in the contracts of physicians after August 7, 2016.

l. Governing body failed to ensure maintain under contract medical staff members that are accountable for the quality of medical care provided to the patients. Contracted medical staff members failed to demonstrates its accountability through its exercise of its duties required on the 23 -hour crisis observations, evaluation , holding and stabilization (adult ) area as required by Puerto Rico Government Health Care insurance (Reforma de Salud ).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol and interview with facility administrator (employee # 1), it was determined that there are serious deficient practices identified that seriously threaten the patient right to receive appropriate services and to ensure psychological well being which makes this condition Not Met ( Cross refer to Tags: A142, A143, A144 and A145 ).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care , review of incidents and complaints reports, review of facility abuse and neglect protocol, review of medical records and interview with facility administrator (employee # 1), it was determined that the patient right to receive appropriate services where their privacy and safety are maintained were not ensured for 3 out of 37 cases reviewed (Case #22, #23 and # 29)
Findings include:
1. A mechanism to ensure that facility promotes privacy and safety requirements while patients are receiving treatment and continuity of care are needed were not followed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:
a. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated February 4, 2016 it was discussed with the administrator by the medical faculty president that facility is not complying with the Puerto Rico Government Health Care insurance (Reforma de Salud ) requirement of the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area for each patient received to a mental health hospital before final disposition of each case. Due to lack of psychiatrists ' to cover weekends shifts on the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area the cases are evaluated by the generalists physicians and their mental condition health treatment are delay for an unforeseen amount of time. This practice does not promote stabilizing treatment needed by the un-well mental health patients are provided without delay. Personnel who manage patients while waiting more than 23 hours for the evaluation of a psychiatrist are exposed to the risk of an exacerbation of patient behavior; safety of those patients and personnel could be endangered by the situation.
b. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated June 15, 2016 it was discussed with the administrator by the medical director that several weeks ago ambulance services transport 3 patients from First Hospital Panamericano main location at Cidra to the First Hospital Panamericano Psychiatric unit located at Ponce. No evidence was found documented of the investigation of this situation. Facility did not determine or investigate whether those 3 patient rights were violated and whether an act of neglect was involved during the situation. The facility did not determine or investigate whether those 3 patient rights were violated and whether an act of neglect was involved during the situation.
c. Accordingly with information provided during survey procedures and reviewed of facility incidents and accidents reports log. On May 20, 2016 ambulance services transport 6 patients from First Hospital Panamericano main location at Cidra to the First Hospital Panamericano Psychiatric unit located at San Juan. The transport of those 6 patients in one ambulance did not reflect facility regulations and procedures. The incident was investigated; however during investigation facility did not determine or investigate whether those 6 patient rights were violated and whether an act of neglect was involved during the situation.
During investigation admissions department personnel and nursing services personnel were involved, however physicians and ambulance services personnel were not involved or documented as involved in the investigation procedures. Admission services department and physicians were re-oriented after investigation of the facility policies and procedures related with transportation of patients from First Hospital Panamericano Psychiatric main Hospital location at Cidra to any one of First Hospital Panamericano Psychiatric Hospital unit ' s locations.
Circumstances were this situation occurs were not clearly investigated or documented as investigated after the incident. Identification of those 6 patients with diagnosis health status and condition during and after the transport was not included in the investigation. Situation appears to be managed from the perspective of administrative level incident; without consider patients health status, and the potential of harm psychological well being of any of those 6 patients during the transport. The entire process of transport a patient from First Hospital Panamericano main location to any one of First Hospital Panamericano Psychiatric Hospital ' s unit location were not assessed in order to determine deviation from facility policies, procedures and requirements.
Responsibility for not compliance were adjudicated to the admission services department however health care professionals who participate in those 6 patients assessment and care and contracted ambulance services were not considered responsible or involved in the process.
Review of the Policies and procedures of the 23-hour crisis observations, evaluation, holding and stabilization (adult) of facility, last reviewed on October /2015, establish that the interdisciplinary team members are responsible for the treatment and care of patients and the psychiatrist is the responsible for the final disposition of the case. Accordingly with information included in the plan of action for the management of cases transported to another hospital location (dated 05/25/16) a memo was sent to the chief of clinical physicians. However no participation of medical staff personnel were identified as involved in this plan of action.
d. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated June 15, 2016 it was discussed with the administrator by the medical faculty members that there is a delay on psychiatric evaluation of patients on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This due to lack of availability of psychiatrists' who perform patient ' s evaluation and be responsible for the treatment and care of patients until the final disposition of each case. This practice does not promote that patients receive services in a secure and protected, medically staffed, psychiatrically supervised treatment environment to patients.

e. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated June 15, 2016 it was discussed with the administrator by the medical faculty members that sometimes several patients are transported to another of the facility locations without psychiatric evaluation of patients on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This due to lack of availability of psychiatrists who performs patient ' s evaluation and be responsible for the treatment and care of patients until the final disposition of each case. The facility did not determine or investigate whether those patient rights were violated and whether an act of neglect was involved during the situation. This practice does not promote that patients who requires emergency or crisis intervention services before being transported to another location are provided by the services; to stabilize their conditions. Personnel who transport those patients to another location are exposed to the risk of an exacerbation of patient behavior during transport. Personnel who receive those patients are exposed to the risk of an exacerbation of patient behavior when they receive them in their location.

f. Accordingly with information reviewed by facility director of nursing (employee #2) on 7/21/16 thought 7/22/16 on thirty seven medical records of patients who receive services in the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area it was identified that facility failed to comply with state Law # 35 of June 28,1994. On three out of thirty seven cases reviewed (case #22,#23 and # 29 ) of patients transferred to another location of the hospital, no information were included on the medical record related with circumstances were the intra hospital transfer occur.

Accordingly with Article 4 of the state Law # 35 of June 28, 1994 the transfer must be performed under appropriate circumstances (information of patient condition must be included and appropriate transport must be used).

g. Accordingly with information provided by the administrator (employee #1) during interview on 07/22/16 at 2:45 pm facility administration had been managing the situation and establish changes to deal or mitigate with the lack of availability of psychiatrists to comply with the evaluation of patients on the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area. He also stated that administration had a compromise to avoid the practice to transport more than one patient from First Hospital Panamericano ' s main location of Cidra to anyone First Hospital Panamericano Psychiatric units locations.

Based on the complaint investigation PR00000558, observations made during the physical environment and patients assessment with the Director of Nursing, it was determined that the facility failed to ensure that patients receive personal privacy during initial and admission assessment for treatment for 1 out of 1 random observation.

Findings include:

During the observational tour performed on 07/22/16 at 9:00 am, the nurse from the triage area was observed performing a patient initial assessment without providing privacy. The front door of the triage room and the medical examination room does not have a (dark plastic film) to provide visual privacy to the patient.

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care , review of incidents and complaints reports, review of facility abuse and neglect protocol and interview with facility administrator (employee #1), it was determined that the patient right to receive care in a safe setting were not ensured.
Findings include:
1. A mechanism to ensure that facility promote that each patient receives care in a safe environment were not followed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:
a. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated February 4, 2016 it was discussed with the administrator by the medical faculty president that facility are not complying with the Puerto Rico Government Health Care insurance (Reforma de Salud ) requirement of the 23-hour crisis observations, evaluation, holding and stabilization (adult ) area for each patient received to a mental health hospital before final disposition of each case. Due to lack of psychiatrists ' to cover weekends shifts on the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area the cases are evaluated by the generalists physicians and their mental condition health treatment are delay for an unforeseen amount of time. Personnel who manage patients while waiting more than 23 hours for the evaluation of psychiatrists are exposed to the risk of an exacerbation of patient behavior; safety of those patients and personnel could be endangered by the situation. The facility failed to protect vulnerable patients, and to provide protection for the patient's emotional health and safety as well as his/her physical safety.

b. Accordingly with information reviewed of facility incidents and accidents reports log. On May 20, 2016 ambulance services transport 6 patients from First Hospital Panamericano Psychiatric Hospital main location of Cidra to the First Hospital Panamericano Psychiatric Hospital unit location of San Juan. The transport of those 6 patients in one ambulance did not reflect facility regulations and procedures. Facility failed to perform supervisory oversight to promote that acutely un-well mental health patients receive transport in a safe environment. Facility failed to protect vulnerable patients, respect, dignity and comfort are not maintained promoting an emotionally safe environment; elements that could affect patient physical safety during transport to another hospital location. While reviewing incident and accident reports it was identified that a similar situation occurs on March 2016; this constituted a pattern of non-compliance concerning a safe environment during patient ' s transportation by ambulance to another hospital location.

c. Accordingly with information provided during survey procedures and reviewed of facility incidents and accidents reports log. On May 20, 2016 ambulance services transport 6 patients from First Hospital Panamericano Psychiatric hospitals ' main location of Cidra to the First Hospital Panamericano Psychiatric hospitals ' unit location of San Juan. The transport of those 6 patients in one ambulance did not reflect facility regulations and procedures. The incident was investigated; however during investigation facility did not determine or investigate whether those 6 patient rights were violated and whether an act of neglect was involved during the situation.
During investigation admissions department personnel and nursing services personnel were involved, however physicians and ambulance services personnel were not involved or documented as involved in the investigation procedures. Admission services department and physicians were re-oriented after investigation of the facility policies and procedures related with transportation of patients from First Hospital Panamericano main location to any one of First Hospital Panamericano Psychiatric Hospital unit locations.
Circumstances were this situation occurs were not clearly investigated or documented as investigated after the incident. Identification of those 6 patients with diagnosis health status and condition during and after the transport was not included in the investigation. Situation appears to be managed from the perspective of administrative level incident; without consider patients health status, and the potential of harm psychological well being of any of those 6 patients during the transport.
The entire process to transport a patient from First Hospital Panamericano Psychiatric Hospital main location at Cidra to any one of First Hospital Panamericano Psychiatric Hospital unit location were not assessed in order to determine deviation from facility policies, procedures and requirements. Responsibility for non compliance were adjudicated to the admission services department however health care professionals who participate in those 6 patients assessment and care and contracted ambulance services were not considered responsible or involved in the process.
Review of the policies and procedures of the 23-hour crisis observations, evaluation, holding and stabilization (adult) of facility, last reviewed on October /2015, establish that the interdisciplinary team members are responsible for the treatment and care of patients and the psychiatrist is the responsible for the final disposition of the case.
Accordingly with information included in the plan of action for the management of cases transported to another hospital location (dated 05/25/16) a memo was sent to the chief of clinical physicians. However no participation of medical staff personnel were identified as involved in this plan of action.
d. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated June 15, 2016 it was discussed with the administrator by the medical faculty members that there is a delay on psychiatric evaluation of patients on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This due to lack of availability of psychiatrists who performs patient ' s evaluation and are responsible for the treatment and care of patients until the final disposition of each case. This practice does not promote that patients receive services in a secure and protected, medically staffed, psychiatrically supervised treatment environment to patients.

e. Accordingly with information provided during survey procedures, on executive committee of the medical faculty meeting dated June 15, 2016 it was discussed with the administrator by the medical faculty members that sometimes several patients are transported to another of the facility locations without psychiatric evaluation of patients on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This due to lack of availability of psychiatrists who performs patient ' s evaluation and be responsible for the treatment and care of patients until the final disposition of each case. Facility did not determine or investigate whether those patient rights were violated and whether an act of neglect was involved during the situation.
This practice does not promote that patients who requires emergency or crisis intervention services before being transported to another location are provided by the services; to stabilize their conditions. Personnel who transport those patients to another location are exposed to the risk of an exacerbation of patient behavior during transport. Personnel who receive those patients are exposed to the risk of an exacerbation of patient behavior when they receive in their location.
The facility failed ensure that the hospital protects vulnerable patients, and to provide protection for the patient's emotional health and safety as well as his/her physical safety.

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol and interview with facility administrator (employee #1), it was determined that facility failed to act upon situations where employees are involved on incidents of fight and verbal abuse while performing duties at the facility and providing care and services to patients for 3 out of 3 incidents reports (IR). (IR. #1, #2 and #3)
Findings include:
1. A mechanism to ensure that facility maintain a proactive approach to identify events and occurrences that may contribute abuse and neglect incidents and represent a potential risk for patients were not followed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:


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2. During survey it was identified that the facility did not promote approaches and implement policies and procedures to investigate and manage complaints filed by staff. Information related with complaints filed by staff for February 2016 and April 2016 reviewed on 07/21/16 at 3:00 pm evidence that rather than investigate and response using systematic proactive approach the concerns referred by staff, facility react but does not investigate through feedback from the individuals in order to determine if it has similar concerns or is an isolated event.
The following information was provided during survey procedures on 07/21/16 through 07/22/16. This information is related with incidents reported during year 2016:
a. Incident # 1 is a register nurse writes an incident report against a facility psychiatrist (employee #5 ) and explain that the psychiatrist call her on 2/16/16 at the facility and she answer the telephone but did not hear the person talking at the telephone and she proceed to hang up the telephone. Few minutes later the psychiatrist calls again and starts screaming to the nurse with insults and bad words in an offensive manner.
b. Incident # 2 on 2/20/16 a facility nurse supervisor arrives at the unit and employee # 5 becomes aggressive against him. The psychiatrist starts claiming that the supervisor pressures the register nurse to make the incident report against him. Another doctor intervenes in the incident because the psychiatrist was approaching the nurse supervisor in a challenging form.
c. Incident # 3 on 4/21/2016 a facility primary therapist write a incident report against employee # 5 and explain that she went to the psychiatrist office and ask him about a medication information for a patient and employee # 5 answers her, " no and look in doctor Google " . The therapist asks the pharmacist for the information. When the therapist arrives at the unit the psychiatrist gives her the information and she told him that she has the information from pharmacy and he told her a bad word.

d. Formal instructions performed in order to protect employee were not found documented or established. Facility did not institute measures for the protection of patients receiving services and staff as means of preventing the re-occurrence or continuation of incidents of verbal abuse.
e. On all those incidents (# 1 # 2 and # 3) previously presented involves facility psychiatrist (employee # 5) behavior. Those incidents were referred to the medical staff for investigation. However no information were provided to the governing body of the circumstances were those incidents happen, interviews of personnel involved in the situations and the potential involvement of patients during events. If an internal investigation were performed results were not informed to the governing body as informed by the administrator on 7/22/16 at 11:15 am.
On 02/23/2016 multiples interviews were perform about the incidents #1, #2 and #3 by the DON (employee #2) and Human Resources Director (employee #6) however no corrective actions by the facility were identified. Facility failed to ensure that a similar act were verbal abuse occur is repeated. The potential of similar behavior from this employee to other employees or to patients are not considered neither forms the medical staff leadership or governing body.
3. A mechanism to ensure that facility comply with state requirements on the employment screening of staff were not followed. These findings were identified during survey procedures on 07/21/16 through 07/22/16 and discussed with the facility administrator (employee #1) 07/22/16 at 10:55 am:

During the review of fourteen medical staff credential files on 7/21/16 from 1:30 pm until 3:00 pm the following was found:
a. Ten out of fourteen medical staff credential file did not have evidence of the criminal background check (Puerto Rico Law 300 from September 2, 1999) (C.F.#2,#3,#4,#6,#7,#8,#9,#10,#11,#14).
This is a contract requirement for The Health Insurance Administration of Puerto Rico (ASES) Puerto Rico Government Health Care insurance (Reforma de Salud ).

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care , review of incidents and complaints reports, review of facility abuse and neglect protocol and interview with facility administrator (employee # 1), medical director (employee #3) and president of medical faculty(employee #4) it was determined that the hospital failed to have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital, which makes this condition Not Met. (Cross refer to Tags A341 and A347).

Based on a complaint investigation ACTS Intake PR00000558, review of fourteen medical staff credential files and review of policies and procedures it was determined that the facility failed to examine the credential files (C.F) to ensure that medical staff have updated Hepatitis B vaccine, updated Influenza vaccines and Criminal Background check for 11 out of 14 medical staff's C.Fs (C.F.#1, #2, #3, #4, #6, #7, #8, #9, #10, #11 and #14)
Findings include:

1. During the review of fourteen medical staff credential files on 7/21/16 from 1:30 pm until 3:00 pm the following was found:

a. One out of fourteen medical staff's credential files did not have evidence of their hepatitis b profiles, hepatitis b antibody HBsAg (Anti-HBs) or hepatitis b responsibility exoneration. (CF #6).

b. Six out of fourteen medical staff' credential files did not have evidence of their Influenza profiles or responsibility exoneration (C.F.#1,#2,#3,#9,#10,#11)
c. Ten out of fourteen medical staff credential file did not have evidence of the criminal background check (Puerto Rico Law 300 from September 2, 1999) (C.F. #2, #3, #4, #6, #7, #8, #9, #10, #11, and #14). This is a contract requirement for The Health Insurance Administration of Puerto Rico (ASES). Accordingly with facility policy and procedure dated October 2015 reviewed every facility employee must provide evidence of the criminal background check Puerto Rico Law 300 from September 2, 1999 every two years.

Based on complaint investigation ACTS Intake PR00000558, observation of delivery of care, review of incidents and complaints reports, review of facility abuse and neglect protocol and interview with facility administrator (employee #1), medical director (employee #3) and president of medical faculty (employee #4) it was determined that facility failed to ensure that contracted medical staff member are well organized and accountable to the governing body for the quality of the medical care provided to the patients.

Findings include:
1. A mechanism to ensure that facility maintain a system of checks and balances within an overall framework of collaboration between the governing body and the medical staff (and, to a certain degree, also between an individual practitioner and the hospital's medical staff and governing body) were not followed not promoted.
a. Review of psychiatrist ' s monthly schedule for coverage the 23-hour crisis observations, evaluation, holding and stabilization (adult) area the following was identified:

On the month of April 2016 on Sunday April 3, 2016 , Saturday April 9, 2016,Sunday April 17, 2016 and Saturday April 23, 2016 no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case.

On the month of May 2016 on Sunday May 1st 2016, Saturday May 7, 2016 Sunday May 8, 2016, Saturday May 14, 2016, Saturday May 21, 2016, Sunday May 22, 2016 and Sunday May 29, 2016 no psychiatrists are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case.

On the month of June 2016 on Saturday June 4, 2016, Sunday June 5, 2016, Saturday June 11, 2016, Saturday June 18, 2016, Sunday June 19, 2016, Saturday June 25, 2016 and Sunday June 26, 2016 no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case.

On the month of July 2016 on Saturday July 2, 2016, Sunday July 3, 2016, Monday (holiday) July 4, 2016,Tuesday July 5, 2016, Thursday July 7, 2016, Friday July 8, 2016, Saturday July 9, 2016, Sunday July 10, 2016, Monday July 11, 2016,Tuesday July 12, 2016,Thursday July 14, 2016, Friday July 15, 2016, Saturday July 16, 2016, Sunday July 17, 2016, Monday July 18, 2016 ,Tuesday July 19, 2016, Saturday July 23, 2016, Sunday July 24, 2016 , Saturday July 30, 2016 and Sunday July 31,2016 no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case.

Accordingly with information provided by the administrator on July 22, 2016 at 11:00 am Puerto Rico Government Health Care Insurance (Reforma de Salud ) require 23-hour crisis observations, evaluation , holding and stabilization (adult ) area for each patient received to a mental health hospital before final disposition of each case. This level of care must provides up to 23 hours of care in a secure and protected, medically staffed, psychiatrically supervised treatment environment. The primary objective of this level of care is for prompt evaluation and stabilization of individuals presenting with acute psychiatric symptoms or distress. To comply with Government Health Plan; members must evidence of the participation in the stabilization unit prior admission to inpatient treatment.

To comply with requirements established by Puerto Rico Government Health Care insurance " Reforma de Salud " , the facility had developed a protocol for the 23-hour crisis observations, evaluation, holding and stabilization (adult) area function and management. Accordingly with this protocol once a patient came to the triage area a general medicine physician, a nurse and a social worker evaluates the patient and determines if the patient requires emergency or crisis intervention services. The general medicine physicians consult the case with the psychiatrist for recommendations on the initial treatment. Then the patient is admitted to the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. This case must be evaluated by a psychiatrist before 23 hours for the final disposition of the case.

In the cases were no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area and accordingly with information provided by administrator on July 22, 2016 at 11:30 am, the instructions given by the administration is to admit the patients to the hospital. Once admitted to the hospital a psychiatrist performs the evaluation.

Accordingly with information provided by the medical director (employee # 3) on July 21, 2016 at 1:30 pm during April 2016, May 2016 and June 2016 weekends no psychiatrist are assigned to perform patients evaluation and be responsible for the treatment and care of patients until the final disposition of each case while receiving services on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area because no psychiatrist are available to cover those shifts.

For the month of July 2016 in addition to the weekends some holidays and week days no psychiatrist are available to cover those shifts because the hospital salaried psychiatrist who cover week days were on vacation.

Accordingly with information provided by the medical director on July 21, 2016 at 1:55 pm this hospital only has 2 salaried physicians ' one psychiatrist and one internal medicine physician. The other physician ' s generalists and psychiatrists ' are employee by contract by the facility. Those contracted psychiatrists ' are the ones approached by the facility to cover weekend ' s shifts on the 23-hour crisis observations, evaluation, holding and stabilization (adult) area, but all of them refused to cover the shifts.

Accordingly with information provided by the president of medical faculty (employee #4) on 7/22/16 at 11:45 am had knowledge of the situation of non-coverage of weekends shifts on the 23-hour crisis observations, evaluation , holding and stabilization (adult ) area and the fact that contracted psychiatrists ' stated that they cannot cover the shifts. He stated that medical faculty is work under the leadership of a new medical director and that some changes are going to be performed in the contracts of physicians after August 7, 2016.

Administration provides documentation on 7/21/16 at 3:30 pm, of the facility efforts to cover weekends schedule with psychiastrists for the 23-hour crisis observations, evaluation, holding and stabilization (adult) area. During review of this documentation it was identified that an average of 22 requests were performed monthly to psychiatrists ' and they stated that they cannot cover on weekends.

2. Facility failed to ensure that medical staff leadership maintains mechanisms by which the medical staff fulfills its responsibility to be accountable for the quality of medical care in the hospital.

Contracted medical staff members failed to demonstrates its accountability through its exercise of its duties required on the 23 -hour crisis observations, evaluation, holding and stabilization (adult) area as required by Puerto Rico Government Health Care insurance " Reforma de Salud " .

Based on a complaint investigation ACTS Intake PR00000558, observations made during the survey for the physical environment with Director of Nursing (employee #2) on 7/22/16 at 9:00 am until 10:45 am, it was determined that the holding area and the stabilization area SEC ( " Sala Establizadora " ) failed to ensure staff provide care in a safe manner, ensuring the well-being of patients receiving services.
Findings include:
1. The holding area was observed on 7/22/16 at 9:55 am. It lacks sufficient space for patients waiting to be admitted. The area has 6 lounge chairs and the separation between them is less than 4 lineal feet and 80 sq. ft. per area.
2. The stabilization room was observed on 7/22/16 at 9:30 am and it was found that the room has 9 lounge chairs and 1 isolation room (quiet room) with the door opened one patient in bed. The bed is observed without linen. The 9 chairs were occupied. It was observed that between chairs their less than 4 linear feet of separation.

Based on a complaint investigation ACTS Intake PR00000558, observations made during the survey for the physical environment with the facility's Director of Nursing (employee #2) , it was determined that the physical structure and care areas of the emergency rooms' waiting area and triage area failed to provide proper ventilation with an air disinfection system.

Findings include:

The Admission area was visited on 7/22/16 from 9:00 am until 10:30 am and provided evidence that the waiting area and triage area are not equipped with an air disinfection system (for example: Ultraviolet lights).
According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) the triage area is the point of entry of undiagnosed and untreated airborne infections and should be designed and ventilated to reduce exposure of staff, patients and families to airborne infectious diseases.
Through the facility's infection control program, determinations must be made related to general ventilation and air disinfection similar to inpatient requirements for airborne infection isolation rooms according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". The waiting area is another area to provide protection with an air disinfection system due to the concentration of patients and space.