HospitalInspections.org

Based on the review of hospital licenses/certifications, it was determined that the facility failed to ensure that it is in compliance with Federal and State laws related to a conditional Fire Department Endorsement and expired State License.

Findings include:

During the review of the facility's licenses/certifications on 9/15/11 at 11:45 am, it was identified that their State License expired on August 31, 2011 and the Fire Department Endorsement is "Conditional Endorsement" (given from 8/30/11 through 2/28/11). The "Conditional Endorsement" was given to the facility until they make corrections for an outside exit staircase and the State License is in the process of being reviewed by the State Department of Health after they received all paper work from the facility to emit the license.

Based on the review of documents, observations, tests and interviews from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm, it was determined that the Governing Body failed to carry out its responsibility for the operation and management of the hospital. It did not provide the necessary oversight and leadership as evidenced by the lack of compliance with: Medical Record Services (42 CFR 482.24), Pharmaceutical Services (42 CFR 482.25), Physical Environment (42 CFR 482.41), Surgical Services (42 CFR 482.51) and Emergency Services (42 CFR 482.55).

Based on five records reviewed (R.R) and Do Not Resuscitate (DNR) Policies and Procedures, it was determined that the facility failed to ensure that patients or their representatives formulate advance directives and comply with these directives related to written DNR or "Do Not Intubate" (DNI) orders in accordance with the patient's signed consent for DNR or DNI for five out of five records reviewed (R.R #5, #6, #7, #9 and #10).
Findings include:
1. The facility failed to inform patients or their representatives that they have the right to formulate advance directives and comply with these directives related to DNR and DNI order requests as reviewed on 9/14/11 from 2:20 pm till 4:00 pm:
a. R.R #5 is an 89 years old male who was admitted on 7/17/11 with a diagnosis of pneumonia. On 9/14/11 at 2:20 pm the record was reviewed with the Technical information manager (employee #5). It was found that the patient's relative signed a consent for DNR and DNI on 7/14/11 at 6:20 pm in the emergency room, no evidence was found who took the consent. The physician progress note performed on 7/14/11 at 6:20 pm provided evidence related to DNR and DNI justification and patient orientation. However no evidence was found related to the physician's order for DNI and DNR order. In the event that an emergency arises it is not clear what will happen with the patient since the patient or his relative signed the DNR and DNI consent, but there is no physician's order for the DNR and DNI. The patient died on 7/17/11 respecting his decision to DNR and DNI but without a medical order for the DNR and DNI. The facility's policies and procedures were reviewed on 9/14/11 at 2:30 pm and it states that Do Not Resuscitate orders will be valid during the stay of the patient and should be checked every 48 hours during the stay. However no evidence was found in the physician's progress notes and in the physician's orders related to the DNR and DNI checked every 48 hours during the stay.
b. R.R # 6 is a 93 years old female who was admitted on 5/31/11 with a diagnosis of pseudomembranous Colitis. On 9/14/11 at 3:00 pm the record was reviewed with the Technical information manager (employee #5). It was found in the nurse's progress notes on 5/31/11 at 3:40 am that the nurse documents that the physician was notified related to the patient's relative desire to sign anticipated measure. The physician authorized the nurse to deliver documents to the patient's relative and to take the consent and then he oriented the patient's relative. It was found that the patient's relative signed a consent for DNR and DNI and no evidence was found related to the date and hour that patient's relative signed the consent. No evidence was found who took the consent. The physician's progress note performed on 5/31/11 at 9:30 am stated that the patient was alone in the room and signed the DNR/DNI today. However no evidence was found related to the physician's order for DNI and DNR. No evidence was found related to the physician's justification and patient's relative orientation related to DNR and DNI. In the event that an emergency arises it is not clear what will happen with the patient since the patient or her relative signed the DNR and DNI consent, but there no physician order for the DNR and DNI were found. The facility's policies and procedures were reviewed on 9/14/11 at 2:30 pm and it states that Do Not Resuscitate orders will be valid during the stay of the patient and should be checked every 48 hours during the stay, However no evidence was found in the physician's progress notes and in the physician's order related to the DNR and DNI checked every 48 hours during the stay.
c. R.R #7 is a 36 years old male who was admitted on 7/29/11 with a diagnosis of Human Immunodeficiency Virus (HIV). On 9/14/11 at 3:15 pm the record was reviewed with the Technical information manager (employee #5). It was found that the patient's relative signed a consent for DNR and DNI and no evidence was found related to the date and hour that the patient's relative signed the consent. No evidence was found who took the consent. However no evidence was found related to the physician's order for DNI and DNR. No evidence was found related to the physician's justification and patient's relative orientation related to the DNR and DNI. In the event that an emergency arises it is not clear what will happen with the patient since the patient or his relative has signed the DNR and DNI consent, but there is not a physician order for the DNR and DNI. The nurse's progress notes performed on 8/1/11 at 7:40 pm stated that the patient was without respiratory effort, did not respond to stimulus, in company of relatives. Patient with DNR/DNI signed by family members. Connected to a cardiac monitor, and heart tracing was performed on patient and the heart rate was "0". The physician was notified and the patient's relative was oriented about the death. The patient died on 7/5/11 respecting his decision to DNR and DNI but without a medical order for the DNR and DNI. The facility's policies and procedures were reviewed on 9/14/11 at 2:30 pm and it states that Do Not Resuscitate orders will be valid during the stay of the patient and should be checked every 48 hours during the stay. However no evidence was found in the physician's progress notes and in the physician order related to the DNR and DNI checked every 48 hours during the stay.
d. R.R # 9 is a 92 years old female who was admitted on 7/15/11 with a diagnosis of Intracranial Hemorrhage. On 9/14/11 at 3:40 pm the record was reviewed with the Technical information manager (employee #5). It was found that the patient's relative signed a consent for DNR and DNI on 7/15/11 at 10:00 am, but no evidence was found of who took the consent. The physician's progress notes performed on 7/15/11 at 11:40 am provided evidence of the physician's justification and orientation related to the DNR and DNI. However no evidence was found related to the physician's order for DNI and DNR. In the event that an emergency arises it is not clear what will happen with the patient since the patient or her relative has signed the DNR and DNI consent, but there was no physician's order for the DNR and DNI. On 7/17/11 at 3:30 pm the nurse's progress notes stated that the patient was in Cardiorespiratory arrest, was noted cyanotic and unresponsive to stimuli. The patient has non-resuscitation and intubation orders signed by patient's relative. No vital signs present, the physician evaluates patient and declared dead at 5:55 pm. The patient dies on 7/17/11 respecting his decision to DNR and DNI but without a medical order for the DNR and DNI. The facility policies and procedures were reviewed on 9/14/11 at 2:30 pm and states Do Not Resuscitate orders will be valid during the stay of the patient and should be checked every 48 hours during the stay, However no evidence was found in the physician's progress notes and in the physician order related to DNR and DNI checked every 48 hours during the stay.
e. R.R # 10 is a 90 years old female who was admitted on 7/2/11 with a diagnosis of Septicemia. On 9/14/11 at 3:50 pm the record was reviewed with the Technical information manager (employee #5). It was found that the patient's relative signed a consent for DNR and DNI on 7/6/11 at 2:16 am, no evidence was found who took the consent. The nurse's notes performed on 7/5/11 at 1:30 am provided evidence that the physician explained to the patient's relative the patient's condition and signed the DNR and DNI consent. However no evidence was found related to the physician's order for DNI and DNR. In the event that an emergency arises it is not clear what will happen with the patient since the patient or her relatives signed the DNR and DNI consent, but there is not a physician order for the DNR and DNI. On 7/5/11 at 3:35 pm the nurse's progress notes states that the patient was in asystole and the physician was notified to declare the patient dead. The patient died on 7/5/11 respecting his decision to DNR and DNI but without a medical order for the DNR and DNI. The facility's policies and procedures were reviewed on 9/14/11 at 2:30 pm and states that Do Not Resuscitate orders will be valid during the stay of the patient and should be checked every 48 hours during the stay, However no evidence was found in the physician's progress notes and in the physician's order related to the DNR and DNI checked every 48 hours during the stay.

2. During the review of the facility's "Do Not Resuscitate Policies and Protocols" on 9/14/11 at 2:20 pm, it was determined that the facility failed to have policies and procedures in place related to:

a. Do Not Intubate (DNI).

3. During the review of the facility's "Do Not Resuscitate Consent" and Do not Intubation Consent on 9/14/11 at 2:20 pm it was found that the consent did not provide the physician's signature, date and hour when the consent was taken by the physician.

Based on six records reviewed (R.R), it was determined that the facility failed to promote the patient's right to be free of restraints and failed to continually assess and monitor five out of six records reviewed (R.R #2, #3, #5, #7 and #8).

Findings include:

1. R.R #2 is a 70 years old female who was admitted on 8/29/11 with a diagnosis of Right Hip Fracture. During the record review on 9/14/11 at 9:15 am with the fifth floor supervisor (employee #2), it was found that the physician ordered restraints on 8/30/11 at 6:00 pm "as needed" (PRN). Physician orders reviewed from 8/31/11 at 8:00 pm, 9/1/11 at 8:00 pm, 9/2/11 at 8:00 pm, 9/3/11 at 8:00 pm and from 9/10/11 at 7:00 am provided evidence that the physician wrote soft restraints of the superior extremities to prevent interruption of treatment during 24 hours. However, no evidence was found that the physician signed the restraint Protocol order. The physician failed to fill in and sign the patient restraint protocol. The physician failed to start the restraint protocol on 8/30/11. On 8/30/11 the nursing reassessment and documentation on the patient's restraint sheet provided evidence that the patient was restrained as a PRN order because the nurse filled in the blank sheet from 7:00 am till 5:00 pm. The nurse's progress notes performed on 8/30/11 at 7:00 am provided evidence that the patient was alert and not oriented during intervals. On 8/31/11, the nurse restrained the patient without a physician's order because the physician did not countersign the restraint order. The restraint assessment sheet provided evidence that the nurse restrained the patient on 8/31/11 from 7:00 pm till 9/1/11 at 5:00 am. The nurse's progress notes provided evidence on 9/1/11 at 8:13 pm that the patient was observed with soft restraints of the superior extremities as ordered to prevent the patient from interrupting treatment. However, no evidence was found that the nurse assess the patients' restraints during the 7:00 am-7:00 pm shift. The restraint assessment sheet was left in blank during the 7:00 am-7:00 pm shift. On 9/2/11 at 6:30 am the nurse's progress notes provided evidence that the patient was sent to the operating room and returned to her room at 2:00 pm. The restraint assessment sheet performed on 9/2/11 at 2:00 pm provided evidence that the patient was started on restraints at 3:00 pm after she returned from the operating room. However, no evidence was found that the physician re-ordered the patient's restraints. On 9/2/11 the patient restrained from 3:00 pm till 9/3/11 at 5:00 am and the restraint order was not signed by the physician. On 9/3/11 from 7:00 am till 5:00 pm no evidence was found that the patient was restrained. However on 9/3/11 at 7:00 pm the patient was restrained and no evidence was found related to a new restraint order until 8:00 pm and the physician failed to sign the restrain protocol order. On 9/11/11 at 7:00 am the nurse's progress notes provide evidence that the patient was alert not oriented and restrained at both hands, however no evidence was found that the physician signed the restraint order and no evidence was found that the nurse reassessed the patient during the restraint. At 8:00 pm on 9/11/11 the nurses progress notes referred that the patient was alert, not oriented in time, space and person and was talking incoherently. No evidence was found related to the restraint assessment. No evidence was found of the updated patient's plan of care related to the restraints by the registered nurse on 8/31/11. No evidence was found related to the patient's or relatives' orientation related to the restraints.

2. R.R #3 is an 89 years old female who was admitted on 8/27/11 with a diagnosis of Acute Coronary Syndrome (ACS) and Congestive Heart Failure (CHF). During the record review on 9/14/11 at 9:45 am with the fifth floor supervisor (employee #2), the patient's restraint reassessment sheet performed on 8/30/11 provided evidence that the patient was started on restraints from 8/30/11 at 7:00 pm till 8/31/11 at 5:00 am, however no evidence was found that the physician ordered the restraints. The patient's restraint reassessment performed on 8/31/11 at 7:00 am provided evidence that the patient was restrained from 7:00 am till 11:00 am, however the restraint protocol was not signed by the patient's physician. On 9/12/11 at 7:00 pm the physician ordered by telephone soft restraints of the superior extremities due to disorientation and security, however no evidence was found that the physician signed the telephone order. The patient's restraint reassessment performed on 9/12/11 provided evidence that the nurse's re-assessment from 7:00 am and 9:00 pm did not include information related to the continued re-assessment or to discontinue the order. No evidence was found that the patient's plan of care related to the restraints was updated and individualized by the registered nurse after 8/30/11. No evidence was found related to the patient's or relatives' orientation related to the restraint.

3. R.R #5 is an 89 years old female who was admitted on 7/17/11 with a diagnosis of pneumonia. During the record review on 9/14/11 at 2:20 pm with the technical information manager (employee #5), it was found that the restraint protocol was ordered by the physician on 7/15/11 at 6:00 pm, however the restraint protocol was left in blank. No evidence was found that the patient's plan of care related to the restraints was updated and individualized by the registered nurse after 8/30/11. No evidence was found related to the patient's or relatives' orientation related to the restraint.

4. R.R #7 is a 36 years old male who was admitted on 7/29/11 with a diagnosis of Septicemia and Human immunodeficiency virus (HIV). During the record review on 9/14/11 at 3:15 pm with the technical information manager (employee #5), it was found that the restraint protocol was ordered by the physician on 6/20/11, however no evidence was found related to the hour when the physician placed the order and no evidence was found related to the area where the restraint was placed and no evidence was found that the nurse completed the patient's restraint reassessment sheet. No evidence was found that the patient's plan of care related to the restraints were activated and updated by the registered nurse. No evidence was found related to patient's or relatives' orientation related to the restraint.

5. R.R #8 is a 60 years old female who was admitted on 6/10/11 with a diagnosis of Acute Respiratory Failure. During the record review on 9/14/11 at 3:35 pm with the technical information manager (employee #5), it was found that the physician ordered Soft restraints of the upper extremities on 6/10/11 at 7:00 pm, however no evidence was found related to the time of use of the restraints, the reason for the use of the restraints and the physician do not activate the restraint protocol. No evidence was found related to the nurse's restraint assessment. On 6/12/11 at 7:00 pm the nurse's progress notes referred that the patient was combative, did not follow instructions, with restraints for security and treatment. However no evidence was found related to the physician's order and nurse's restraint assessment. On 6/13/11 the adult intensive re-assessment performed at 7:00 am and 7:00 pm referred that the patient was restrained, however no evidence was found related to the physician's order and nurse's restraint assessment. On 6/14/11 the patient's restraint re-assessment performed by the registered nurse provided evidence that the patient was restrained from 6/14/11 at 7:00 am till 6/15/11 at 5:00 am, however no evidence was found related to the physician's order and nurse's restraint assessment. On 6/16/11 the physician signed the restraint protocol order, however it lacked the time that the physician placed the order and the patient's restraint assessment sheet provide evidence that the patient was restrained at 7:00 am and 9:00 am, no evidence was found of the nursing restraint assessment at two hour intervals for 11:00 am, 1:00 pm, 3:00 pm and 5:00 pm, and the continued restraint assessment every two hours. On 6/17/11 the physician reordered the restraint, however no evidence was found of the hour when the physician placed the order. The patient's restraint assessment sheet from 6/17/11 provided evidence that the patient was restrained from 7:00 am till 5:00 pm and no evidence was found of the nursing restraint assessment at two hour intervals from 6/17/11 at 7:00 pm till 6/18/11 at 5:00 am. On 6/18/11 the physician reordered the restraint order, however no evidence was found of the hour when the physician placed the order. No evidence was found of the nurse's restraint assessment every two hours. On 6/19/11 the physician reordered the restraint order, however no evidence was found of the hour when the physician placed the order. No evidence was found of the nurse's restraint assessment at two hour intervals on 6/19/11 from 7:00 am till 5:00 pm. No evidence was found that the patient's plan of care related to the restraints was activated and updated by the registered nurse. No evidence was found related to patient's or relatives' orientation related to the restraint.

Based on seven medical records reviewed, review of policies and procedures (P&P) related to the restraint protocol, it was determined that the facility failed to ensure that the order for the use of restraints is never used as on a "as needed basis" (PRN) for three out of six records reviewed (R.R #2, #3 and #8).

Finding included:

1. R.R #2 is a 70 years old female who was admitted on 8/29/11 with a diagnosis of Right Hip Fracture. During the record review on 9/14/11 at 9:15 am with the fifth floor supervisor (employee #2), it was found that on 8/30/11 at 6:00 pm the physician ordered restraints "as needed" (PRN) and on 8/31/11 at 8:00 pm, on 9/1/11 at 8:00 pm, on 9/2/11 at 8:00 pm, on 9/3/11 at 8:00 pm and 9/10/11 at 7:00 am the physician documents to provide restraints with soft restraints of the superior extremities to prevent interruption of treatment for 24 hours. The nursing re-assessment and documentation of the patient's restraint sheet provided evidence that the patient was restrained as a PRN order because the nurse filled in the blanks of the sheet on 8/30/11 from 7:00 am till 5:00 pm, on 9/1/11 from 7:00 am till 5:00 pm, on 9/2/11 from 7:00 am till 3:00 pm and on 9/3/11 from 7:00 am till 5:00 pm.

2. R.R #3 is an 89 years old female who was admitted on 8/27/11 with a diagnosis of Acute Coronary Syndrome (ACS) and Congestive Heart Failure (CHF). During the record review on 9/14/11 at 9:45 am with the fifth floor supervisor (employee #2), it was found in the physician ordered soft restraint of the right and left wrist for 24 hours on 9/12/11 at 7:00 pm. The nursing re-assessment and documentation of the patient's restraint sheet provided evidence that the patient was restrained as a PRN order because the nurse filled in the blanks of the sheet on 9/12/11 from 11:00 pm till 9/13/11 at 5:00 am.

3. R.R #8 is a 60 years old female who was admitted on 6/10/11 with a diagnosis of Acute Respiratory Failure. During the record review on 9/14/11 at 3:35 pm with the technical information manager (employee #5), it was found that the physician ordered soft restraints for the right and left wrist for 24 hours on 6/16/11, 6/17/11, 6/18/11, 6/19/11, 6/20/11, 6/19/11, 6/20/11 and 6/21/11. The nursing re-assessment and documentation on the patient's restraint sheet provided evidence that the patient was restrained as a PRN order because the nurse filled in the blanks of the sheet on 6/16//11 from 11:00 am till 5:00 pm, on 6/17/11 from 7:00 pm till 6/18/11 at 5:00 am, on 6/19/11 from 7:00 am till 5:00 pm.

Based on the review of documents and interview with the quality assurance officer (employee #9), it was determined that the facility failed to ensure that aspects of performance that assess processes of care and hospital services and operations are measured and track quality indicators by the quality assurance program.

Findings include:

1. A mechanism to ensure that the facility actively identifies potential and actual adverse drug events and medication errors in the emergency room that include direct observations of medication administrations and review of patient's clinical records were not evidenced on 9/15/11 at 10:00 am. Emergency room department pharmacy services at the facility are provided by a contractor who must have in place a mechanism for the proactive identification and management of irregularities in the administration of medications in this area, however this was not performed nor evidenced during the survey procedures.

2. Facility Quality Assurance Performance Improvement activities pertaining to emergency room department pharmaceutical care were not evidenced nor provided during the survey procedures on 9/15/11 at 10:20 am.

3. Facility Quality Assurance Performance Improvement activities pertaining to the emergency room department were not informed to the hospital wide quality assurance program on 9/13/11 at 1:18 pm.

Based on the review of forty medical staff credential files, it was determined that the facility failed to examine credential files (C.F) to ensure that medical staff have updated Health Certificates, Cardio-pulmonary Resuscitation Certificates (CPR), Mal Practice Assurance Federal Narcotic License, State Narcotic License and Physician Professional College for twelve out of forty credential files reviewed (C.Fs #5, #6, #7, #11, #12, #16, #18, #20, #23, #27, #28 and #40).

Findings include:

1. During the review of forty medical staff credential files on 9/15/11 from 1:00 pm till 1:30 pm the following was found:

a. Seven out of forty medical staff credential files provided evidence of expired Health Certificates for C.Fs #5, #7, #12, #16, #20, #23 and #28.

b. Two out of forty medical staff credential files provided evidence of expired cardio- respiratory certificates for C.Fs #18 and #27.

c. Three out of forty medical staff credential files provided evidence of expired Mal Practice Assurance for C.Fs #18, #27 and #40.

d. One out of forty medical staff credential files did not provide evidence of Federal Narcotic License for C.Fs #40.

e. One out of forty medical staff credential files did not provide evidence of State Narcotic License for C.Fs #40.

f. Five out of forty medical staff credential files did not provide evidence of professional college of 2011 for C.Fs #5, #6, #11, #16 and #28.

Based on nursing supervisor roster review and interview with the Director of Nursing (DON) (employee #6), it was determined that the hospital failed to provide 24-hours of registered nurse staffing to cover every unit of the hospital during seven days a week twenty hours a day.

Findings include:

1. During review of the nurses staffing schedule for a one-week period from 9/4/11 through 9/10/11 on the Intensive Care Unit, on 09/15/11 at 10:00 am the following was found:

a. On 9/4/11 the census of the Adult Intensive Care Unit is nine (9) patients and the unit have two register nurses (RN) to cover shift from 7:00 am till 7:00 pm and two RNs ' to cover shift from 7:00 pm till 7:00 am.
b. On 9/5/11 the census of the Adult Intensive Care Unit is eleven (11) patients and the unit have three RNs ' to cover shift from 7:00 am till 7:00 pm and three RNs ' to cover shift from 7:00 pm till 7:00 am.
c. On 9/6/11, 9/7/11 and 9/8/11 the census of the Adult Intensive Care Unit is eleven (11) patients and the unit have three RN to cover shift from 7:00 am till 7:00 pm and two RN s ' to cover shift from 7:00 pm till 7:00 am.
d. On 9/9/11 the census of the Adult Intensive Care Unit is ten (10) patients and the unit have three RNs ' to cover shift from 7:00 am till 7:00 pm and two RNs ' to cover shift from 7:00 pm till 7:00 am.
e. On 9/10/11 the census of the Adult Intensive Care Unit is eleven (11) patients and the unit has two RNs ' to cover shift from 7:00 am till 7:00 pm and two RNs ' to cover shift from 7:00 pm till 7:00 am.
2. During review the nurse staffing schedule for the second-week period from 9/11/11 through 9/15/11 on 9/15/11 at 10:05 am the following was found:
a. On 9/11/11 the census of the Adult Intensive Care Unit is nine (9) patients and the unit has two RNs ' to cover shift from 7:00 am till 7:00 pm and two RN ' s to cover shift from 7:00 pm till 7:00 am.
b. On 9/12/11 the census of the Adult Intensive Care Unit is eleven (11) patients and the unit has three RNs ' to cover shift from 7:00 am till 7:00 pm and two RNs ' to cover shift from 7:00 pm till 7:00 am.
c. On 9/13/11 the census of the Adult Intensive Care Unit is eleven (11) patients and the unit has three RN ' s to cover shift from 7:00 am till 7:00 pm and three RN ' s to cover shift from 7:00 pm till 7:00 am.
d. On 9/14/11 the census of the Adult Intensive Care Unit is eleven (11) patients and the unit has three RN ' s to cover shift from 7:00 am till 7:00 pm and four RNs ' to cover shift from 7:00 pm till 7:00 am.
e. On 9/15/11 the census of the Adult Intensive Care Unit is eleven patients (11) and the unit have three RNs ' to cover shift from 7:00 am till 7:00 pm and two RNs ' to cover shift from 7:00 pm till 7:00 am.

3. During review the nurse staffing schedule for a one-week period from 9/4/11 through 9/10/11 on the Medicine and Surgery Department on 9/15/11 at 10:10 am the following was found:

a. On 9/4/11 the census is twenty-seven (27) patients and have 3 RN's to cover shift from 7:00 am till 7:00 pm and 3 RNs ' to cover shift from 7:00 pm till 7:00 am.
b. On 9/5/11 the census is thirty-three (33) patients and 4 RNs ' to cover shift from 7:00 am till 7:00 pm and 3 RNs ' to cover shift from 7:00 pm till 7:00 am.
c. On 9/6/11 the census is forty (40) patients and has 4 RNs ' to cover shift from 7:00 am till 7:00 pm and 4 RNs ' to cover shift from 7:00 pm till 7:00 am.
b. On 9/7/11 and 9/8/11 the census is forty-nine (49) patients and 4 RNs ' to cover shift from 7:00 am till 7:00 pm and 3 RNs ' to cover shift from 7:00 pm till 7:00 am.
b. On 9/9/11 the census is fifty (50) patients and 4 RNs ' to cover shift from 7:00 am till 7:00 pm and 3 RNs ' to cover shift from 7:00 pm till 7:00 am.
b. On 9/10/11 no evidence of patients census and 4 RNs ' to cover shift from 7:00 am till 7:00 pm and 3 RNs ' to cover shift from 7:00 pm till 7:00 am.

3. During review the nurse staffing schedule on 9//11 at 10:15 am for a two-weeks period from 9/4/11 through 9/15/11 the OB Gyn Department that maintain a census enter one to nine patients and covered with one to two register nurses and the Pediatric Department maintain a census under four to ten patients and covered with one to two register nurses.
4. According of review on 9/ 15/11 at 10:20 am of the facility patient classification, categorization, care description and service required per hours related to the patients needs the facility did comply with these requirements. The facility established a nurse staffing pattern for Pediatric Intensive Unit Care, Neonatal Unit Care and Intensive Adult Unit Care of one register nurse per every two patients, on Nursery Constant Care, one register nurse per every three patients and on Emergency room, Operating room and Recovery room the staffing was calculate based on team work or services unit required, amount of patients, attendance and expertise of the leaders at the departments.
4. During interview with the Director of Nursing (DON) (employee #6) on 9/15/11 at 10:30 am, she stated: '' I have a nursing supervisor on-site at the hospital from Monday through Sunday from 7:00 am till 7:00 am. However, the facility did not have adequate staffing to cover all clinical hospital departments and I covered with perdiems personnel. There are three patient's shifts at San Juan Bautista Hospital (7:00 am till 3:00 pm, 3:00 pm till 11:00 pm and 11:00 pm till 7:00 am) and two patient's shifts from (7:00 am till 7:00 pm and 7:00 pm till 7:00 am). Actually the Emergency room of this hospital was administered by a private company ''Universally Training Emergency Group'' and all of the nursing personnel were contracted by this company. This private company does not have licensed practical nurse (LPN), they only have one LPN assigned to supplied the department during the shifts 7:00 am till 3:00 pm seven days a week. However, due to this situation related to staffing pattern, a study was conducted on May of 2011 related to all problems of the nursing department and it showed that we need five RNs' on Medicine Intensive Unit Care, two RN's on Neonatal Intensive Unit Care, three RN's and one LPN on Pediatric Unit department, two RN's and three LPN's on OB Gyn and Delivery room department, three RN's and two LPN's on Medicine and Surgery department, two LPN's on Nursery department and one RN on Operating room department to cover patients nursing needs.''

Based on the review of sixty nursing credential files, it was determined that the facility failed to examine credential files (C.F) to ensure that nursing staff have updated professional licenses, Health Certificates, Cardio-pulmonary Resuscitation Certificates (CPR), hepatitis B vaccines, updated annual evaluations and competencies and updated competencies for fifty-seven out of sixty credential files reviewed (C.Fs #1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59 and #60).

Findings include:

1. During the review of sixty nursing credential files on 9/15/11 at 3:00 pm the following was found:

a. Thirty-two out of sixty nursing credential files provided evidence of expired Health Certificates for C.Fs #3, #4, #8, #11, #12, #13, #15, #16, #17, #18, #19, #20, #21, #23, #24, #25, #29, #31, #32, #33, #35, #36, #37, #39, #40, #45, #46, #49, #51, #54, #56 and #60.

b. Twenty out of sixty nursing credential files provided evidence of expired cardio- respiratory certificates for C.Fs #1, #9, #10, #11, #13, #14, #16, #18, #21, #22, #24, #25, #27, #33, #37, #39, #40, #42, #45 and #49.

c. Two out of sixty nursing credential files did not contain evidence of Hepatitis B vaccines (C.F #16 and #60).

d. Fifty-six out of sixty nursing credential files did not contain evidence of updated annual evaluation (C.F #1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #42, #44, #45, #46, #47, #48, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59 and #60).

e. Two out of sixty nursing credential files did not contain evidence of the updated competencies (C.F #59-the last competency was performed in September 2006). The last competency of the housekeeping operating room personnel (employee #60) was performed in November of 2007.

e. R.R #1 is an 80 years old female who was admitted on 9/1/11 with Active Pulmonary Tuberculosis. The patient's record was reviewed on 9/14/11 at 8:45 am and evidence was found that the registered nurse do not activated the restraint plan of care according to the patient's needs during the hospitalization and no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

f. R.R #2 is a 70 years old female who was admitted on 8/29/11 with a Right hip fracture. The patient's record was reviewed on 9/14/11 at 9:15 am and evidence was found that the registered nurse activated the restraint plan of care according to the patient's needs during the hospitalization, however no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

g. R.R #3 is an 89 years old female who was admitted on 8/27/11 with Acute Coronary Syndrome and Congestive Heart Failure. The patient's record was reviewed on 9/14/11 at 9:45 am and evidence was found that the registered nurse activated the restraint plan of care according to the patient's needs during the hospitalization, however no evidence was found of that it was individualized and revised for the patients' needs according to the patient's changes during the in-patient stay.

h. R.R #5 is an 89 years old male who was admitted on 7/14/11 with Pneumonia. The patient's record was reviewed on 9/14/11 at 2:20 pm and evidence was found that the registered nurse activated the restraint plan of care according to the patient's needs during the hospitalization, however no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

i. R.R #7 is a 36 years old male who was admitted on 7/29/11 with Septicemia. The patient's record was reviewed on 9/14/11 at 3:14 pm and evidence was found that the registered nurse activated the restraint plan of care according to the patient's needs during the hospitalization, however no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

j. R.R #8 is a 60 years old female who was admitted on 6/10/11 with Acute Respiratory Failure. The patient's record was reviewed on 9/14/11 at 3:30 pm and evidence was found that the registered nurse do not activated the restraint plan of care according to the patient's needs during the hospitalization and no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.


17959


Based on the review of eleven clinical records and policies/procedure with the Director of Nursing (DON) (employee #6), it was found that the facility failed to ensure that nursing staff develop appropriate nursing interventions and implement, individualized and updated care plans for ten out of eleven records reviewed (R.R #1, #2, #3, #5, #7, #8, #46, #47, #48 and #49).

Findings include:

1. Ten out of eleven records reviewed for care plans on 9/14/11 from 9:15 am till 4:00 pm and on 9/15/11 from 10:00 am through 11:45 am provided evidence that a patient did not have written nursing care plans during the patients' hospitalization and did not provide evidence of an individualized and updated plan of care.

a. R.R #46 is a 10 years old male who was admitted on 9/9/11 at 7:30 pm with abdominal pain post- Appendectomy. The patient's record was reviewed on 9/15/11 at 10:00 am and evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization but did not individualize the standardized plan of care. No evidence was found of the revision of patients' needs according to the patient's changes during the in-patient stay.

b. R.R #47 is a 4 years old male who was admitted on 9/5/11 with Left Knee Cellulitis, Leucocytosis and Osteomyelitis. The patient's record was reviewed on 9/15/11 at 10:10 am and evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization but was not individualized for the standardized plan of care.

c. R.R #48 is a 38 years old female who was admitted on 9/12/11 with Anemia, Vaginal Bleeding and Acute Pelvic Pain. The patient's record was reviewed on 9/15/11 at 10:20 am and evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization and did not individualize the standardized plan of care and no evidence of the date when the nurse activated the plans of care. No evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

d. R.R #49 is a 68 years old male who was admitted on 9/13/11 with Bradycardia Symptomatic. The patient's record was reviewed on 9/15/11 at 2:30 pm and evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization however no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

Based on observations of the medication drug cart with the Infection control officer (employee #1), it was determined that the facility failed to ensure that drugs and biologicals are stored and protected in a proper manner related to medications not secured in the medication cart.

Findings include:

1. During the observational tour of the fifth floor medical/surgical ward on 9/13/11 at 2:30 pm with the Infection Control Officer (employee #1), the medication cart was observed in the medication room but the door do not latch. The medication cart was observed opened without a lock.

a. Medication drug carts were observed unlocked and unattended with the medication room door unlocked. Patient's medications were observed pre-served in patient's drawers to be administered at 5:00 pm, 6:00 pm and 9:00 pm (oral medications and piggy bags) in drawers #5-145 B, 5-147 B, 5-155 A, 5-156 A, 5-156 B, 5-158 A, 5-162 A and 5-163 A.

Based on the observational tour of the medical records department on 9/15/11 from 9:30 am till 3:00 pm through the central file area, alternate storage area, review of the policies and procedure's manual, a manual of abbreviations and incomplete medical records report provided by the medical record supervisor (employee #21), it was determined that the facility failed to complete clinical records within 30 days following discharge and maintain an updated and approved by the Governing Body abbreviations and signature registry and are reviewed and revised as needed, failed to properly secure an alternate storage room, the central file of the medical records department is completely full to capacity, failed to ensure that unauthorized individuals can gain access to the record department and that the records are protected, failed to ensure that medical staff, nursing personnel and other disciplines maintain legible entries for fifty out of fifty records reviewed (R.R #1 through #50) failed to ensure that hospital staff complete histories and physical examinations before admission or within 24 hours after admission for a procedure for two out of ten records reviewed (R.R #38 and #39) and failed to ensure that hospital staff complete the final diagnosis within 30 days following discharge for five out of ten records reviewed (R.R #38, #39, #40, #42 and #43) all of which makes this condition "Not Met".

Based on the review of the policies and procedure's manual, a manual of abbreviations and incomplete medical records report provided by the medical record supervisor (employee
#21), it was determined that the facility failed to complete clinical records within 30 days following discharge and maintain an updated and approved by the Governing Body abbreviations and signature registry and are reviewed and revised as needed.

Findings include:

1. No evidence was found on 9/15/11 at 9:10 am that the facility has a person assigned as a Registered Information Manager Administrator (full or part time) who maintains the direction of services according with state law #117 (article #3).

2. No evidence was found on 9/15/11 at 1:30 pm of an abbreviation manual that was updated and approved by the Governing Body and includes the pharmacy supervisor's signature of participation.

3. The signature registry of physicians and other disciplines were reviewed with the Medical Record Supervisor (employee #21) on 9/15/11 at 1:30 pm. The signature registry was not updated nor was it approved by the Governing Body.

4. The incomplete medical record report reviewed on 9/15/11 at 1:45 pm with the Medical Record Supervisor (employee #21), revealed that there are 1,021 incomplete records over 30 days. However, the medical record report provided evidence that the incomplete medical record provided by employee #21 corresponded to the last month (August 2011) for the nursing staff and other disciplines (125 incomplete medical records). There is an average of 259 monthly discharges.

Based on the observational tour of the medical records department through the central file area, alternate storage area with the medical record supervisor (employee #21) and interviews, it was determined that the facility failed to properly secure an alternate storage room, the central file of the medical records department is completely full to capacity.

Findings include:

1. The central file of active records was visited on 9/15/11 at 9:15 am and was found completely full to capacity (first floor and the lower floor). The physical area does not have extra space available for new records to be filed. Approximately 20,000 emergency room clinical records were observed over different counter tops, desks and tables without being filed because there is not enough space for storage. Approximately 2,000 emergency room clinical records were observed over the desk near the entrance of the medical record room without being filed. Twenty-five boxes with inactive medical records were observed directly on the floor of the medical record department waiting to be moved to a second floor storage area to be disposed.

2. The lower floor of the medical record department was visited on 9/15/11 at 9:30 am and found with approximately 100 boxes with clinical records directly on the floor in a hallway between the metal storage cabinets waiting to be moved to a second floor storage room to be disposed of. Four stacks of boxes with medical record were observed in the path of travel to access the back exit door. The area was observed dusty and with poor air circulation. The medical record employee (employee #42) was observed on 9/15/11 at 9:35 am working with the medical records with a mask on, and she stated on 9/15/11 at 9:40 am that this area has a lot of dust, there are a lot of medical records and most of them are old.

3. An alternate storage room on the second floor used to maintain inactive records and those that are ready to be disposed of were observed on 9/15/11 at 9:45 pm very dirty, no ventilation, a fire extinguisher near the entrance and lacked emergency lighting. Boxes were observed open and broken. The entrance door which gives direct access to the hallway near the entrance to receive materials from the hospital was observed with 36 boxes with clinical records directly on the floor near the entrance. This room contains approximately 1,000 boxes with inactive clinical records and other boxes with medical insurance paperwork. The medical record supervisor (employee #21) was interviewed on 9/15/11 at 10:00 am and she stated that since the hospital was opened, no medical records have been disposed of and the department of medical records has problems with the lack of medical record storage space.

Based on the observational tour of the medical record department with the medical record supervisor (employee #21), it was determined that the facility failed to ensure that unauthorized individuals can gain access to the record department and that the records are protected.

Findings include:

On 9/15/11 from 9:30 am till 12:00 noon and during the rest of the day, medical record personnel were observed entering and leaving the medical record department. The entrance door of the medical record department has access control with a key pad, but when personnel leave from this door, the door did not swing closed and was left opened (the door needs a door closer) to prevent unauthorized access. This door is located in the main hospital hallway and was left unlocked at 12:00 noon and personnel were not in this area at all times to observe who enters. This entrance is used by medical record personnel to file and review records that were placed on a table near the entrance (approximately 2,000 emergency room clinical records).

Based on the review of fifty closed and active clinical records with the medical record supervisor (employee #21), it was determined that the facility failed to ensure that medical staff, nursing personnel and other disciplines maintain legible entries for fifty out of fifty records reviewed (R.R #1 through #50).

Findings include:

Fifty clinical records reviewed from 9/13/11 through 9/15/11 from 9:30 am till 3:00 pm contained portions that are not legible. Most notable were the physician ' s progress notes, nurse's notes, signatures (physicians and nurses), consults, diagnosis, operative reports, informed consent forms, anesthesia reports and physician's orders.

Based on the review of ten closed clinical records with the medical records supervisor (employee #21), it was determined that the facility failed to ensure that hospital staff complete histories and physical examinations before admission or within 24 hours after admission for a procedure for two out of ten records reviewed (R.R #38 and #39).

Findings include:

Ten clinical records reviewed on 9/15/11 from 9:30 am till 3:00 pm provided evidence that a medical history and physical examination was not performed before admission or within 24 hours after admission for two out of ten records reviewed (R.R #38 and #39).

Based on the review of fifty records reviewed (R.R), it was determined that the facility failed to ensure that one out of fifty records contain appropriate documents related to consult evaluations and appropriate findings by clinical and others staff involved in the care of the patient (R.R #46).

Findings include:

1. During the review of clinical records on 9/13/11 at 3:00 pm and 9/15/11 from 10:00 am till 2:35 pm the following was determined:

a. R.R #46 was reviewed on 9/15/11 at 10:00 am and failed to provide evidence of
the requested consults with the specified reason for the consult (it was written "Please evaluation"), lacks of the date, hour, the patient's diagnosis and signature of the consultant.

h. R.R #1 was reviewed on 9/14/11 at 8:45 am and provided evidence that the nurse's history was incomplete, there is a lack of Activities of Daily living, risk factors, obstetrical history, integumentary system, and nutritional screening.

i. R.R #2 was reviewed on 9/14/11 at 9:15 am and provided evidence that the nurse's history
was left in blank. The physical restraint authorization lacked the patient's or patient's relative signature and lacked the physician's signature. The restraint protocol lacked the physician's assessment and lacked the physician's signature, date and hour when the physician placed the order.

j. R.R #3 was reviewed on 9/14/11 at 9:45 am and provided evidence that the physician placed a telephone order on 9/12/11 at 7:00 pm and lacked the physician's signature, date and hour. The physical restraint authorization lacked the physician's signature. The restraint protocol lacked the physician's signature, date and hour when the physician placed the order.

k. R.R #5 was reviewed on 9/14/11 at 2:20 pm and provided evidence that the physical restraint authorization lacked the patient's or patient's relative signature. The restraint protocol lacked the physician's assessment. The Do Not Intubate (DNI) and Do not Resuscitate (DNR) consent lacked the physician's signature and date and hour when the physician took the consent.

l. R.R #6 was reviewed on 9/14/11 at 3:00 pm and provided evidence that the Do Not Intubate (DNI) and Do not Resuscitate (DNR) consent lacked the physician's signature and date and hour when the physician took the consent.

m. R.R #7 was reviewed on 9/14/11 at 3:15 pm and provided evidence that the Restraint protocol reactivation lacked the hour when the physician reactivated the protocol and did not describe the area of the restraint. The Do Not Intubate (DNI) and Do not Resuscitate (DNR) consent lacked the physician's signature and date and hour when the physician took the consent.

n. R.R #8 was reviewed on 9/14/11 at 3:30 pm and provided evidence that the physician's telephone order performed on 6/15/11 lacked the time when the telephone order was placed and lacked the date and hour when the physician countersigned the order. The restraint protocol lacks the of hour when the restraint protocol was placed and reactivate.

o. R.R #9 was reviewed on 9/14/11 at 3:40 pm and provided evidence that the Do Not Intubate (DNI) and Do not Resucitate (DNR) consent lacked of the physician's signature and date and hour when the physician took the consent.

p. R.R #10 was reviewed on 9/14/11 at 3:50 pm and provided evidence that the Do Not Intubate (DNI) and Do not Resucitate (DNR) consent lacked the physician's signature and date and hour when the physician took the consent.


17959


Based on the review of fifty active and closed records reviewed (R.R) it was determined that the facility failed to ensure that clinical records have documentation related to consent forms, post-anesthesia notes, post-operative patient instructions, physician history, risks and benefits on the Operation Consent form, consult evaluations, nurse's notes and pain assessments and re-assessment for sixteen out of seventeen records reviewed (R.R#1, #2, #3, #5, #6, #7, #8, #9, #10, #44, #45, #46, #47, #48, #49 and #50).

Findings include:

1. During the review of seven clinical records with the Nurse Director ( employee #6) on 9/13/11 at 3:00 pm and 9/15/11 from 10:00 am till 2:35 pm the following was determined:

a. R.R #44 was reviewed on 9/13/11 at 3:00 pm and failed to provide evidence of documentation of risks, benefits, date and hour when the informed consent form was taken by the surgeon. No evidence of the date, hour and signature on the post-anesthesia note. No evidence of the post-operative patient instructions, hour, patient and nurse signature on the post-operative nurse notes.

b. R.R #45 was reviewed on 9/13/11 at 2:00 pm and failed to provide evidence of documentation of risks, benefits, and the surgeon signature was not clear on the surgeon's informed consent form. No evidence of the date on the history and physical short stay. No evidence of the nurse's signature on the patient's admission on 9/13/11. The patient developed pain post-surgery and Toradol 30 mgs, I.V was administered by the nurse in accordance with the physician's order, the patient was discharged home on 9/13/11 at 12:20 pm and no evidence was found of the pain re-assessment. The admission orders lack of nurse signature.

c. R.R #46 was reviewed on 9/15/11 at 10:00 am and failed to provide evidence of documentation of nursing progress notes related to pain assessment and re-assessment. No evidence of risks and benefits on the Operation Consent form (no evidence was found of the date and hour). No evidence of the hour when the patient's mother signed the consent form.
The patient pain assessment was performed on the nurse's history on 9/9/11 at 7:30 pm and she described that the patient had abdominal pain and superior extremity pain on a pain scale of ten, however the localization of the pain was documented as no pain. No evidence of the description of the surgical wound and nutritional assessment and no evidence was found of the discharge planning or nurse history.

d. R.R #47 was reviewed on 9/15/11 at 10:10 am and failed to provide evidence of the patient's pain assessment on 9/6/11 at 7:00 pm.

e. R.R #48 was reviewed on 9/15/11 at 10:15 am and failed to provide evidence of the date when the nurse identified needs related to falls on the plan of care and re-assessment. No evidence of initial nutritional assessment on the nurse history performed on 9/12/11.

f. R.R #49 was reviewed on 9/15/11 at 2:30 pm and failed to provide evidence of the patient's sex, age, allergy history, present illness, temperature, respiratory rate, medication reconciliation, record number, date, physician license and physician's signature on the patient's history.

g. R.R #50 was reviewed on 9/15/11 at 2:35 pm and failed to provide evidence of the patient's destrostix on 9/14/11 at 9:00 pm. The nurse's history was performed on 9/10/11 however it was not completed by the nurse on 9/15/11.

Based on the review of ten closed clinical records with the medical records supervisor (employee #21), it was determined that the facility failed to ensure that hospital staff complete the final diagnosis within 30 days following discharge for five out of ten records reviewed (R.R #38, #39, #40, #42 and #43).

Findings include:

Ten clinical records reviewed on 9/15/11 from 9:30 am till 3:00 pm provided evidence that the final diagnosis was not completed within 30 days following discharge nor were the records encoded due to the lack of the final diagnosis for five out of ten records reviewed (R.R #38, #39, #40, #42 and #43).

Based on the review of the pharmaceutical services, interviews accompanied by the facility's hospital pharmacist and emergency room pharmacist (employee #10 and employee #8) on 9/15/11 from 8:25 am till 4:30 pm, it was determined that the facility failed to ensure an
effective provision of pharmaceutical services related with the lack of inspections to controlled drug areas, lack of updated pharmacy credential files, drugs and biologicals are not stored in a proper and safe manner and failed to promote that drug reactions and drug incompatibilities are immediately reported to the attending physician and if appropriate to the hospital-wide quality assurance program all of which makes this condition "Not Met".

Based on the review of pharmacy reports of inspections of controlled drug areas with the Pharmacy Director (employee #10) and interview, it was determined that the facility failed to comply with policies and procedures which govern pharmaceutical services.

Findings include:

1. During the review of pharmaceutical services administrative duties and responsibilities with the pharmacy director (employee #10) on 9/13/11 from 1:00 pm though 3:01 pm the following was found:

a. In August of 2011 the operating room, pediatric ward, Ob-gyn ward, nursery and neonatal care unit controlled medication stocks were not inspected by pharmacy personnel.

b. In July of 2011 the operating room department controlled medication stock was not inspected by pharmacy personnel.

c. In June of 2011 the intensive care unit, nursery, neonatal Ob-gyn and pediatric ward controlled medication stock was not inspected by pharmacy personnel.

d. In May of 2011 the operating room department controlled medication stock was not inspected by pharmacy personnel.

e. In April of 2011 the operating room department controlled medication stock was not inspected by pharmacy personnel.

f. In March of 2011, February of 2011 and January of 2011 controlled medication stock of operating room department, pediatric, Ob-gyn, medicine intensive care, nursery and neonatal care unit controlled medication stock were not inspected by pharmacy personnel.

g. At the emergency room department evidence of the inspection of controlled medication stock for the months of July of 2011 and August of 2011 were not found available at the facility during the survey procedure.

2. The Pharmacy Director (employee #10) stated during interview on 9/13/11 at 2:17 pm that controlled medication stocks must be inspected on a monthly basis in order to ensure that these areas are managed according with applicable Federal and State Law and accepted professional principles. However pharmacy services does not have an adequate number of personnel to comply with these inspections.

3. Written policies and procedures that describe the mechanism used to dispense medications for the use of respiratory therapy treatments were not found in the pharmacy policy manual. The Pharmacy Director (employee #10) stated during an interview on 9/13/11 at 3:00 pm that medications dispensed for the use with patients who were ordered respiratory therapy while at the emergency room department were provided in a bulk form, if the patient is admitted to the hospital the medications are provided in unit dose. However this procedure was not found written in the pharmacy policy and procedures manual.

4. A formulary that includes medications available at the emergency room department was not available during survey procedures on 9/13/11 at 1:45 pm . During interview on 9/15/11 at 10:52 am emergency room contractor pharmacist (employee #8) stated that a formulary that includes medications available at the emergency room was not developed. Emergency room department pharmacy services at the facility is provided by a contracted service that must comply with the development of a formulary that includes medications available at the area, however this was not performed nor evidenced during the survey procedure.

5. A mechanism to ensure that the facility actively identifies potential and actual adverse drug events and medication errors in the emergency room that include direct observations of medication administration and review of patient's clinical records was not evidenced. Emergency room department pharmacy services at the facility are provided by a contracted service that must have in place a mechanism for the proactive identification and management of irregularities in the administration of medications in this area, however this was not performed nor evidenced during the survey procedures on 9/13/11 at 1:50 pm.

6. Pharmacy records with sufficient detail to follow the flow of pharmaceuticals from their entry into the emergency room department through dispensing/administration were not found for review on 9/13/11 at 2:05 pm.

7. Facility's Quality Assurance Performance Improvement activities pertaining to emergency room department pharmaceutical care were not evidenced nor provided during the survey procedure on 9/13/11 at 2:10 pm.

8. Emergency room department pharmacy services are not integrated to the hospital-wide Quality Assurance Performance Improvement program as determined on 9/13/11 at 2:20 pm.

Based on observations and review of policies/procedures and seven credential files of pharmacy service employees with personnel from the human resource officer (employee
#41), it was determined that the facility failed to supervise all activities of the pharmacy as evidenced by a lack of updated health certificates for six out of seven credential files and performance evaluations for five out of seven pharmacy credential files (#1, #2, #3, #4, #5 and #6).

Findings include:

1. Six out of seven pharmacy employees credential files were reviewed on 9/15/11 at 3:15 pm with the human resource officer (employee #41) and provided evidence that C.Fs
#1, #2, #3, #4, #5 and #6) did not have updated health certificates.

2. Five out of seven pharmacy employees credential files were reviewed on 9/15/11 at 3:15 pm with the human resource officer (employee #41) and provided evidence that C.Fs #2, #3, #4, #5 and # 6 did not have annual updated performance evaluations.

Based on observations of the medication storage room with the Pharmacist (employee #10) and interview, it was determined that the facility failed to ensure that all drugs and biologicals are stored in a proper and safe manner accessible only to authorized personnel.

Findings include:

1. During the initial observational tour with the pharmacist (employee #10) on 9/13/11 from 9:15 am though 2:35 pm the following was found:

a. The emergency crash cart located at the intensive care unit (6th floor) was observed without a lock. Medications inside the cart are available to non authorized personnel. The cart was observed in need of repair, the handle of a drawer was broken and had rust on the edges.

b. The room where medications are stored and the medication refrigerator is located at the intensive care unit on the sixth floor was found with the door open. Medications inside this room were available to non-authorized personnel.

c. A plastic carrying case used to store emergency medications and equipment to be use in case of transporting a patient from the intensive care area to another area and was found with emergency medications inside. The case was observed open and does not have a list of medications available inside.

d. At the fifth floor there is a room where the PYXIS medication dispenser system is located. This room door was kept without lock, the nursing supervisor (employee #44) and pharmacist (employee #10) did not have information about the key for the door or procedures to maintain the medications in the area accessible only to authorized personnel. Written policies that include the procedures for medication automated distribution units with security features, such as log on and password or biometric identification were not found implemented nor evidenced during the survey procedure.

e. At the fifth floor two emergency crash carts were observed without locks. Medications inside were available to non-authorized personnel.

f. At the emergency room the emergency crash cart located at the pediatric area and the crash cart located at the critical care area were observed without locks. Medications inside were available to non-authorized personnel.

g. The OB-GYN and Pediatric ward at the seventh floor were observed with two metal medication storage cabinets without lock. Medications inside were available to non-authorized personnel.

h. At the emergency room department it was found that a room with medications was stored in two metal cabinets. Those cabinets were found without locks. Medications stored inside were available to non-authorized personnel.

i. At the emergency room a vial of Calcium Gluconate 10 ml and a vial of Enalapril 1.25/1ml were found over the top of the medication cart. Explanation of why the medications were left on the top of the medication cart was not provided.

j. Three medication carts in use at the medicine ward (fifth floor) one use at the intensive care unit (sixth floor), two used at the emergency room department and two used in Ob-gyn and Pediatric ward (seventh floor) were found without locks. Medications stored inside were available to non-authorized personnel.

Based on the review of medication adverse drug reactions reports with the Pharmacist
(employee #10), it was determined that the facility failed to promote that drug reactions and drug incompatibilities are immediately reported to the attending physician and if appropriate to the hospital-wide quality assurance program.

Findings include:

This facility dispatches approximately 25,494 medications monthly as reviewed on 9/13/11 at 3:29 pm. However from the period of January through August of 2011 only two adverse drug reactions were documented. The facility failed to promote the immediate reporting of drug reactions and incompatibilities to the pharmacy department.

Based on the review of medication adverse drug reaction reports with the Pharmacist
(employee #10), it was determined that the facility failed to promote that drug reactions and drug incompatibilities are immediately reported to the attending physician and if appropriate to the hospital-wide quality assurance program.

Findings include:

1. Written policies and procedures reviewed on 9/13/11 at 1:55 pm which describes the mechanism used to intervene during the identification of drug-interactions in patients was not found in the pharmacy policy manual. Facility pharmacy services failed to have in place a mechanism to ensure that cases with food and drug interactions are identified and interventions to prevent adverse consequences were coordinated with dietary services to prevent adverse consequences.

2. Written policies and procedures reviewed on 9/13/11 at 1:50 pm which describes the mechanism used to intervene during the identification of drug-drug interactions in patients was not found in the pharmacy policy manual. Facility pharmacy services failed to have in place a mechanism to ensure that cases with drug-drug interactions are identified and intervened appropriately to prevent adverse consequences.

Based on observations, review of policies and procedures and routine equipment testing with the supervisor of the X-ray department (employee #13) and interview, it was determined that the facility failed to ensure that the physicist periodically verifies the badge for radiation exposure.

Findings include:

On 9/14/11 at 2:18 pm the supervisor of the X-ray department (employee #13) stated that he has in use 20 radiation dosimetry used by X-ray department personnel, and the dosimeters must be reviewed by a physicist annually; however this review was not performed since the year 2010.

Based on the review of documents with the human resource officer (employee #41) and nine credential files (C.F), it was determined that the facility failed to ensure that credential files of the Radiology Department are updated related to three out of nine credential files that lacked updated health certificates one out of nine credential files lacked updated cardiopulmonary certificate and eight out of nine lacked the annual performance evaluations (C.F #1, #2, #4, #5, #6, #7, #8 and #9).

Findings include:

1. Review of nine radiology credential files on 9/15/11 at 3:39 pm provided evidence of the following:

a. Three out of nine radiology employee credential files were reviewed on 9/15/11 at 3:39 pm with the human resource officer (employee #41) and provided evidence that C.Fs #1, #4 and #9 did not have updated health certificates.

b. One out of nine radiology employee credential files were reviewed on 9/15/11 at 3:39 pm with the human resource officer (employee #41) and provided evidence that C.F #1 did not have updated cardiopulmonary certificate.

c. Eight out of nine radiology employee credential files were reviewed on 9/15/11 at 3:39 pm with the human resource officer (employee #41) and provided evidence that C.Fs #1, #2, #4, #5, #6, #7, #8 and #9 did not have updated performance evaluations.

1. Based on records review, direct observation and technical supervisor interview, it was determined that the laboratory failed to ensure that the ventilation system properly removes vapor and fumes in the histology processing area.

The findings include:


a. At 9:30 AM, the hood in the gross histology examination area showed that the hood electric inspection ' was due since 10/09.

b. The laboratory did not perform annually the staff ' s vapor check. The last vapor check was performed on 7/1/2010.


2. Based on records review and technical supervisor interview, it was determined that the laboratory failed to document each time of use the quality control of the H & E stain.

The finding includes:

a. The laboratory documented weekly the H & E ' s stain quality control records since 6/7/10.

3. Based on records review and technical supervisor interview, it was determined that the laboratory failed to follow written procedures to maintained requisition information.

The finding includes:

a. The following cytology ' s requisition did not include the date of the specimen collection: SB336-11(reported on 7/2/11), SB334-11(reported on 7/2/11), SB371-11 and SB371-11(reported on 7/26/11).


4. Based on records review and technical supervisor interview, it was determined that the laboratory failed to follow written procedures to handling the cytology specimens.

The finding includes:

A.The laboratory did not document the cytology specimens receiving dates from 6/18/11 to 8/14/11, approximately 50 specimens (from SB337-11 to SB385-11).

5. Based on records review and technical supervisor interview, it was determined that the laboratory failed to follow written procedures for the turn around time of the cytology results reports.

The findings include:

A.The technical supervisor confirmed that the turn around time of the cytology results reports should be 72 hrs.

b. The laboratory examined thirty (30) cases (SB307-11 to SB336-11) on 7/2/11. Those specimens were received on 6/17/11.

c. The laboratory examined twenty one (21) cases (SB340-11 to SB360-11) on 7/9/11. Those specimens were received on 6/29/11.

d. The laboratory examined twenty (20) cases (SB368-11 to SB387-11) on 7/26/11. Those specimens were received on 7/8/11.

6. Based on lack of records, observation and interview with the transfusion services testing personnel, it was determined that the transfusion services freezer used to store fresh frozen plasma units did not have an audible alarm system.
The finding includes:


a. The transfusion services stored their fresh frozen plasma units in a Kelvinator freezer.
b. The testing personnel stated that the freezer did not have an internal neither a remote alarm system connected. Four fresh frozen plasma unit were stored in the freezer


7. Based on review of possible transfusion reaction records and interview with the transfusion services testing personnel, it was determined that the transfusion services failed to ensure the promptly evaluation of the possible transfusion reaction.

The findings include:

a. The possible transfusion reaction evaluation records were reviewed showing the following:
? Patient 1102986- The record showed that during transfusion performed on 08/21/2010 the patient had a respiratory distress by circulatory overload. The possible reaction was evaluated on 10/14/2010.
? Patient 24965 - The transfusion reaction record showed that on 11/30/2010 the patient was transfused with the pack cell unit 54C58228. A respiratory distress was observed. The possible transfusion reaction was evaluated on 04/04/2011.

8. Based on review of quality control records and interview with the laboratory director, it was determined that the laboratory failed to check the new of reagents lots with samples of acceptable reactivity before testing patients samples.

The findings include:

a. The laboratory did not include samples of acceptable reactivity for the new MONO test reagent kit (0111241) opened on 09/02/2011. One patient was processed and reported on 09/02/2011.
b. The laboratory did not include samples of acceptable reactivity for the new RA test reagent kit (1010046) opened on 06/07/2011. Twelve patients were processed and reported from 06/07/2011 to 07/09/2011.


9. Based on observations, review of manufacturer ' s instructions and interview with the testing personnel, it was determined that the laboratory did not follow the manufacturer ' s instructions regarding to the proper incubation of the yeast biochemical card.

The findings include:

a. The laboratory used the Yeast Biochemical card to identify the more frequently isolated yeasts in the Vitek identification system.
b. The manufacturer instructions instructed the laboratory to incubate the card in a horizontal position at 30?C for 24 hours.
c. At 12:35 PM, in the general immunology a yeast identification card (patient 12127) was observed in the base of the electrical burner.
d. The general immunology testing personnel stated that the bacteriology testing personnel incubated the yeast identification cards under the electrical burner in the immunology area to reach the 30?C required temperature.
e. The identification card was observed in a vertical position instead of horizontal as the manufacturer required.
f. The wall thermometer showed a 29?C temperature.
g. There were no temperatures records (for 24 hours) when yeast cards were incubated in the general immunology area.
h. The laboratory processed 50 patient samples for yeast identification from 01/01/2011 to 09/14/2011.

10. Based on laboratory written procedures review and manufacturer ' s instructions, it was determined that the laboratory failed to follow specimen collection instructions for blood culture samples.

The findings include:

a. The laboratory process blood culture samples for adult and pediatric patient by BacT-Alert system.
b. The manufacturer ' s instructions and bacteriology written procedures states that for each adult bottle must be add 5-10 ml blood and up to 4 ml Pedi- Bact for pediatric sample.
c. The adult bottle contains 40 ml of aerobic growth media and pediatric bottle contain 20 ml. of growth media.
d. Since April 26, 2010 the laboratory failed to follow the manufacturer ' s instructions; when began to take the pediatric blood culture samples in the adult blood bottle.
e. Since April 26, 2010 to September 26, 2011, the laboratory processed and reported 645 pediatric blood culture samples in the inadequate media.


11. Based on review of records and laboratory general supervisor interview, it was determined that the failed to perform the calibration verification procedures for the hematology system at least each six month.

The findings include:

a. The laboratory uses the LH 500 system (back-up) to perform hematology samples.
b. The laboratory performed the calibration verification on 12/09, 10/10 and 2/11.
c. The laboratory failed to perform the calibration verification each six month during 2010.


12. Based on review of records and laboratory general supervisor interview, it was determined that the laboratory failed to perform the calibration verification for routine chemistry system at least each six months.

The findings include:

a. The laboratory uses the LX-20 and LXi systems to perform routine chemistry tests.
b. The laboratory failed to perform the calibration verification procedures each six month since 12/09.

Based on the observational tour of the facility's kitchen that prepares patient's meals, review of menus and policies/procedures, temperature verification with the kitchen dietitian manager (employee #20) , it was determined that the facility failed to ensure that clean trays are not stored wet, failed to maintain and prepare food in a safe and sanitary manner related to hot temperature, failed to place dates on trays of prepared and refrigerated food of when prepared and defrosted and failed to ensure that food arrives to the patient at the appropriate temperatures.

Findings include:

1. During the kitchen observational tour performed with the kitchen manager dietitian (employee #20) on 9/14/11 from 10:00 am till 11:55 am the following was observed:

a. Already cleaned metal trays (approximately 20 trays) were found on 9/14/11 at 10:30 am stacked upside down one on the other on shelves and they were found wet with an accumulation of water.

b. The third kettle was observed on 9/14/11 at 10:40 am before cleaning. The hose used to fill the kettle with water for cooking and to clean it was found on the floor. The kitchen manager dietitian (employee #20) took the hose from the floor and put the hose inside of kettle. The kettle did not have a hose holder near the kettle to keep it from falling on the floor. The facility failed to ensure infection control standards by allowing the hose to fall on the floor and then placing it into the kettle.

c. The steam table was observed on 9/14/11 at 10:10 am with two open slots where metal trays are supposed to be placed and the hot vapor from the steam table was seen above these two open slots. The temperature of the steam table water was taken by the kitchen supervisor (employee #45) on 9/14/11 at 10:15 am and was found to be over 140?F. The steam table contained covered trays with chopped meat and the temperature was also obtained and found to be over 150?F. Also, the amount of water in the steam table was not to touch part of the tray to ensure that the food is maintained at the temperature of the steam table. When the amount of food cooked does not allow a tray for each slot the facility must ensure that these slots are covered to reduce heat loss and the temperature and amount of water in the steam table needs to be at the appropriate temperature (140?F or above) and height to guarantee that food is safe for consumption and patients can eat hot food.

Based on the review of twenty diet personnel credential files (certified) by human resources with the administrative dietitian (employee #20), it was determined that the facility failed to examine credential files (C.F) to ensure that diet staff have updated current evaluations and competencies for eighteen out of twenty credential files reviewed (C.F #2 through #12 and
#14 through #20).

Findings include:

1. During the review of twenty diet personnel staff credential files on 9/15/11 from 2:30 pm till 3:30 am the following was found:

a. Eighteen out of twenty diet personnel credential files provided evidence that the credential files did not have current evaluations and competencies since 2008 (C.F #2 through #12 and #14 through #20).

Based on clinical record reviewed (R.R), policies/procedures and dietitian interview, it was determined that the facility failed to ensure that patients receive appropriate diets for those who are at nutritional risk, initial nutritional assessments and failed to ensure that patients receive appropriate fluids to complete the fluid needs recommended by the dietitian for R.R #33 and #34.

Findings include:

1. R.R #33 is a 57 years old female who was admitted on 9/7/11 with a diagnosis of Septic Shock, Sacral Ulcer and Aspiration Bronchopneumonia. The record was reviewed on 9/14/11 at 2:30 pm and provided evidence that the physician ordered a nasogastric tube and diet evaluation since admission on 9/7/11 to the intensive care unit. On 9/8/11 the physician ordered Nutren 1.5 to run 42 ml continuous per hour. The patient's laboratory results were reviewed for albumin and provided evidence of the following on 9/7/11 (2.9 g/dl), on 9/8/11 (2.8g/dl) and on 9/13/11 (1.9 g/dl) levels were lower than the normal range. Also, on 9/7/11 the hemoglobin results of 12.6 g/ml and on 9/13/11 of 9.3 g/ml were low. The patient was transferred to the medicine ward on 9/12/11. On 9/12/11 at 10:26 am the dietitian's evaluation provided evidence that the patient was dependent on the nasogastric tube for feeding, low hemoglobin and low albumin. The facility ' s dietitian is recording estimated weight and also documenting that the patient is below weight and estimating a diet of 1,500 k/cal per day with 52 grams of protein. The dietitian's evaluation recommends to change enteral nutrition with Glucerna 1.5 750 kcal to run 21 ml per hour, increase if tolerates to 1,500 kcal to run 42 ml per hour and the patient should be given a minimum of 1,500 ml of fluids per day. Also, the dietitian's evaluation recommends verify tolerance, glucose monitoring and administered 8 ounces of water. The dietitian ' s nutritional risk evaluation for the patient identified a level of care of " 4 " according with the patient ' s age, nutritional plan, diagnosis, albumin levels and follow-up (at 24 hours or before 5 days). On 9/9/11 for the 11-7 shift the patient received 100 ml of fluids on 9/10/11 for the 3-11 and 11-7 shift the patient received 200 ml of fluid, however the quantity of liquids did not specify the water used by enteral nutrition in order to complete the fluids needed as recommended by the dietitian. According to the nurse's notes from 9/11/11 and 9/12//11 (intake/output chart) the patient did not receive the required amount of fluids per day. Also, no evidence was found in the nursing progress notes if the patient tolerated the parenteral nutrition or elimination pattern. No evidence was found that the nutritional assessment was performed by the dietitian since the patient was admitted on 9/7/11 when the nutritional risk was identified due to the resident's laboratory test results.

2. R.R #34 is a 90 years old male who was admitted on 9/6/11 with a diagnosis of Bronchopneumonia, Dehydration and Malnutrition. The record was reviewed on 9/14/11 at 2:00 pm and provided evidence that the physician ordered a nasogastric tube with Jevity 1,600 kcal to run 30 ml per hour since admission on 9/6/11 to the medicine ward. The patient's laboratory results were reviewed for albumin and provided evidence of the following on 9/8/11 (2.9 g/dl), levels are lower than the normal range. Also, on 9/10/11 the hemoglobin results of 8.4 g/ml and on 9/14/11 of 9.3 g/ml were found lower than the normal range. On 9/12/11 at 8:40 am the dietitian's evaluation provided evidence that the patient was dependent on a gastrostomy tube for feeding, low hemoglobin and low albumin. The facility ' s dietitian is recording estimated weight and documenting that the patient is below weight and estimating a diet of 1,700 k/cal per day with 62 grams of protein. The dietitian's evaluation recommends to change enteral nutrition to Jevity 1.5 850 kcal to run 24 ml per hour, increase if tolerates Jevity 1.5 1,700 kcal to run at 47 ml per hour and then should be given a minimum of 1,700 ml of fluids per day. Also, dietitian's evaluation recommends verify tolerance and administered 8 ounces of water. The dietitian ' s nutritional risk evaluation for the patient identified a level of care of " 3 " according with the patient ' s, nutritional plan, diagnosis, albumin levels and follow-up (at 24 hours or before 7 days). According to the nurse's notes from 9/8/11 through 9/14/11 it was found that the patient was not receiving the required amount of fluids in order to complete fluids needed as recommended by the dietitian. No evidence was found that the nutritional assessment was performed by the dietitian when admitted on 9/6/11 when the nutritional risk was identified due to resident's laboratory test results.

Based on tests performed on equipment, review of policies and procedures, incident and accident reports and observations made during the survey for the physical environment from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm with the facility's Engineer (employee #15) and interview, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well being of patients receiving services related to the temperature of the emergency room, maintenance closets with cleaning chemicals left unlocked, no air extractors or door closers, regular and biohazardous trash rooms without door closers and air extractors and operating suite walls are not monolithic,
it was determined that this facility's physical structure is not designed in accordance with Federal laws to provide protection of patient's rooms related with the use of roller latches on patient's room doors instead of positive latching devices, the facility failed to follow established procedures for the storage of biohazardous trash related to the outside metal biohazardous storage container that was found with one of its four doors unlocked, the facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to a non working water heater in the emergency room, (E.R) the roof is leaking in the emergency room, pediatric and adult scales were not calibrated on a periodic basis, a metal hook on a wall in the treatment room is used to hang patients' I.V bags, the hand sink in front of cubicle #1 of the Emergency Room was loose, crash carts were found without type E oxygen cylinders or without the regulator, the examination bed in the pediatric emergency room was found with a rip, no evidence was found that the biomedical technician verified the function of the negative pressure of the isolation rooms or the ultra violet lamp of the stabilization room of the E.R, there is a roof leak at the kitchen paper storage area and the kettle hose was on the floor, maintenance carts found with cleaning chemicals on top and in the middle of the carts accessible to non authorized persons, the dirty utility room on the fifth floor was found unlocked, the medical record department is not properly maintained and no evidence was found of the cisterns' cleaning or periodic bacteriology tests, the facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff related to handicapped bathrooms, the triage room does not allow for visibility into the waiting room, cribs #8 and #9 do not have appropriate square footage in the pediatric emergency room (E.R), the oxygen therapy area of the E.R is not designed properly, the glass of a fire hose cabinet in the E.R was found cracked, ramps of the E.R are not appropriately designed, the operating room department is not appropriately designed, Cidex OPA is not used in an appropriate manner, the emergency rooms' decontamination room is not appropriately designed, the facility does not have an accessible entrance protected from the weather by canopy or roof overhang, the laboratory department showers are not maintained, the fifth floor hallway only has one handrail along one side of the hallway, no evidence was found of the elevator recall and the signs in the staircase are in Spanish but not in English, the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas which are not equipped with an air disinfection system (such as ultraviolet lights) and failed to ensure that applicable provision of the 2000 edition of Life Safety Code of the NFPA 101 are met: K0046, K0051, K0064, K0069, K0072, K0075 and K0130. These findings make this condition "Not Met".

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Engineer (employee #15), it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well being of patients receiving services related to the temperature of the emergency room, maintenance closets with cleaning chemicals left unlocked, no air extractors or door closers, regular and biohazardous trash rooms without door closers and air extractors and operating suite walls are not monolithic.

Findings include:

1. During observations of the Emergency room on 9/13/11 from 9:20 am till 2:00 pm, it was found that the observation area, waiting room and pediatric area were warm. A wall thermometer was found and it registered a temperature of 78?F. According with the Guidelines for Design and Construction for Health Care Facilities the temperature range shall be between 70?F and 75?F. Also, a large square fan was found on the top of a desk in the triage room.

2. All maintenance closets were visited from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm. These closets were found with chemicals to clean the facility and equipment and were found unlocked and accessible to non-authorized persons and did not have door closers or air extractors.

3. All regular trash storage closets and biohazardous waste storage closets were visited from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm and did not have air extractors and door closers. These closets are used as holding areas until they are collected and deposited outside of the facility. However, these closet were found unlocked and accessible to non-authorized persons and the regular trash closets were found with full trash containers and trash bags directly on the floor.

4. The operating suites were visited on 9/14/11 from 3:00 pm through 4:00 pm with the facility's Engineer (employee #15) and provided evidence of the following:
a. The walls of operating suites #1, #2 and #3 were not monolithic, they were found with tiles and grout lines between the tiles and were not sealed which can allow dirt to enter and does not allow for proper cleaning.

Based on the observational tour of the fifth floor inpatient ward of the hospital with the facility's Engineer (employee #15), interview and tests on patient's doors made during the survey for the physical environment, it was determined that this facility's physical structure is not designed in accordance with Federal laws to provide protection of patient's rooms related with the use of roller latches on patient's room doors instead of positive latching devices.

Findings include:

During the observational tour of the inpatient ward of the fifth floor with the facility's Engineer (employee #15) on 9/14/11 from 1:30 pm through 2:30 pm it was found that patient's room doors have roller latches and not positive latching devices. Beginning March 13, 2006, Medicare-participating hospitals may not keep in service roller latches even when these roller latches demonstrate the ability to keep the door closed against 5lbf. The fifth floor of this hospital was found with approximately 50% of these room doors that have recently been changed from roller latches to positive latching. The facility's Engineer stated during an interview on 9/14/11 at 2:00 pm that he will complete the rest of the doors on this floor when rooms are not occupied and will also continue on other floors and he demonstrated that the new positive latching door knobs for the fifth floor were at the facility and waiting to be installed.

Based on the review of policies/procedures (P&P) and observations made during the survey for the physical environment with the facility's Engineer (employee #15), it was determined that the facility failed to follow established procedures for the storage of biohazardous trash related to the outside metal biohazardous storage container that was found with one of its four doors unlocked.

Findings include:

The outside metal biohazardous storage container located at the back of the facility was visited on 9/14/11 at 9:35 am with the facility's Engineer (employee #15) and provided evidence that one of the doors was not locked to prevent unauthorized access. Facility policies and procedures reviewed on 9/15/11 at 2:30 pm provided evidence that these doors where biohazardous materials are placed are to be kept in a locked and secure area, away from unauthorized persons.

Based on observations made during the survey for the physical environment with the facility's Safety Officer (employee #16) and Engineer (employee #15) and interview, it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to a non working water heater in the emergency room, (E.R) the roof is leaking in the emergency room, pediatric and adult scales were not calibrated on a periodic basis, a metal hook on a wall in the treatment room is used to hang patients' I.V bags, the hand sink in front of cubicle #1 of the Emergency Room was loose, crash carts were found without type E oxygen cylinders or without the regulator, the examination bed in the pediatric emergency room was found with a rip, no evidence was found that the biomedical technician verified the function of the negative pressure of the isolation rooms or the ultra violet lamp of the stabilization room of the E.R, there is a roof leak at the kitchen paper storage area and the kettle hose was on the floor, maintenance carts found with cleaning chemicals on top and in the middle of the carts accessible to non authorized persons, the dirty utility room on the fifth floor was found unlocked, the medical record department is not properly maintained and no evidence was found of the cisterns' cleaning or periodic bacteriology tests.

Findings include:

1. The emergency room (E.R) was visited on 9/13/11 at 9:00 am and it was found that circuit breaker panel (ERP2-3) was found with a piece tape over a breaker switch that stated that the hot water heater did not work. The hot water faucet at the emergency room hand sinks were verified for hot water however the water was cold on 9/13/11 from 9:20 am till 12:00 noon. The facility could not provided evidence that the hot water tank was working and could not provide evidence that the hot water tank was in the process of being fixed.

2. The E.R was visited on 9/13/11 from 9:20 am till 2:00 pm and provided evidence that the ceiling acoustic tiles were wet, there were active ceiling leaks with baskets under the leaks to catch the water and rooms were closed due to the water leaks while repairs were under way as evidenced by the following:
a. In the hallway in front of intensive care cubicle #4 the ceiling tiles were stained.
b. Observation cubicle #7 was found with missing ceiling acoustic tiles.
c. In front of the ambulatory triage area near the exit sign was a missing ceiling acoustic tile.
d. A missing ceiling acoustic tile was found above the door of the male bathroom.
e. A large ceiling leak was found near observation cubicle #6, the facility placed a long plastic cover from the ceiling down into a bucket so that the water would leak directly into the bucket.
f. An active water leak was observed in front of the nursing station, it was leaking directly into a bucket.
g. Observation cubicle #5 was found with missing ceiling acoustic tiles.
h. In the triage area of the emergency room ceiling acoustic tiles were found stained.
i. Two small storage rooms in front of the nursing station were found with pad locks and the the E.R medical Director (employee #43) stated during an interview on 9/13/11 at 11:45 am that due to roof leaks and mold, a previous Department of Health inspection instructed them that they needed to close this room and seal the door edges with tape. The facility must open these rooms and repair the roof leak and eliminate the mold. If the rooms remain sealed closed at the doors and the roof leak is not fixed the water in this room does not have anywhere to go and the mold will eventually found its way to the patients' treatment area if it hasn't already. The Medical Director of the E.R (employee #43) also stated that he was going to repair the roof and remove the mold but the Department of Health made him close the rooms on the same day of that visit.
j. The Ob-gyn observation area was found with ceiling leaks, stained acoustic ceiling tiles and closed rooms.

3. During observations of the facility (emergency room and hospital) from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm, it was found that pediatric and adult scales were not calibrated on a periodic basis. No evidence was found on 9/15/11 at 11:00 am of the preventive maintenance and calibrations of the facility's scales used to weigh patient's throughout the hospital.

4. The treatment room located next to the triage area of the Emergency Room was found on 9/13/11 at 11:30 am with a metal hook on the wall above the seat used by patients to hang I.V bags. An I.V stand is needed to ensure infection control procedures and for patient's safety.

5. The hand sink in front of cubicle #1 of the Emergency Room was visited on 9/13/11 at 9:50 am and provided evidence that it was not fastened securely to the wall and there is a risk that it may detach from the wall.

6. The crash cart located at the Pediatric CPR room of the emergency room was found without a regulator (valve meter) on the type E oxygen cylinder attached to the cart on 9/13/11 at 11:15 am. To ensure that patients receive immediate care in the event of an emergency the oxygen cylinder shall have the valve meter attached to ensure that it is ready to use.

7. The treatment room of the pediatric emergency room was visited on 9/13/11 at 11:45 am and provided evidence that the examination bed was found with a large tear and covered with tape and pushed up against the wall. The bed needs to be repaired to ensure that it can be cleaned appropriately and needs to be repositioned to ensure that patients can be attended by staff on three sides of the beds in the event of an emergency.

8. The adult and pediatric isolation rooms of the emergency room were visited on 9/13/11 at 11:00 am and provided evidence that the pediatric isolation room was closed due to a roof leak and the adult isolation room has working negative pressure. No evidence was found that a biomedical technician verified the function of the negative pressure of these rooms nor was documentation found of the periodic filter changes as suggested by the manufacturer or daily nursing log.

a. The observational tour of the facility was performed from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm with the facility's Engineer (employee #15) and provided evidence that the facility has isolation rooms (located at the emergency room and wards). However, these isolation rooms do not have negative pressure meters to monitor the pressure inside of these rooms when used by patients who require this special condition. The Infection Control Officer (employee #1) stated during an interview on 9/15/11 at 5:25 pm that they perform a paper test, where they place a piece of paper on the floor near the door and observe if the paper is sucked into the room. Negative pressure meters are required where patients' conditions warrant their use, the pressure levels are recorded on a daily basis to ensure it is functioning properly and is extremely important when patients use these rooms and the pressure drops it emits an alarm to notify personnel that the room is not maintaining its negative pressure.

9. The stabilization room located near the ambulance entrance of the emergency room was visited on 9/13/11 at 10:00 am and was found with a wall mounted ultra violet lamp used to disinfect the air. However, no evidence was found on 9/13/11 at 3:00 pm that the lamp was working (it was heard running but the indicator light was not on) or the periodic maintenance performed on this lamp to ensure that it is working to its optimum capacity.

10. The kitchen was visited on 9/14/11 at 9:45 am with the facility's Engineer (employee
#15) and the following was determined:
a. There is a roof leak near the paper and plastic supply area.
b. The hose used to clean and fill the kettle was found on the floor.

11. The crash cart located at the Intensive Care Unit was found without a valve meter (regulator) on the type E oxygen cylinder attached to the cart on 9/14/11 at 11:45 am with the facility's Engineer (employee #15). To ensure that patients receive immediate care in the event of an emergency the oxygen cylinder shall have the valve meter (regulator) attached to ensure that it is ready to use.

12. Maintenance carts were observed from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm with cleaning chemicals on top and in the middle of the carts and did not have a cabinet on these carts where personnel can lock these cleaning solutions to limit its accessibility to non authorized persons.

13. The dirty utility room on the fifth floor was visited on 9/14/11 at 1:30 pm with the facility's Engineer (employee #15) and provided evidence of the following:
a. The two doors to access this room were found unlocked and accessible to non-authorized persons.
b. This room was found with a container of Cidex OPA and a tray to use it in and this room does not have appropriate ventilation for its use and the Cidex OPA was accessible to non-authorized persons.
c. Four large dirty linen carts were found placed in this room next to two patient commodes.

14. The crash cart located at the fifth floor "Crash Cart Room" was found without a type E oxygen cylinder attached to the cart on 9/14/11 at 2:00 pm with the facility's Engineer (employee #15). To ensure that patients receive immediate care in the event of an emergency the oxygen cylinder shall be attached to the crash cart to ensure that it goes where the cart goes.

15. The crash cart located at the C.T scan department was found without a type E oxygen cylinder attached to the cart on 9/15/11 at 10:45 am with the facility's Engineer (employee #15). To ensure that patients receive immediate care in the event of an emergency the oxygen cylinder shall be attached to the crash cart to ensure that it goes where the cart goes.

16. The medical records department storage room on the second floor was visited on 9/15/11 at 2:00 pm and was found with boxes of medical records stack one on the top of the other to a height of greater than five feet which may cause a potential hazard for personnel working in this area.

17. The medical records department lower floor was visited on 9/15/11 at 2:00 pm and provided evidence that the air conditioner system does not have air return vents. A medical record employee (employee #42) was observed sitting at a table working and she had on a surgical mask and she stated during an interview on 9/15/11 at 2:25 pm that the lower level is very dusty. The facility failed to provide appropriate ventilation related to the lack of air returns.

18. Written evidence about bacteriological tests and cleaning of the water cistern was requested on 9/15/11 at 1:00 pm. No evidence was provided that bacteriology tests are performed consistently on a monthly basis to the water used at the facility and no evidence was provided of the annual cleaning of the cistern according with state law requirements (Chapter XXV, Article #1, from November 7, 1999).

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Safety Officer (employee #16) and Engineer (employee #15), review of policies and procedures, incident and accident reports and interview, it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff related to handicapped bathrooms, the triage room does not allow for visibility into the waiting room, cribs #8 and #9 do not have appropriate square footage in the pediatric emergency room (E.R), the oxygen therapy area of the E.R is not designed properly, the glass of a fire hose cabinet in the E.R was found cracked, outside ramps of the E.R are not appropriately designed, the operating room department is not appropriately designed, Cidex OPA is not used in an appropriate manner, the emergency rooms' decontamination room is not appropriately designed, the facility does not have an accessible entrance protected from the weather by canopy or roof overhang, the laboratory department showers are not maintained, the fifth floor hallway only has one handrail along one side of the hallway, no evidence was found of the elevator recall and the signs in the staircase are in Spanish but not in English.

Findings include:

1. The handicapped toilet rooms (male and female) located at the waiting area of the emergency room were visited on 9/13/11 at 9:40 am and the following was found:
a. The handicapped toilets both male and female were measured to be 15 inches in height from the seat to the floor. In order for these bathrooms to comply with Americans with Disabilities Act (Ley ADA) requirements for toilet height, the toilet seat must be between 17 and 19 inches in height from the floor.
b. The door of these bathrooms did not have the international symbol related to handicapped accessibility.

2. The emergency room was visited on 9/13/11 at 11:00 am and provided evidence that the triage room is looking out into the waiting room and main entrance. The triage room has three windows facing the waiting room and the door to access this room is a large sliding door of glass. The inside of the triage room was visited on 9/13/11 at 11:05 am and it was found that the windows and doors that surround this room has a covering to prevent persons in the waiting room from seeing inside of the triage room when patients are being treated. However it was also found that this covering over the windows and doors also prevents the triage nurse from seeing clearly out into the waiting room (patient's facial expression) and incoming patients from the main entrance. According with "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) section 5.1.3.4 and appendix A5.1.3.4, triage shall be located to permit staff observations and control of access to treatment areas, pedestrian and ambulance entrances and public waiting area. Also, the ambulance triage area is located to the side of the emergency room where nursing personnel were not posted.

3. The handicapped female toilet located within the emergency room (E.R) near cubicle #10 was visited on 9/13/11 at 1:45 pm and the following was found:
a. The toilet only has one grab bar located on one side of the toilet, but to comply with Americans with Disabilities Act (Ley ADA) requirements there needs to be at least two grab bars per toilet (either on both sides of the toilet or on one side and to the back of the toilet)..
b. The bottom portion of the mirror over the sink is higher than 40 inches from the floor.
c. The hand paper towel dispenser was found at 54 inches in height for this front access dispenser. However, front access dispensers handles to extract paper can not be higher 48 inches from the floor to ensure accessibility.
4. The bathroom located at the back of the pediatric emergency room was visited on 9/13/11 at 11:20 am and provided evidence that it does not have an emergency call system.
5. The pediatric emergency room was visited on 9/13/11 at 11:20 am and provided evidence that cribs #8 and #9 do not have the square footage around them to provide care in a comfortable and appropriate manner (these cribs were moved around due to the problem that the facility is having with the roof leaking).
6. A utility room located at the emergency room (E.R) (pediatric area) was visited on 9/13/11 at 11:30 am and it was found that there were open trays of Cidex OPA. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media (this room did not have a working air extractor) and no evidence was found that this room has a spill kit to use if Cidex OPA accidentally falls on the floor.
7. The pediatric emergency room was visited on 9/13/11 at 11:20 am and provided evidence that cribs #6 and #9 do not have nursing call systems.
8. The hospital's emergency room was visited on 9/13/11 at 11:50 am with the facility's Safety Officer (employee #16) and provided evidence that there are three type H oxygen cylinders in an area that is used to provide respiratory therapy to patients. Three lounge chairs were placed side by side with little space between them and no curtains were found between the lounge chairs. In order to provide emergency treatment to a patient at least four feet between lounge chairs is needed to accommodate emergency staff and equipment and the curtains are needed to provide privacy during treatment.
9. During the observational tour of the emergency room on 9/13/11 at 11:55 am it was determined that the fire hose cabinet located near the adult isolation room has a glass door that was found cracked. The glass door is approximately three feet by three feet in size and poses a potential hazard if broken by accident. The glass is not tempered, laminated or wire mess to prevent shattering.

10. The emergency room was visited on 9/13/11 at 11:55 am and provided evidence that the facility has a decontamination room that does not comply completely with the Guidelines for Design and Construction of Health Care facilities (GDCHCF) for the 2006 edition in chapter 2.1, section 5.1.3.7, number 5 and appendix A5.1.3.7 (4) on page 72 "Decontamination room within the facility"). This decontamination room does not have a curtain for privacy, does not have two hand held shower heads with temperature controls, does not have portable or hard-piped oxygen or portable suction for this room and no evidence was provided that the water drainage system is a contained system to safely dispose of the used water to ensure that it does not enter into the hospital or community drainage systems. Also the outside door does not have a sign identifying the room from the outside and the floor is not mark where the door swings open to the outside near the ambulance entrance.

11. During observations of the handicapped ramps used to access the sidewalk of the emergency room on 9/14/11 at 9:00 am with the facility's Engineer (employee #15), it was found that the ramps do not have handrails. The ramps are too steep (does not comply with the "one to twelve rule"). The height at the top of the ramps are approximately 14 inches above the level of the bottom of the ramp and the total length of the ramps are 5 feet which causes them to be steep (for every inch in height the ramp should extend out 12 inches-this ramp should be 14 feet long and not 5 feet long).

12. The diesel tank located outside of the emergency room was observed on 9/13/11 at 1:35 pm and provided evidence that it has a containment dike, however the drain of this dike was found opened to remove rain water and shall be closed to retain diesel in dike in the event that the tank leaks. The dike has a shut off valve that was immediately adjusted to the closed position.

13. The facility has a room on the second floor with the autoclaves used to sterilize equipment as observed on 9/14/11 at 9:30 am with the facility's Engineer (employee #15). Cidex OPA was found at the entrance of this room where personnel disinfect equipment before passing it to the autoclave. The exhaust fan in the area with the Cidex is not working and is not directly over the area where Cidex is used, which causes employees working in this area to be in the direct line of the ventilated exhaust. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media and a spill kit was not found for personnel to use in the evidence that Cidex OPA accidentally falls to the floor.

14. The laboratory department was visited on 9/14/11 at 11:20 am with the facility's Engineer (employee #15) and the following was determined:

a. No evidence was found that the emergency showers were periodically tested and documented.
b. The "Chemical Room" has a work counter that was found with sample test tubes and behind this counter is a window that was found with a hole in it (used to pass a drainage tube from the air conditioner console). The hole in the window does not protect the test tube samples from the outside environment.

15. The handicapped toilet room (male and female) located at the fifth floor was visited on 9/14/11 at 1:30 pm with the facility's Engineer (employee #15) and the following was found:
a. The handicapped toilet was measured to be 16 inches in height from the seat to the floor. In order for this bathroom to comply with Americans with Disabilities Act (Ley ADA) requirements for toilet height, the toilet seat must be between 17 and 19 inches in height from the floor.
b. The door of this bathroom did not have the international symbol related to handicapped accessibility.
c. The toilet only has one grab bar located on one side of the toilet, but to comply with Americans with Disabilities Act (Ley ADA) requirements there needs to be at two grab bars per toilet (either on both sides of the toilet or on one side and to the back of the toilet)
d. This bathroom did not have a hand paper towel dispenser.
16. The hallways of the fifth floor were observed on 9/14/11 at 1:20 pm and were found with handrails on only one side of the hallway. To ensure that all patients can travel through these hallways and receive support from either side of their bodies, handrails are needed for both sides.

17. The elevators were visited on 9/14/11 at 1:00 pm with the facility's Engineer (employee #15) and failed to provide evidence that they have recall capacity (if the fire alarm is activated the elevator shall open to the closest floor and remain open). The facility's Engineer (Employee #15) stated during an interview on 9/14/11 at 1:10 pm that the company that is on site making the final repairs to the fire alarm system will set the recall function of the elevators once the entire system is finished.

18. The operating room department was visited on 9/14/11 from 3:00 pm through 4:00 pm with the facility's Engineer (employee #15) and provided evidence of the following:
a. The facility operates on ambulatory patients but they do not have a designated phase II area. The lounge chairs for this area must be separated by curtains and there needs to be at least four feet between each chair and the seats should be placed to avoid visual contact from patient to patient, there needs to be a bathroom for patients, area for patient's family members and area for nursing personnel to write and have visual contact with patients.
b. Operating suites #1, #2 and #3 provided evidence that they are equipped with central air conditioner system and each suite has returns. However, each suite was found with split unit air conditioner and they were on blowing air into the suites. The facility's Engineer (employee #15) stated on 9/14/11 at 3:30 pm that the split units are only used if the central air conditioner system is not working. Split unit air conditioners are not recommended in suites because they blow and push air and particles around the suite where as central air conditioning is a constant, even flow. According with "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) chapter 2.1, Appendix A10.2.2.4. The system should have a single directional flow regime, with both high and low exhaust locations, 20 to 25 air changes per hour and turbulence and air movement shall be considered to minimize the fall of particulates on sterile surfaces.
c. The air return system in operating suites #1, #2 and #3 were not working.
d. The facility has a room that is used to process equipment with Cidex OPA. The exhaust fan in this room is located across from the the Cidex OPA tray which places employees working in this area in the direct line of the ventilated exhaust. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media. This room has an exposed sink drain and holes were found through the walls.
e. Operating suite #3 was found with rust around the observation window and two regular ceiling acoustic tiles (these acoustic tiles will not allow for proper disinfecting).
f. Operating suite #2 was found with a broken wall tile near the air return, the x-ray film viewer had a broken plastic cover and space was observed between ceiling acoustic tiles (this will not allow for proper disinfecting).
g. The bathroom of the pre-induction area does not have a bench for patients to sit on when changing their clothes.

19. This facility has ten floors as determined on 9/14/11 at 3:30 pm with the facility's Engineer (employee #15). The stair cases have signs at each floor stating in Spanish that there is no exit at the roof and what floor to exit on, however this facility served a varied population and the signs should also be in English.

20. Observations made from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm of patients being dropped off to receive services and patients being picked up after receiving these services (medical appointments, laboratory tests, ambulatory surgery and X-rays are some of the services provided at this facility) provided evidence that the main entrance of this hospital is not equipped with a covered entrance to protect patients from the sun and rain to allow patients to be dropped off and picked in a safe and comfortable manner. According to the Americans with Disabilities Act (ADA) section 6.2, "At least one accessible entrance shall be protected from the weather by canopy or roof overhang. Such entrances shall incorporate a passenger loading zone".

21. The handicapped toilet rooms (male and female) located at the X-ray department was visited on 9/15/11 at 10:30 am with the facility's Engineer (employee #15) and the following was found:
a. The handicapped toilet (male and female) was measured to be 15 inches in height from the seat to the floor. In order for this bathroom to comply with Americans with Disabilities Act (Ley ADA) requirements for toilet height, the toilet seat must be between 17 and 19 inches in height from the floor.
b. The toilet only has one grab bar located on one side of the toilet, but to comply with Americans with Disabilities Act (Ley ADA) requirements there needs to be at least two grab bars per toilet (either on both sides of the toilet or on one side and to the back of the toilet).

Based on observations made during the survey for the physical environment with the facility's Safety Officer (employee #16), it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas which are not equipped with an air disinfection system (such as ultraviolet lights).

Findings include:

The emergency room was visited on 9/13/11 at 2:00 pm with the facility's Safety Officer (employee #16) and provided evidence that the waiting area, triage area and the observation area of the emergency room 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 and observation area are other areas to provide protection with an air disinfection system.

Based on the observational tour with the infection control officer (employee #1) and review of policies/procedures (P&P) and interview, it was determined that the facility failed to promote sanitary and safe care through its infection control program at the seventh floor Pediatric ward, OB-Gyn ward, Nursery and Neonatal Intensive Care unit, Delivery room, Sixth floor Intensive care Unit, and fifth floor medical/surgical ward, the biomedical waste area, sharp containers without security racks, expired medication, multiple dose vial without label with date and hour when opened, medication under the sink, respiratory equipment exposed to the environment, biohazardous and regular waste containers with loose lids, Intravenous bags without labels with the patient's name, date and hour when opened, non-sterile gauze pads exposed to the environment, Foley bags without labels with the foley number, date and hour when it was placed it and clean linen exposure to the environment.

Findings include:

1. During the observational tour with the infection control officer (employee #1) at the Seventh floor Pediatric ward on 9/13/11 from 9:15 am till 12:00 noon the following was found:

a. It was observed in the medication rooms, that twosharp containers were not in security racks.

b. It was observed in the medication refrigerator, two single dose vials of Famotidine 20 mg/ 2 ml opened available for patient use.

c. It was observed in the medication refrigerator, one multiple dose vial of Famotidine 200 mg/ 20 ml opened available for patient's use without the date and hour when opened.

d. Under the sink of the medication room, a tray was observed with a bottle of 16 ounces of Betadine Surgical scrub with pump. A bottle of Dermal Wound Cleanser and a tube of Lidocaine Hydrochloride Jelly USP 2%.

e. It was observed that the metal cabinet has mold in the drawers.
f. In the treatment room, it was found that a vial of 50 ml of Lidocaine HCL 2% 20 mg/ml was opened since 7/10/11. A vial of 50 ml of lidocaine HCL 2% ws opened since 5/31/11. A bottle of Povidone iodine 10% solution with a dirty and opened top. It was observed that five red sample tubes with an expiration date of June of 2011 an August 2011 and five blue sample tubes with an expiration date of May of 2011. The sharp containers of the crash cart were without security racks. It was observed that two syringes (Asepto) for patient's feeding were without a label with the date and hour when opened and a tube of Jelly lubricant had an expiration date of October 2009.
g. It was observed that respiratory equipment were not placed in plastic bags between patient use exposing them to the environment, in rooms #7-145 B, #7-146 B and #7-148 B.
h. It was found that the biohazardous trash containers were with loose fitting lids in rooms #7-146 and #7-149

i. It was observed that the intravenous bag lacked the patient's name, date and hour when opened in room #7-148.

j. It was observed that dirty sheets were in the biohazardous trash container in rooms #7-148 and #7-149.
k. It was observed that the food tray was on the regular trash container in room #7-150.

2. During the observational tour with the infection control officer (employee #1) at the seventh floor Ob-Gyn ward on 9/13/11 from 10:15 am till 11:00 am the following was found:
a. It was observed that a piggy bag labeled with Cleocin 900 mg but did not have the patient's name, date and hour when it was prepared.
b. It was observed that a Foley bag that was placed on a patient in the operating room on 9/12/11 was without a label with the date, hour, Foley number and signature of the person who placed it in patient room #7-153A.
c. It was found that the regular trash container was with a loose fitting lid or without lids in room #7-153, #7-156 and #7-159.
d. It was observed that the intravenous bag lacked the patient's name, date and hour when opened in rooms #7-154, #7-155, #7-156 and #7-157.
e. It was observed that respiratory equipment without a plastic bags exposing it the environment was found in room #7-154.
f. It was observed that the mattress was ripped in room # 7-160 which will not allow proper cleaning between patients.

3. During the observational tour with the infection control officer (employee #1) at the Seventh floor clean Utility Room on 9/13/11 at 11:00 am, the following was found:

a. It was observed the clean sheet cart with two bed sheets were exposure to the environment without a plastic bag to protect them. In the cabinet with sample tubes it was observed with 67 green sample tubes with an expiration date of June of 2011.
b. It was observed that a package of 200 non sterile gauze 2 x 2 opened and exposed to the environment on the top of the sample tray.
c. It was observed on the sample tray, an open bottle of 100 ml of 0.9% of Normal saline for irrigation available for patient use. The manufacturer recommends to discard unused portion.
4. During the observational tour with the infection control officer (employee #1) at the Seventh floor Dirty Utility room on 9/13/11 at 11:10 am, the following was found:
a. It was observed with a wheelchair with tape on the arm rest.
5. During the observational tour with the infection control officer (employee #1) at the Seventh floor Nursery and Neonatal Intensive Care Unit ward on 9/13/11 at 11:15 am, the following was found:
a. It was observed that the sharp containers on the sample tray and medication cart did not have security racks.
b. It was observed that a package of 200 gauze 2 x 2 were exposed to the environment.
c. It was observed that a bottle of Betadine Surgical Scrub had a dirty cap.
6. During the observational tour with the infection control officer (employee #1) at the Seventh floor housekeeping room in the area of the Delivery room on 9/13/11 at 11:20 am, the following was found:
a. It was observed that the facility has only two mops for the area of the delivery room, one mop for the isolation and one mop for the office with one pail for both areas. Also, the mops were not labeled for the different areas where they are used.
7. It was observed on 9/13/11 at 11:30 am in the hallway near the delivery ward a biohazardous waste storage room with the door closed but it was not locked.
8. During the observational tour with the infection control officer (employee #1) at the Sixth floor Intensive Care Unit on 9/13/11 at 1:15 pm, the following was found:
a. It was found that the regular trash containers were without lids in rooms 601 through 612.
b. It was observed that the Intravenous line was exposed to the environment without a cover for the part that goes directly to the patient.
c. It was observed that patient's urinals were full of urine on the IVF stand in rooms #603 and #605.
d. It was observed that a package of 200 gauze 2 x 2 exposed to the environment on the sample cart. It was observed that on the glucometer cart the biohazardous trash container was without a lid.
e. It was observed that in the intubation tray two laryngoscopes exposed to the environment.
f. It was observed that two syringes (Asepto) for patient's feeding were without a label with the date and hour when opened in rooms #607 and #608.
g. It was observed that patient's belongings were directly on the floor in room #612.
h. It was observed that the bathroom of the isolation room was without a dispenser for the paper towels, the paper towels were on the sink in room #612.
i. It was observed that the toilet paper dispenser of the bathroom of the isolation room was broken and the toilet paper was exposed to the environment room #612.
j. It was found that in the pantry room had a container of Cidex OPA, the room did not have an air extractor. The infection control officer stated during an interview on 9/13/11 at 1:30 pm that personnel from housekeeping have the emergency spill kit. If an emergency arises with the Cidex, personnel call housekeeping personnel to get the kit and clean up the area.
9. During the observational tour with the infection control officer (employee #1) at the Fifth floor Medical/Surgical ward on 9/13/11 at 1:45 pm, the following was found:
a. It was observed that the intravenous bag lacks the date and hour when opened in rooms #5-133, #5-134, #5-137 B, #5-138, #5-139 A, #5-139 B, #5-140 B, #5-140 B, #5-141 B, #5-142 A, #5-143 B, #5-145 A, #5-146 A, #5-147 A and #5-147 B.
b. It was observed that the metal cabinet in the bathroom of room #5-133 had mold.
c. It was observed that the linen change cart with four linens were without a plastic bag exposing them to the environment near room #5-135.
d. It was observed that syringes (Asepto) for patient's feeding without a label with the date and hour when opened in rooms #5-137 B, #5-147 B and #5-150 B.
e. It was observed that patient's belongings were directly on the floor in room #5-138 A.
f. It was observed that the venipuncture site was without a label with the number of the angio catheter, date, hour and signature of the person who assessed the venepuncture site in room #5-138 A.
g. It was observed that the mattresses were broken in rooms # 5-143, #5-153 A, #5-157 A and #5-165 A.
h. It was observed that respiratory equipment without a plastic bag exposed to the environment in rooms #5-157 B and #5-158 A.
i. It was observed that two bottles of 1000 ml of Sodium Chloride 0.9% for irrigation used for wound cleaning were opened available for patient use. The manufacturer recommends to discard the unused portion after opened.
10. During the observational tour with the infection control officer (employee #1) at the Fifth floor Medical/Surgical medication room on 9/13/11 at 2:40 pm, the following was found:
a. It was observed that four medication carts were dirty with yellow spots over the cart and inside the drawers.
11. Record Review #1 is an 80 years old female who was admitted on 9/1/11 with a diagnosis of Active Pulmonary Tuberculosis. On 9/14/11 at 8:45 am the record was reviewed with the Infection Control Officer (employee #1). No evidence was found related to the patient's and patient's relative orientation about the isolation precaution. No evidence was found related to the intervention of the infection control officer.
12. During the observational tour with the infection control officer (employee #1) at the second floor Biomedical waste area on 9/14/11 at 11:45 am, the following was found:
a. It was observed in the biomedical waste area a large dumpster with two doors, the two doors were observed without a security lock.
b. It was observed that a large waste container near the biohazardous dumpster with a biohazardous waste bag was not locked.
13. During the observational tour with the infection control officer (employee #1) at the second floor Central Supply area on 9/14/11 at 1:45 pm, the following was found:
a. It was found that in the central supply dirty area there was a container of Cidex OPA but this room does not have an air extractor.
b. Employee #4 stated during an interview on 9/14/11 at 1:50 pm that Enzol is diluted in a container with one squirt of Enzol per gallon of water, however she did know how many gallons of water the container could hold. The facility did not provide evidence of the policies and procedures related to the use of Enzol and the amount of water to fill in the container to dilute the Enzol.
14. During the review of the autoclave cultures on 9/14/11 at 2:00 pm with the infection control officer (employee #1) it was found that the facility failed to perform the daily spore cultures of the autoclave. The infection control officer (employee #1) stated on 9/14/11 at 2:00 pm that the autoclave is cultured for microorganisms and spores every week. However no evidence was found of the weekly microorganism and spore culture during the months of February 2011, May 2011 and June 2011 and during the weeks of 1/16/11 through 1/22/11, 1/23/11 through 1/29/11, 1/30/11 through 2/5/11, 3/6/11 through 3/12/11, 3/13/11 through 3/19/11, 3/20/11 through 3/26/11, 3/27/11 through 4/2/11, 4/3/11 through 4/9/11, 4/7/11 through 4/23/11, 4/24/11 through 4/30/11, 7/3/11 through 7/9/11, 7/10/11 through 4/16/11, 7/24/11 through 430/11 and 8/7/11 through 4/13/11.

Based on the review of policies and procedures related to the Discharge Planning Program and five records reviewed, it was determined that the facility failed to ensure that discharge planning policies and procedures include provisions to comply with the process for weekends and after hours and to ensure that information about rights to request discharge planning are provided to patients and caregivers.

Findings include:

1. During the review of policies and procedures and medical records reviewed on 9/14/11 from 8:56 am till 10:19 am with the discharge planning officer (employee #40), the following was identified:

a. Discharge planning screening evaluations are performed for every patient. The process of screening is performed with the participation of nursing personnel and physicians. If special needs for the discharge process are identified, a consult is requested from the discharge planning office to intervene. Facility policies and procedures for discharge planning evaluations and services establishes that the discharge planning officer must answer the consult and plan the discharge of the patient within 24 hours. The discharge planning officer only works from Monday through Friday from 8:00 am through 4:00 pm. During the weekends, holidays and after hours nursing personnel and the physician in charge of the patients intervene related to the discharge planning, and if considered necessary they call the discharge planning officer. The mechanism of evaluating patients in need of discharge planning on weekends and after hours is not included in the facility's policies and procedures.

b. Five medical records reviewed (#22, #24, #25, #28 and #29) provided evidence that the pamphlet "Important Message from Medicare " were not given to patients and caregivers in order to make them aware of their rights to request a discharge plan.

Based on observations made of the surgical department located on the third floor, interview and review of policies/procedures with the Operating Room Manager (employee #24) on 9/13/11 from 9:20 am till 3:30 pm and on 9/14/11 from 9:30 am till 11:45 am and 9/15/11 from 8:30 am till 10:30 am, it was determined that the facility failed to ensure that surgical services are provided in accordance with acceptable standards of practice related to access of the operation and recovery areas, aseptic and sterile techniques by individuals in the surgical area, infection control measures, the temperature and humidity control not maintained within accepted standards of practice, the facility offers outpatient surgical services but did not comply with all requirements and failed to perform follow up calls to ensure the needs of the patient at home all of which makes this condition "Not Met".

Based on nursing supervisor roster review and interview with the Nurse Manager of the Operating Room Department (employee #24) and review of policies and procedures, it was determined that the facility failed to review staffing schedules to determine adequacy of staff and registered nursing supervision.

Findings include:

1. During nursing supervisor roster review on 9/13/11 at 10:00 am, the following was found from 8/3/11 through 9/9/11:

a. The facility has eight operating rooms suites located on the third floor but only three operating rooms (#1, #2 and #3) available to performed the different surgeries for inpatient and outpatients. During the review of the daily personnel assignment, it was found that the daily roster was performed by the nursing manager (employee #24) however it did not identify the employees position.
b. On 8/3/11, 8/4/11, 8/8/11, 8/12/11, 8/22/11, 8/23/11, 9/2/11, 9/8/11 and 9/9/11 the facility did not have a registered nurse covering the 5:00 pm till 7:00 am supervisory shift from Monday to Sunday.
c. On 8/3/11, 8/4/11, 8/8/11, 8/12/11, 8/22/11, 8/23/11, 9/2/11, 9/8/11 and 9/9/11 the facility did not have a registered nurse covering the shift from 3:00 pm till 11:00 pm and 11:00 pm till 7:00 am they only had an operating room technician to cover Monday through Friday.
d. On 8/3/11, 8/8/11, 8/12/11, 8/22/11, 9/2/11, 9/8/11 and 9/9/11 no evidence was provided on the daily assignment of personnel designated to operating suites #2, #3, pre-anesthesia and cesarean.
e. During interview with the Nurse Manager of the Operating Room Department (employee #24) on 9/15/11 at 1:00 pm, she stated "I have nursing personnel from Monday through Friday from 7:00 am till 3:00 pm to cover the operating room, then from 3:00 pm till 7:00 am I covered on call in the event of a situation or an emergency. The facility has a nurse supervisor on-site at the hospital from Monday through Sunday from 3:00 pm till 7:00 am and she is called in case of an event or situation or an emergency". According with the facility's policies, the operating room department provides services twenty-four hours a day seven days a week, however the facility did not provide evidence of a registered nurse during the 3:00 pm till 11:00 pm shift, the 11:00 pm till 7:00 am shift and on Saturday and Sunday.

Based on observations made of the surgical department located on third floor, interview and review of policies/procedures with the Operating Room Manager (employee #24) and staff nurse (employee #6), it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice and patient care.

Findings include:

1. Observations made of the surgical department on 9/13/11 from 9:20 am till 3:30 pm and 9/14/11 from 9:30 am till 11:45 am and 9/15/11 from 8:30 am till 10:30 am provided the following evidence:

a. Delineation was observed on 9/13/11 at 9:20 am for employees to access sterile and non-sterile areas (dressing room-street clothes to operating room attire, pre-induction room, surgical area and recovery room). The surgical facility is divided into three designated areas: unrestricted, semirestricted and restricted with signs at each area indicating the surgical attire required. Lines on the floor were not visualized, the paper signs were observed deteriorated and the colors did not integrate into the signs at the different areas. During the visit it was observed that the persons who accompanied the patients, hospital employees and guards were entering the recovery room and induction area without scrubs. Also, strict vigilance is required at the main entrance of the operating department.

b. The hospital's operating room department does not have a designated phase II area. It does not have lounge chairs to place patients after they change back into their street clothes to continue with their stabilization process (lounge chairs should be separated by at least four feet from one another, should have curtains between the chairs). The phase II area needs a hand washing station, should have designated storage space or space for family members, the lounge chairs should be set up so that patients have privacy from one another, but are in the direct line of sight of the nurse. The phase II area also needs a patient's bathroom that complies with "Americans with Disabilities Act" (Ley ADA) related to door width (a minimum of 32 inches is needed), toilet seat height (height should be between 17 and 19 inches) and grab bars (should be located behind and on the side of the toilet).

c. The temperature and humidity log form used in the operating room department did not establish the parameter range of temperature and humidity of the operating room department. During review the log form register for temperature and humidity for 2011 provide evidence that during the months of January, February, March, April, May and June no evidence of temperature and humidity were taken at the Recovery room, Operating rooms suites #2, #3, #4 and #5, Medical surgical sterile room and material storage. The log form provided evidence that the temperature was maintained from 57.1?F to 62.3?F and the relative humidity was maintained at 60.7% through 83%. The facility's policies and procedures reviewed on 9/13/11 at 1:20 pm states that the temperature parameters were maintained on 65? F to 70? F and the relative humidity at 50% to 60%. It is required by local law to comply with the guidelines for Design and Construction of Hospital and Health Care Facilities. These guidelines on table 7.2 (ventilation requirements for areas affecting patient care in hospitals and outpatient facilities) requires that the relative humidity must be kept between 30-60 % and temperature of 68-73?F in the operating suites, the following relative humidity were measured on 9/13/11: in suite #1 the temperature registered 62.8?F at 11:00 am, in suite #2 the temperature registered 66.1?F at 11:15 am, in suite #3 the temperature registered 67.6?F at 10:40 am. In accordance with policies and procedures of the operating room if the temperature exceeds 10? F and the humidity is 10% of the established parameter limits on anyone of the operating rooms suites they closed and perform cultures to immediately analysis and then take corrective actions in accordance with institutional infection control committee. The facility's log form did not provide evidence of corrective actions or measures taken to maintain and control the temperature and the relative humidity on the operating room department and no evidence of the institutional infection control committee taking actions related to this situation.

d. The facility provides outpatient surgical services however, no evidence of post-operative follow-up to coordinated the post-operative care and appropriate provisions for follow-up care of out patient surgery needs. No evidence was provided of the hospital's outpatient surgical services quality. The nurse manager (employee #24) was interviewed on 9/15/11 at 9:15 am and she stated "I did not realize that the post-operative calls for outpatients is made in accordance with the patients needs. The ophthalmologist evaluated the patients the next day of the surgery. Post-operative patient from the prison visit the emergency room in case of complications. The facility's personnel did not has access at to prison personnel however the personnel did provide information as per their security. The secretary of the surgeon (employee #38) calls the prison for all occasions when there occurs any complications and the prison guard is oriented about the post-operative complications and to visit the operating department or visit the emergency room". However, the facility failed to ensure the health and the safety of post-operative patients.

e. On 9/14/11 at 2:55 pm the operating room nurse manager (employee #24) did not provided evidence of cleaning and disinfecting registry log of the operating room suites. The operating room nurse manager (employee #24) was interview on 9/14/11 at 3:00 pm and she stated "The designated personnel perform the cleaning and disinfecting of the operating room suites between surgical cases, daily and weekly. However, this registry log is not taken from the operating room department".

f. On 9/13/11 at 9:20 am it was observed an operating room technician (employee #27) and the surgeon (employee #29) at the elevator with operating room scrubs, then went to the operating room department located on the third floor and entering operating room area with the same scrubs.

g. The recovery room was visited on 9/14/11 at 3:00 pm accompanied by the operating room technician (employee #34) and registered nurse (employee #32) and it was observed in the corridor near the recovery room, maintenance personnel (employee #30) took out of the operating room area with a supermarket plastic bag in his hands, on interview with the employee on 9/14/11 at 3:10 pm related to the bag contents and she stated "It's my scrubs and I take it to my house to clean". The operating room technician (employee #34) and the registered nurse (employee #32) referred that the majority of the operating room personnel including the physicians (employees #36, #37, #38 and #39) wash and dry their scrubs in their home and then they bring the scrubs with them to work in the operation rooms because the facility provides the scrubs. The facility's policies ad procedures establishes that the scrubs are provided by the institution or they provided scrubs by themselves. However, the facility did not develop policies and procedures regarding the identification of contaminated scrubs and the process for washing at employee's home. No evidence was provided of the monitoring of the scrubs to assure risk of infection transmission. In accordance with the Association for Professionals in Infection Control and Epidemiology Inc. "OSHA" holds the facility responsible for laundering any clothes including scrubs, worn by health care workers that becomes contaminated with blood or other potentially infectious body fluids, regardless of who owns the scrubs". According to the AORN Guideline 2002 (Recommended practice for surgical attire), it states that after the daily use of the surgical attire, it has to be cleaned by an authorized laundry and supervised. The surgical attire has to be protected from contamination during the transfer and storage and it is not recommended to wash surgical attire in the home. During the visual visit at the supply area located at the recovery room the supply cart only had two scrubs available which is not sufficient for employees needs. The nurse manager was interviewed on 9/14/11 at 3:05 pm related to this situation and she stated "I performed an inventory of the operating room personnel scrubs on 12/3/10 and I sent to the Finance Director (CPA) the need to maintain sufficient scrubs according to the operating room employer".

h. The paper hand dispenser was observed in the nurse's dressing room on 9/13/11 at 9:20 am at the left side of the hand sink and when nursing personnel rolled out the paper it would touch the top of the hand sink. The hand soap dispenser was observed located on the left side of the main entrance of the nurse's dressing room at approximately seven inches distance from the hand paper and the hand washing sink.

i. The housekeeping maintenance room was visited on 9/13/11 at 11:40 am and was observed with four mops, two yellow mops and two red mops, only one pail without identification labels dedicated for all areas which includes operating suite #3 designated for contaminated cases. The only pail was observed with water and one mop was observed in the interior of the pail. One opened gallon of disinfectant (Full San) was observed without a lid on the border of the drain. The housekeeping maintenance room was found without an air extractor or mop hanger to ensure that mops dry properly. The regular trash container did not have an identification label and plastic bag. The housekeeping maintenance room was observed unorganized and deteriorated with black stains, humid and dust. The door was maintain without a security lock. Old cleansing products, paper towels and hand towels were observed on a wood shelf located approximately five feet from the floor exposing personnel to accidents.

j. The pre-anesthesia area was visited and the following was observed on 9/13/11 at 9:30 am: One I.V. line was observed in the interior of the regular trash can, the sharp container lacked the hospital's identification number, a bag of Dextrose 5% and N/SS 9% 1000 ml. with an expiration date of June/11, a tube of triple antibiotic and one surgical lubricant gel opened without an identification label, a patient at cubicle #1 and one patient at cubicle #3 were observed with angio catheter on the left arm that were not identified with labels containing the number of the catheter, date and hour canalized and nurse's signature.

k. In operating suite #1 during the patient procedure the following was observed on 9/13/11 from 10:25 am till 11:30 am: The anesthesiologist (employee #28) was observed with his surgical mask under his nose during the patient operation procedure and was observed with two bracelets on the left arm and one bracelet on right arm. During the surgical procedure a gauze fell to the floor near the anesthesiologist and with sterile gloves on he picked up the gauze from the floor and discarded into the garbage container but did not discard the sterile gloves, and continued with the surgical procedure. During the patient operation procedure it was observed that the anesthetist registered nurse (employee #35) did not fasten the surgical mask at the jaw and did not covered her earrings during the surgical procedure with her cap. A registered nurse (employee #32) was observed with a waist purse. Three operating room technicians (employees #25, #26, #27) and one surgeon (employee #29) were observed with cloth cap and surgical scrubs entering surgery operating suite #1 without sterile cap protection. At 10:35 am one operating room technician (employee #27) was observed with a cloth cap using it outside of the operating room department, she used the same cloth cap at operating room suite #1 without covered her earrings and without a surgical cap during the patient's surgical procedure. The surgeon (employee #29) was observed restraining the left arm of a patient and during the procedure the restriction strap touched the floor and the surgeon continued to put the restriction around the patient's arm. A bag of saline solution .9% 50 ml fell down on the floor and the registered nurse (employee #32) picked up the bag from the floor with the gloves and then put it on the material stainless steel table, the nurse did not discard the saline solution and continue with the same gloves in the operating room. One opened bottle of sterile water single use was observed in the medication area of the operating room suite #1. A bottle of Povidine Iodine 10% and one bottle of Betadine Surgical Scrub were observed opened without identification labels at the medication area. A vial of Methylene Blue without an identification label was observed under the drawer of the medication area. A registered nurse (employee #32) was observed on 9/13/11 at 10:43 am discarding his gloves and put on another pair of gloves without washing his hands. A deteriorated identification label of the biohazardous trash container was observed in operating room suite #1. Operating room suite #1 has a closed cubicle used to maintain a laparoscopy and orthopedic equipment this equipment were observed with dust and white stains. The aluminium cabinets were observed with a lot of rust. One bowl set was found expired since 8/26/11. Gauze "4x4" were observed on 9/13/11 at 10:15 am exposed to environment on the top of the material table used during the surgery procedure. The first drawer did not have the handle to opening it and a provisional plastic handle was observed. One suture syringe without a cover was exposed to the environment was observed in the interior of the I.V cabinet. One opened vial of Labetalol 100 mgs/20 ml without an identification label was observed on the emergency medication cart on 9/13/11 at 11:00 am. The plastic mattress of the operating room bed was observed on 9/13/11 at 11:15 am broken and covered with hospital surgical adhesive tape, when the operating room personnel ended the surgery procedure cleaning the bed with water and disinfectant solution the mattress absorbed the liquid exposing patients to possible cross contamination. The bed was observed with white spots and mold. No evidence was found when maintenance personnel moved the bed to cleaning the floor that had black stains under the bed. The table used to maintain the cauterization machine was observed with mold.

l. In the operating room suite #3 the following was observed on 9/13/11 from 11:25 am till 11:45 am: Gauze "4x4" were observed on 9/13/11 at 11:25 am exposed to the environment on the top of the material table used during the surgery procedure. The first drawer did not have the handle to opening it and a provisional plastic handle was observed. Two sharp containers without identification labels were found. Biohazardous trash cans without identification labels were observed. One laryngoscopy exposed to the environment without a cover. One humidifier connected at the electrical outlet was observed on the right side of the operating room suite, dirty water was observed in the interior of the second drawer. The plastic mattress of the operating room bed was observed on 9/13/11 at 11:30 am broken and covered with hospital surgical adhesive tape, when the operating room personnel ended the surgery procedure cleaning the bed with water and disinfectant solution the mattress absorbed the liquids exposing the patients to possible cross contamination. The bed was observed with white spots and mold. The large lamp of operating room #3 did not have the electric bulb, the operating room nursing director (employee #24) was interview on 9/13/11 at 11:35 am and she stated "I have requested the bulb when it broke, however they have not given it to her yet, this operating room is used for small surgical interventions and contaminated cases". No evidence of documentation when the operating room director requested the bulb.

m. The recovery room was visited and the following was observed on 9/14/11 at 3:00 pm: Four sharps containers were observed without security bases at suites #1, #2, #5 and #8. The log form used to register the medications temperature was observed in the refrigerator. The temperature parameters established for the medication refrigerator was 36 F to 46 F. The log form registry for temperatures was reviewed on 9/14/11 at 2:30 pm and provided evidence that during the months of January, February, March, April, June and September of 2010 no evidence of temperature were registered. For seven days the temperature was taken and provide evidence of 50?F but no evidence was provided of the corrective actions taken for this situation. No evidence was found of temperatures on 6/1/11, 7/18/11 and 9/1/11. Two plastic culture glasses containing a patients' foreign bodies (a screw taken from patient
#110400050 on 7/2/11 and a piece of glass taken from patient #110100329) were observed under the wash stand. The facility's policies and procedures establishes that the supervisor is responsible to save the foreign bodies to deliver it to the police or to the patient. No evidence of daily inspection of the emergency cart for April 14, 15, 25, 26, 27, 28 and 29/11, for May 24, 25, 27 and 31/11, for June 1 through 30/11, for July 1, 4, 6, 7, 8, 11,12, 13, 14, 16, 19, 20, 21, 22, 24, 26, 27, 28 and 29/11. No evidence of monthly revision by the pharmacy department for January, February, March, April, May, June, July and August of 2011.

n. Toxic solutions room was visited and the following was observed on 9/14/11 at 10:00 am: Cidex OPA tray was observed on the right side on top of the counter. No evidence was found on the ''Cidex solution log sheet'' of the name of the hospital, location/department, type of Cidex Solution, test start time and test end time on the log sheet for 12/10/10, January, February, March and April of 2011. No evidence was found in the housekeeping maintenance room that the mop and pail are identified and designated for this area to used in case of Cidex OPA spills on the floor. No evidence was found that the operating room department has a spill kit to deal with spills.

o. The anesthesia room was visited and the following was observed on 9/14/11 at 1:30 pm: The log form used to register the daily medication temperature was observed on the door of the refrigerator. The temperature parameters established for the medication refrigerator is 36 F to 46 F. The log form registry for the temperature was reviewed on 9/14/11 at 1:30 pm and provided evidence that on 1/5/11 the temperature was 34? F, on 2/2/11 it was 35? F, on 3/1/11 it was 35? F, on 3/5/11 it was 34? F, on 4/5/11 it was 34?F, 4/9/11 it was 35? F, on 5/4/11 it was 34? F, on 5/9/11 it was 35? F, on 6/4/11 it was 35? F, 7/4/11 it was 35? F and 8/3/11 it was 35? F. For eleven days the temperature was taken and provided evidence of 34? F and 35? F but no evidence was provided of the corrective actions taken for this situation.

Based on the review of four medical records and policies/procedures of the operating room with the Operating Room Manager (employee #24), it was determined that the facility failed to execute complete surgery informed consents that includes surgeon risk, benefits, date, hour and name of the physician for three out of four records reviewed (R.R #44, #45 and #46).

Findings include:

1. During the review of four records on 9/15/11 from 10:00 am till 3:00 pm, the following was determined:

a. R.R #44 provided evidence that the surgical procedure consent form lacks the risks, benefits, the date and the hour when the physician took the consent.

b. R.R #45 provided evidence that the surgical procedure consent form did not include the name of the physician, the risks and benefits when the physician took the consent.

c. R.R #46 provided evidence that the surgical procedure consent form did not specified if it was a pediatric patient, did not include the risks and benefits, date and hour when the physician that took the consent.

Based on documents reviewed with the Operating Room Manager (employee #24), it was determined that the facility failed to ensure that the operating room log registry is complete.

Findings include:

A surgery registration log book and recovery room registration log book was observed on 9/15/11 at 2:00 pm with incomplete spaces and spaces left in blank (pre-operative diagnosis, indication for surgery, anesthesiologist name, circulating nurse name, type of surgery, post-op diagnosis and pathology report).

Based on visual inspection for anesthesia services, it was determined that the facility failed to ensure that the anesthesiologist and the anesthetist nurse maintains infection control measures in accordance with policies and procedures.

Findings include:

1. In the operating room suite #1 during the patient procedure the following was observed on 9/13/11 from 10:25 am till 11:30 am.

a. The anesthesiologist (employee #28) was observed with the surgical mask under the nose during the patient operation procedure and was observed with two bracelets on the left arm and one bracelet on the right arm.

b. During the surgical procedure a gauze fell to the floor near the anesthesiologist, with the sterile gloves he gather the gauze from the floor and discarded it into the garbage container then did not discard his sterile gloves and continued with the surgical procedure.

c. During the patient surgery procedure it was observed that the anesthetist nurse (employee #35) did not fasten the surgical mask at the jaw and did not covered her earrings with the surgical procedure cap.

Based on the review of six closed and active records reviewed (R.R), policies/procedures manual, interview and the observational tour with the emergency room head nurse (employee #17) on 9/13/11 from 9:15 am till 3:00 pm, it was determined that the facility failed to comply with sign posting in the ambulance entrance, a sign was not posted in the entrance/waiting area notifying patients that arrive to the emergency room (E.R) where the triage is located, emergency personnel do not have a plan or assignments for all specific tasks in the event of an emergency, drug preparation area of the different drug compatibilities or drug dilutions for nursing staff to adhere to, two carts used to administer medications located in front of the nursing station were found open and accessible to non authorized persons, crash carts in the critical and minor surgery care areas were found unlocked, failure to provide proper infection control measures, two out of six clinical records did not have evidence of where the patient was sent after being seen by the physician until the nurse took the patient's blood sample (R.Rs #36 and #37), three out of six clinical records reviewed provided evidence that nursing staff failed to document pain re-assessment after physician's order for pain medications (R.R #31, #35 and #37), two out of six clinical records reviewed provided evidence that nursing staff failed to document the physician's treatment order at the moment of the transfer or when discharged from the emergency room (R.R #35 and #37) and one out of three transfers of closed records provided evidence that the physician failed to document the correct date/hour at the moment that the patient was transferred and the disposition (R.R #35) and the Emergency Room failed to examine credential files (C.F) to ensure that nursing staff have updated current evaluations for sixteen out of twenty-three credential files reviewed (C.F #1, #2, #6, #8, #9, #11 through #15, #17 through #22, all of which makes this condition "Not Met".

Based on the review of six closed and active records reviewed (R.R), policies/procedures manual, interview and the observational tour with the emergency room head nurse (employee #17), it was determined that the facility failed to comply with sign posting in the ambulance entrance, a sign was not posted in the entrance/waiting area notifying patients that arrive to the emergency room (E.R) where the triage is located, emergency personnel do not have a plan or assignments for all specific tasks in the event of an emergency, drug preparation area of the different drug compatibilities or drug dilutions for nursing staff to adhere to, two carts used to administer medications located in front of the nursing station were found open and accessible to non authorized persons, crash carts in the critical and minor surgery care areas were found unlocked, failure to provide proper infection control measures, two out of six clinical records did not have evidence of where the patient was sent after being seen by the physician until the nurse took the patient's blood sample (R.Rs #36 and #37), three out of six clinical records reviewed provided evidence that nursing staff failed to document pain re-assessment after physician's order for pain medications.(R.R #31, #35 and #37), two out of six clinical records reviewed provided evidence that nursing staff failed to document the physician's treatment order at the moment of the transfer or when discharged from the emergency room (R.R #35 and #37) and one out of three transfers of closed records provided evidence that the physician failed to document the correct date/hour at the moment that the patient was transferred and the disposition (R.R #35).

Findings include:

1. The following was observed related to the review of the policies/procedures manual and observations of the emergency department with the E.R head nurse (employee #17) on 9/13/11 from 9:15 am till 3:00 pm and 9/14/11 from 8:00 am till 10:00 am:

a. Policies and procedures related to compliance with EMTALA requirements did not include the following related to: anti-dumping provisions, report suspected incidences of individuals with an emergency medical condition transferred in violation, sign posting to notify of the rights of the individuals who enter the emergency room, maintain transfer records for five years, on call physicians, complete emergency room log, appropriate medical screening, stabilizing treatment, no delay in examination or treatment to inquire about payment status, appropriate transfer, whistleblower protection and recipient hospital responsibilities.

2. No signs were posted at the entrance (ambulatory/ambulance), waiting, treatment and admitting area for the notification of the rights of the individuals who enter the E.R as observed on 9/13/11 at 10:45 am. Also, the ambulatory triage area is located in the hallway near the observation area, however a sign was not posted in the ambulance entrance area notifying patients that arrive to the E.R where triage is located.

3. No evidence was found on 9/13/11 at 10:35 am that emergency personnel have a plan or assignments for all specific tasks in the event of an emergency. All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

4. No evidence was found on 9/13/11 at 1:45 pm in the drug preparation area of the different
drug compatibilities or drug dilutions for nursing staff to adhere to.

5. Two carts used to administer medications and store blood sample tubes, small vein Angiocatheters and Vacutainer's needles located in front of the nursing station was found open and can be accessed by non authorized persons on 9/13/11 at 10:20 am.

6. A crash cart in the critical and minor surgery care areas were observed unlocked on 9/13/11 at 9:55 am which could allow unauthorized access to the medications inside without breaking the plastic lock.

7. On 9/13/11 at 9:15 am a patient (R.R #30) was being wheeled out of the emergency room on a stretcher. The patient had an intravenous line with Tridil and he was asked where he was going and he stated to the echocardiogram area for a study. Observations of the patient provided evidence that the facility did not have him connected to a monitor nor was an oxygen tank available for his trip to the echocardiogram area. Policies/Procedures reviewed on 9/13/11 at 2:00 pm provided evidence that patients with chest pain are to be transported with a monitor and oxygen.

a. R.R #30 is a 62 years old male who visited the emergency room on 9/12/11 with a diagnosis of Congestive Heart Failure, Shortness of Breath and Chest pain and the record review was performed on 9/14/11 at 8:30 am. The patient was triaged at 4:46 am and was classified "urgent" with the following vital signs (V/S): temperature-36.5?C, pulse-81, respiration-22 and blood pressure-187/99. The patient was evaluated by the physician at 5:30 am and ordered cardiac monitor in the observation area, Normal Saline to keep vein open, Lasix 80 mg IV, Tridil 50mg in 250 of dextrose in water, laboratory samples and oxygen at 3 liters per nasal cannula. The emergency room physician consulted a cardiologist on 9/12/11 and the consultant evaluated the patient and admitted the patient to the medicine intensive care unit on 9/12/11 at 12:25 pm.

8. On 9/13/11 at 9:30 am the emergency room was visited and it was found that a patient (R.R #31) was lying on a stretcher in the ambulance entrance triage area. The patient was observed from down the hall and it could be seen that he was in pain. The triage nurse (employee #19) was found at the observation nursing station and she stated on 9/13/11 at 9:35 am that she was not called to see the patient and did not know that he was there. The patient ' s wife was interviewed on 9/13/11 at 9:40 am and she stated that they were waiting for about 15 minutes and they need attention because her husband has strong back pain. The triage nurse then took the information from the patient and took vital signs and sent him to the observation area cubicle #2 classified as "non-urgent". At 10:15 am the patient and his wife were observed leaving the observation area and the wife was asked if they finished receiving treatment and she stated on 9/13/11 at 10:15 am that her husband is in a lot of pain and no one has seen him since triage and they are going to another facility to receive care. The patient and wife were asked to please return to the cubicle to receive a medical evaluation and treatment which was performed at 10:40 am (medical evaluation) and 10:50 am (pain medication).

a. RR #31 is a 38 years old male who visited the emergency room on 9/13/11 with a diagnosis of Lower Back Pain and the record review was performed on 9/14/11 at 8:45 am. The patient was triaged at 9:30 am and was classified as "non-urgent" with the following vital signs (V/S): temperature-37?C, pulse-96, respiration-20 and blood pressure-142/80. The patient was evaluated by the physician at 10:40 am and ordered .9% of Normal Saline to run 80 ml per hour, Decadron 2 ml, Norflex 2 ml IM, Toradol 2 ml and Morphine and lumbar CT. The physician's orders were taken by the registered nurse on 9/13/11 at 10:50 am and immediately administered after it was ordered.

9. The ambulatory treatment area near the triage area was visited on 9/13/11 at 10:30 am with the Head Nurse (employee #17) located in the hallway near the entrance area. The treatment area is across from the triage area and waiting area in a hallway and was observed with medications (Protonix vial, Ondansetion 4mg/ml, Lidocaine 1% vial and stored blood sample tubes, small vein Angiocatheters, Vacutainer's needles and IV fluids bags were available to non-authorized persons

10. The OB-Gyn area used for the management of gynecology patients was visited on 9/13/11 at 11:00 am. A warmer was found in this area and it was plugged into a receptacle but was found to not maintain proper temperature in the event that it has to be used in an emergency.

11. The Pediatric examination room located in the emergency room (E.R) was observed with the facility's E.R Head Nurse (employee #17) on 9/13/11 at 11:10 am and provided evidence that the vinyl of the examination bed was broken. Also, the bed needs to be repositioned to ensure that patients can be attended by staff on three sides of the beds in the event of an emergency.

12. On 9/13/11 at 10:20 am the housekeeping employee (employee #23) was found cleaning the floor in the hallway in front of the treatment area, a bottle of Toilet Bowl cleaner, a bottle of Trial disinfectant and Glass Cleaner were available to non-authorized personnel on the top of the cart. This procedure of leaving the cart does not limit the access to this supplies and solutions to only authorized personnel. Also, a material safety data sheet (MSDS) in the housekeeping room was not found.

13. Housekeeping employee (employee #23) was called to the treatment room on 9/13/11 at 10:20 am to clean a blood spill from the floor. When he arrived at the treatment room with the maintenance cart (a pail with water, a mop and cleaning solutions) he was asked what he was going to use to clean the blood from the floor and he stated on 9/13/11 at 10:25 am that he will use the mop and pail on the cart. He stated that it is the same mop and pail that he uses throughout the E.R, but after he cleans the blood he will wash and disinfect the mop and pail, because the mop and pail for contaminated use was locked in a closet by the contracted maintenance service.

14. The dirty utility room was visited on 9/13/11 at 11:20 am and was found with its door open and two containers on the counter (one with Cidex OPA and the other with Enzol). The tray with Cidex OPA was found uncovered with a laryngeal blade that was not completely covered with the disinfectant. The Enzol solution that was in the container was not prepared as instructed by the manufacturer and this room did not have a functional air extractor and was not placed over the work counter. Also, no evidence was found of the log tests of the date when the Metricide solution was change to validate its concentration and effectiveness.

15. The following was observed in the emergency room on 9/13/11 from 9:15 am till 3:00 pm related to infection control procedures:

a. Large packages of gauze were observed on 9/13/11 from 9:30 till 12:00 noon in the treatment area, triage area, pediatric area, critical/surgery care area and on the I.V access cart without protective covers, exposing them to the environment
b. All soap dispenser located at the emergency room were found on 9/13/11 from 9:30 am till 12:00 noon without soap available for hand washing.
c. Ear and nose speculum were found loose on the pediatric physician ' s desk and in a plastic container, but it could not be determined which were clean and which were used.
d. A plastic container with tongue depressors were observed in the examination area, treatment area and critical/trauma room without protective covers exposing them when personnel take them out of the container.
e. Four boxes of I.V bags of normal saline were observed on 9/13/11 at 1:30 pm in the medication room directly on the floor

16. Six active and closed clinical records were reviewed on 9/14/11 from 8:30 am till 10:00 am and 9/15/11 from 8:30 am till 10:00 am for emergency room services and provided evidence of the following:

a. Two out of six clinical records reviewed for emergency room services provided evidence that the triage nurse failed to document the location of the patients after the initial evaluation of the emergency room visit (R.R #36 to #37).
b. Three out of six clinical records reviewed for emergency room services provided evidence that nursing staff failed to document pain re-assessment after the physician ordered medications for pain (R.R #31, #35 and #37).
c. Two out of six clinical records reviewed for emergency room services provided evidence that nursing staff failed to document the physician's treatment order at the moment of the transfer or when discharged from the emergency room (R.R #35 and #37).

17. One out of three transfers of closed records provided evidence that the physician failed to document the correct hour at the moment that the patient was transferred and the disposition (R.R #35).

a. R.R #35 is a 60 years old male who visited the emergency room on 9/12/11 at 5:24 pm with Abdominal Pain, Diabetes mellitus and Morbid Obesity. The triage was performed at 5:24 pm and the patient was categorized as "urgent". The record was reviewed on 9/14/11 at 9:30 am and provided evidence that the ER physician evaluated the patient related to abdominal pain, fever and nauseas and ordered treatment at 6:30 pm. The patient's condition was observed and was transferred to another facility on 9/14/11 at 1:50 am, the E.R registered nurse documents that the patient was transferred The transfer sheet was reviewed and provided evidence that the physician documents the date/hour of 9/12/11 at 5:00 pm for when the patient was transferred. For the disposition of the patient in the medical record, the physician documents that the patient was transferred on 9/13/11 at 5:00 pm, but it is not until 1:50 am on 9/14/11 that the patient was transferred. The facility failed to ensure that the patient's condition was re-evaluated by an E.R physician at the moment that the patient was transferred to the other facility to verify if the patient's needs had changed from 5:00 pm (hour of the transfer note) till 1:50 am (when the patient was actual transferred) which is a span of almost 8 hours (the physician who transferred the patient at 5:00 pm and signed the note did so before the patient was actual transferred).

Based on the review of twenty-three contract nursing credential files (certified) with nursing supervisor (employee #46), it was determined that the Emergency room failed to examine credential files (C.F) to ensure that nursing staff have updated current evaluations for sixteen out of twenty-three credential files reviewed (C.F #1, #2, #6, #8, #9, #11 through #15, #17 through #22).

Findings include:

1. During the review of twenty-three contract nursing staff credential files on 9/15/11 from 3:30 pm till 4:30 am the following was found:

a. Sixteen out of twenty-three nursing credentials files staff provided evidence that the credential files did not have current evaluations (C.F #1, #2, #6, #8, #9, #11 through #15 and #17 through #22).

Based on the review of policies and procedures and observations with the supervisor of the Respiratory Therapy Department (employee #7), it was determined that the facility failed to ensure that services are provided in accordance with acceptable standards of practice related to respiratory equipment not labeled with the date and hour when started on the equipment and equipment exposed to the environment for seven out of seven patient's rooms using respiratory equipment (in patient's rooms #5-157 B, #5-158 A, #7-145 B, #7-146 B, #7-148 B, #7-163 B and #7-154) and failed to perform policies and procedures related to respiratory therapy needs updating the care plan.

Findings include:

1. No evidence was provided from the supervisor of the Respiratory Therapy Department
(employee #7) on 9/15/11 at 1:40 pm of written policies for the delivery of respiratory care services which are developed and approved by the medical staff related to the time frame for updating the respiratory therapy plan of care.

2. During the observational tour on 9/13/11 from 9:00 am till 3:30 pm with the infection Control officer (employee #1), patient's sleeping rooms #7-145 B, #7-146 B, #7-148 B and
#7-163 B were visited and provided evidence that the patient's respiratory equipment were found exposed to the environment without a plastic bags on the patient's night tables and in the patient's bed. Evidence was found of the respiratory equipment in plastic bags without labels with the patient's name, room, date and hour when the equipment was opened in patient's sleeping rooms #5-157 A, #5-158 A and #7-154.

3. The Respiratory Therapy Department was visited with the respiratory therapist supervisor (Employee #7) and the space used to disinfect and store clean mechanical ventilators was observed on 9/15/11 at 9:40 am. The area was observed with a bath with a sink that was out of service, the respiratory personnel have to pass from the dirty area and cross to the clean area to another room to perform the hand washing process prior to passing the clean equipment to the clean area.

Based on the review of ten respiratory therapists credential files (C.F) with the Respiratory therapy supervisor (employee #7), it was determined that the facility failed to ensure that ten out of ten respiratory therapists personnel meet the qualifications specified and consistent with State laws related to License registration, updated certificate of health, updated Cardio Pulmonary Resuscitation Certification (CPR), updated annual evaluations and competency for nine out of ten C.F (C.F #1, #2, #3, #4, #5, #7, #8, #9 and #10.

Findings include:

1. One out of ten respiratory therapist credential files provided evidence of expired license registration since 8/3/11 (C.F #5).

2. Seven out of ten respiratory therapist credential files provided evidence of expired Health Certificates for C.F #2, #3, #4, #7, #8, #9 and #10.

3. Six out of ten respiratory therapist credentials did not contain evidence of updated CPR for C.Fs #1, #4, #7, #8, #9, and #10.

4. Seven out of ten respiratory therapist credentials did not contain evidence of updated annual evaluations for C.F #1, #2, #4, #7, #8, #9 and #10.

5. Seven out of ten respiratory therapist credential files did not contain evidence of updated competencies for C.F #1, #2, #4, #7, #8, #9 and #10.

Based on the review of six medical records and policies/procedures, it was determined that the facility failed to ensure that the organization of respiratory therapy services is appropriate to the scope and complexity of the services provided for five out of six clinical records reviewed (R.R #11, #12, #13, #14 and #15).

Findings include:

1. Six medical records were reviewed on 9/15/11 from 10:00 am till 12:00 noon and provided evidence that respiratory therapists do not administer respiratory therapy treatment in accordance with the physician's order for five out six records reviewed with respiratory therapy.

a. R.R #11 is an 89 years old female admitted on 8/29/11 with a diagnosis of Cardiac Failure and Pneumonia. The record review was performed on 9/15/11 at 10:00 am with the Respiratory Therapist Supervisor (employee #7) and provided evidence that the physician ordered on 8/30/11 at 8:00 pm Albuterol 0.5 ml/ 3 ml NSS by power nebulizer (PN) every 15 minute (min) per two doses then every 4 hours. The Respiratory therapy medication sheet from 8/30/11 provide evidence that the first treatment was administered at 8:20 pm, however no evidence was found of the second dose every 15 min. On 9/2/11 at 10:40 am the physician places an order of Albuterol 0.5 mg/ 3 ml of NSS by PN every 4 hours. However evidence was found that the patient received treatment on 9/2/11 at 8:24 am, no evidence was found that the respiratory therapy treatment was provided until 9/3/11 at 1:06 am. On 9/4/11 at 4:20 am the patient received respiratory therapy treatment at 9:10 am, 50 minutes later than every 4 hours. On 9/6/11 at 4:32 am the respiratory therapist documented in the respiratory therapy sheet that the family did not want to awake the patient, however no evidence was found that the nurse and the physician were notified. On 9/6/11 at 8:20 am the physician ordered Albuterol 0.5 mg/ Atrovent 250 mcg every 4 hours, According to facility's polices and procedures reviewed on 9/15/11 at 10:10 am the respiratory therapy must be re-evaluated by the physician every 72 hours. The respiratory therapy sheet provided evidence that the patient continued receiving respiratory therapy without a physician's order on 9/9/11 at 9:15 am, at 5:10 pm at 9:10 pm, on 9/10/11 at 1:34 am, at 4:50 am, at 9:15 am, at 1:30 pm. On 9/11/11 at 10:11 am the physician ordered Albuterol 0.5 ml/ 3 ml NSS every 4 hr, the respiratory therapy sheet provided evidence that the patient received respiratory treatment on 9/11/11 at 8:05 pm then on 9/12/11 at 1:38 am, 1 hour and 30 minutes later which is not in accordance with the physician's order.

b. R.R #12 is a 91 years old male admitted on 9/12/11 with a diagnosis of Bronchopneumonia. The record review was performed on 9/15/11 at 10:30 am with the Respiratory Therapist Supervisor (employee #7) and provided evidence that the physician ordered on 9/12/11 at 11:10 pm Albuterol 0.5 mg/ 3 ml NSS by power nebulizer (PN) every 4 hours. The Respiratory therapy medication sheet from 9/14/11 provided evidence that the respiratory treatment was administered at 8:40 pm, however evidence was found that the next treatment was administered on 9/15/11 at 2:04 am, 1 hour 20 minute later.

c. R.R #13 is an 83 years old male admitted on 9/4/11 with a diagnosis of Left Leg Cellulitis. The record review was performed on 9/15/11 at 10:50 am with the Respiratory Therapist Supervisor (employee #7) and provided evidence that the physician ordered on 9/8/11 at 10:40 am Albuterol 0.5 mg /3 ml NSS by power nebulizer (PN) every 4 hours. The Respiratory therapy sheet from 9/11/11 provided evidence that the respiratory treatment was administered at 9:05 am, and the next treatment was administered at 5:05 pm, at 9:10 pm, then on 9/12/11 at 1:30 am, at 5:32 am, at 9:20 am at 1:25 pm, at 5:08 pm at 9:10 pm, on 9/13/11 at 12:00 mn and at 5:20 am without a physician's order. The physician's order was to be re-evaluated on 9/11/11 at 10:40 am. According to facility's polices and procedures reviewed on 9/15/11 at 10:10 am respiratory therapy must be re-evaluated by the physician every 72 hours.

d. R.R #14 is a 90 years old male admitted on 9/6/11 with a diagnosis of Pneumonia. The record review was performed on 9/15/11 at 11:10 am with the Respiratory Therapist Supervisor (employee #7) and provided evidence that the physician ordered on 9/10/11 at 6:00 pm Albuterol 2.5 mg /3 ml NSS by power nebulizer (PN) every 4 hours. The Respiratory therapy sheet from 9/10/11 provided evidence that the respiratory treatment was administered at 8:00 pm, two hours later. On 9/11/11 at 9:10 am the respiratory therapy was administered at 5:25 pm, 4 hours and 25 minutes later. On 9/13/11 the respiratory therapy was administered at 8:30 am, no evidence was found that the respiratory therapist provided the patient treatment as ordered by the physician, the next treatment was provided at 8:00 pm, 12 hours later. On 9/13/11 at 4:30 pm the physician ordered Proventyl 0.3 ml/ a ml NSS every 6 hours, the respiratory treatment was administered on 9/13/11 at 8:00 pm and the next treatment was administered at 12:50 am every 4 hours not every 6 hours according to the physician's order. Then at 8:50 am, 2 hours later, then at 8:26 pm, 6 hours later which is not in accordance with the physician's order.

e. R.R #15 is a 28 years old female admitted on 9/12/11 with a diagnosis of Bronchitis. The record review was performed on 9/15/11 at 11:30 am with the Respiratory Therapist Supervisor (employee #7) and provided evidence that the physician ordered on 9/12/11 at 3:00 pm Proventyl 0.5 mg /3 ml NSS by power nebulizer (PN) every 4 hours. The nurse took the order at 5:55 pm, however the Respiratory therapy sheet from 9/12/11 provided evidence that the respiratory therapist started the treatment at 8:10 pm, two hour later.