HospitalInspections.org

Based on the review of hospital licenses during the follow-up visit, it was determined that the facility failed to ensure that it is in compliance with Federal and State laws related to an expired State License.

Deficiencies Not Corrected

Findings include:

During the review of the facility's licenses on 11/9/11 at 2:45 pm during the follow-up visit, it was identified that their State License expired on August 31, 2011. However the facility provided evidence that they submitted all required documentation on 9/2/11 and on 9/7/11 to the State Department of Health, however they have not processed or emitted the license as of the follow-up survey.

Based on two records reviewed (R.R) and Do Not Resuscitate (DNR) Policies and Procedures during the follow up visit, 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 one out of two records reviewed (R.R #1).
Deficiencies Not Corrected
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 11/09/11 from 10:45 am till 4:00 pm:
a. R.R #1 is an 67 years old male who was admitted on 10/12/11 with a diagnosis of Pneumonia, Congestive Obstructive Pulmonary Desease (COPD), Parkinson, Alzahaimer and Diabetes Mellitus. On 11/09/11 at 11:15 am the record was reviewed with the Infection Control Officer (employee #8). It was found that the patient's relative signed a consent for and DNI, no evidence was found of who took the consent, no evidence was found of the date and hour that patients' relative sign the consent. No evidence was found related to the physician's order for DNI order. No evidence was found of the physician justification and patient realtive orientation related to the DNI 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 DNI consent, but there is no physician's order for the 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.

2. During the review of the facility's "Do Not Resuscitate Policies and Protocols" on 11/09/11 at 3:30 pm, it was determined that the facility failed to have policies and procedures in place related to:

a. Do Not Intubate (DNI).

Based on five records reviewed (R.R)during the follow up visit, 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 two out of five records reviewed (R.R #1 and #17).

Deficiency Not corrected

Findings include:

1. R.R #1 is a 67 years old male who was admitted on 10/12/11 with a diagnosis of Pneumonia, Congestive Obstructive Pulmonary Disease (COPD), Parkinson, Alzheimer and Diabetes Mellitus. On 1/9/11 at 11:15 am the record was reviewed with the Infection Control Officer (employee #8); it was found that the physician ordered restraints on 10/16/11 at 8:00 pm. Physician orders reviewed on 10/17/11 at 8:00 am and provided evidence that the physician wrote soft restraints of the superior extremities due to disorientation 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. On 10/16/11 the nursing reassessment and documentation on the patient's restraint sheet provided evidence that the patient was restrained until 7:00 am till on 10/17/11 at 5:00 am, on 10/20/11 from 7:00 am till 7:00 pm, on 10/21/11 from 7:00am till 7:00 pm, on 11/5/11 from 7:00 am till 11/6/11 at 5:00 am, on 11/6/11 from 7:00 am till 11/7/11 at 5:00 am, on 11/7/11/11 from 7:00 am till 7:00 pm, on 11/8/11 from 7:00am till 11/9/11 at 5:00 am. The nurse restrained the patient without a physician's order. No evidence was found of the updated patient's plan of care related to the restraints by the registered nurse on 10/17/11 on 10/20/11, on 10/21/11, on 11/5/11, on 11/6/11, on 11/7/11/11, on 11/8/11. No evidence was found related to the patients ' or relatives' orientation related to the restraints.


2. R.R #17 is a 68 years old male who was admitted on 9/28/11 with a diagnosis of Gastroenteritis. During the record review on 11/9/11 at 4:00 pm with the technical information manager (employee #9), provide evidence that the physician provide a telephonic order on 10/2/11 at 12:35 am for restraint patient with soft restriction in four extremities due to disorientation and treatment interruption. The patient's restraint reassessment sheet performed on 10/3/11 from 1:00 am till 7:00 p m, however no evidence was found that the physician counter sign the restraint telephonic order.

Based on observations made during the follow-up survey and review of twenty eight clinical records and policies/procedure with the Director of Nursing (DON) (employee #7), it was found that the facility failed to ensure that nursing staff develop appropriate nursing interventions and implement, individualized and updated care plans for five out of eleven records reviewed (R.R #1, #7, #9, #10 and #19).

Findings include:

Deficiencies Not Corrected

1. Five out of eleven records reviewed for care plans on 11/09/11 from 3:35 am till 4:30 pm 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 #7 is a 16 years old male who was admitted on 10/05/11 with Acute Appendicitis post- Appendectomy. The patient's record was reviewed on 11/09/11 at 3:35 pm 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 re-evaluation of patients' needs according to the patient's changes during the in-patient stay and did not closed the plan of care on patient discharge home.

b. R.R #9 is a 62 years old female who was admitted on 10/17/11 with Inflam Breast Disease. The patient's record was reviewed on 11/09/11 at 3:40 pm and evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization but the standardized plan of care was not individualized as per patients needs.

c. R.R #10 female who was admitted on 9/16/11 with Splenomegaly. The patient's record was reviewed on 11/09/11 at 3:45 pm 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. No evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay and no evidence was found when the nurse closed the plans of care on discharge to home.



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d. R.R #1 is a 67 years old male who was admitted on 10/12/11 with Pneumonia, Congestive Obstructive Pulmonary Disease (COPD) Parkinson, Alzheimer and Diabetes Mellitus. The patient's record was reviewed on 11/09/11 at 11:15 am and evidence was found that the registered nurse do not activated the plan of care according to the patient's needs during the hospitalization and no evidence was found of the revision and individualized of the patients' plan of care needs according to the patient's changes during the in-patient stay.

e. R.R #19 is a 29 years old male who was admitted on 11/7/11 with Abdominal Pain. The patient's record was reviewed on 11/9/11 at 10:45 am and evidence was found that the registered nurse do not activated the plan of care according to the patient's needs during the hospitalization and no evidence was found of the revision and individualized of the patients' plan of care needs according to the patient's changes during the in-patient stay.

Based on the observational tour during the follow-up visit of the medical records department through the central file area, alternate storage area with the medical record staff (employee #2) 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.

Deficiencies Not Corrected.

Findings include:

1. The central file of active records was visited during the follow-up survey on 11/9/11 at 2:00 pm 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. Forty 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 during the follow-up survey on 11/9/11 at 2:15 pm and found with approximately 200 boxes with clinical records directly on the floor at the end of the hallway near the metal storage cabinets waiting to be moved to a second floor storage room to be disposed of. Five 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.

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 during the follow-up survey on 11/9/11 at 2:45 pm very dirty, no ventilation, with 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. A medical record employee (employee #2) was interviewed on 11/9/11 at 2:45 pm and she stated that the evaluation of the medical records began to start to move them to from the first floor to the third floor until the disposition of the medical records is started which will create more space.

4. The hospital's administrator (employee #13) stated during interview on 11/9/11 at 2:45 pm that since the hospital first opened, no medical records have been disposed of and the department of medical records has problems with the lack of medical record storage space. He also stated that they have placed an announcement in the news papers as of two weeks ago so that previous patients can request their old medical records until November 28, 2011 so that they can start the disposition process of the medical records.

Based on the follow up visit and seven records reviewed (R.R), it was determined that the facility failed to ensure that one out of seven records reviwed contain appropriate documents related to consult evaluations. (R.R #12).

Findings include:

Deficiencies Not Corrected

1. During the review of clinical records on 11/09/11 at 3:55 pm the following was determined:

a. R.R #12 was reviewed on 11/09/11 at 3:55 pm and failed to provide evidence of
the requested consult however lacks the date, hour and signature of the consultant.

Based on the review of seven closed records reviewed (R.R) during the follow up survey it was determined that the facility failed to ensure that clinical records have documentation related to consent forms, post-operative patient instructions, risks and benefits on the Operation Consent form, consult evaluations, nurse's notes, nurse signature on the physician orders, pain assessments and re-assessment for six out of seven records reviewed (R.R#7, #8, #9, #10, #11 and #12).

Findings include:

Deficiencies Not Corrected

1. During the review of seven clinical records with the Medical Record Technician (employee #9) at 3:45 pm. till 4:15 pm. the following was determined:

a. R.R #7 is a 16 years old male who was admitted on 10/05/11 with Acute Appendicitis post- Appendectomy. The patient's record was reviewed on 11/09/11 at 3:35 pm 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 re-evaluate patients' needs according to the patient's changes during the in-patient stay and closed the plan of care on patient discharge home. Failed to provide evidence of documentation of risks, benefits, date and hour when the informed consent form was taken by the surgeon on 10/05/11.

b. R.R #8 is a 54 years old male who was admitted on 10/18/11 with Scalp / Neck Skin CA. The patient's record was reviewed on 11/09/11 at 3:50 pm and did not provide evidence of the date when the patient signed the anesthesia consent form and the anesthesiologist signature. No evidence of nurse signature on physician order for 10/18/11 at 8:00 am and 10/18/11 at 10:20 am. No evidence of documentation of risks, benefits, and the hour on the surgeon's informed consent form

c. R.R #9 is a 62 years old female who was admitted on 10/17/11 with Inflam Breast Disease. The patient's record was reviewed on 11/09/11 at 3:40 pm and evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization; the standardized plan of care was not individualized. The physician orders for 10/15/11 at 9:00 am., 10/16/11 at 11:00 am., 10/17/11 at 2:00 pm. and 10/18/11 at 2:30 pm lacks of nurse signature. The insulin protocol orders for 10/16/11 at 11:00 am lacks of nurse signature. No evidence of documentation of risks, benefits, and the hour on the surgeon's informed consent form.

d. R.R #10 female who was admitted on 9/16/11 with Splenomegaly. The patient's record was reviewed on 11/09/11 at 3:45 pm 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. The nurse history performed on 9/16/11 at 10:10 pm lacks of information (potential risk for suicidal attempt, pain assessment, and nutritional evaluation). The transferred form lacks of the person who notify the transfer. No evidence of nurses notes on 9/17/11, 9/20/11 and 9/21/11 on shift 7:00 am. through 7:00 pm. No evidence of nurses notes for patient re-assessment for falls on 9/19/11 and 9/20/11. The emergency physician patient record lacks of physician re-evaluation, final diagnosis, patient disposition, date and hour of discharge, patient signature and physician signature. The nurse initial assessment of emergency room lacks information related to health history, anticipated directives and potential ricks to suicidal attempt. No evidence was found of nurse license and signature on the pain assessment form. The pain assessment form lacks information related to intensity, duration, frequency and what kind of treatment the patient had to management the pain.

e. R.R #11 was reviewed on 11/09/11 at 3:50 pm and failed to provide evidence of documentation of risks and benefits.

f. R.R #12 was reviewed on 11/09/11 at 4:00 pm and failed to provide evidence of documentation of risks, benefits, hour on the surgeon's informed consent form. No evidence of the date and the hour on the surgery consults. No evidence of the nurse's signature on the physician order's on 10/7/11 at 12:00 am., 10/7/11 at 11:45 am and 10/8/11 at 1:00 pm.

Based on the observational tour during the follow-up visit and review of pharmacy reports of inspections of controlled drug areas with the Pharmacy Director (employee #3) and interview, it was determined that the facility failed to comply with policies and procedures which govern pharmaceutical services.

Deficiencies Not Corrected

Findings include:

The Pharmacy Director (employee #3) stated during interview on 11/09/11 at 10:40 am 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.

Based on observations during the follow-up visit of the medication storage room with the Pharmacist (employee #3), 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.

Deficiencies Not Corrected.

Findings include:

1. During the initial observational tour with the pharmacist (employee #3) on 11/09/11 from 9:40 am though 12:00 noon the following was found:

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

Based on observations during the follow-up visit and review of policies and procedures and routine equipment testing with the supervisor of the X-ray department (employee #5) and interview, it was determined that the facility failed to ensure that the physicist periodically verifies the badge for radiation exposure.

Deficiencies Not Corrected.

Findings include:

On 11/09/11 at 2:38 pm the supervisor of the X-ray department (employee #5) stated that he has in use 20 radiation dosimeters used by X-ray department personnel, and the dosimeters must be reviewed by a physicist monthly; however this review was not performed since January 2011.

Based on the follow-up visit and review of documents with the supervisor of the X-ray department (employee #5) 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 eight out of nine lacked the annual performance evaluations (C.F #1, #2, #4, #5, #6, #7, #8 and #9).

Deficiencies Not Corrected.

Findings include:

1. Review of nine radiology credential files on 11/09/11 at 2:20 pm provided evidence of the following:

a. Eight out of nine radiology employee credential files were reviewed on 11/09/11 at 2:00 pm with the human resource officer (employee #5) and provided evidence that C.Fs #1, #2, #4, #5, #6, #7, #8 and #9 did not have updated performance evaluations.

Based on tests performed on equipment and observations made during the follow-up survey for the physical environment with the facility's Engineer (employee #1), 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 maintenance closets with cleaning chemicals left unlocked and did not have door closers and regular and biohazardous trash rooms did not have door closers.

Deficiencies Not Corrected

Findings include:

1. Maintenance closets were visited during the follow-up survey on 11/9/11 from 9:30 am till 12:00 noon. 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.

2. Regular trash storage closets and biohazardous waste storage closets were visited on 11/9/11 from 9:30 am till 1200 noon and did not have 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.

Based on tests to equipment, observations and review of documentation made during the follow-up survey for Life Safety from fire with the facility's Engineer (employee #1), it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101.

Deficiencies Not Corrected

Findings include:

The Life Safety from Fire follow-up survey was performed with the facility's Engineer (employee #1) on 11/9/11 from 9:30 am till 5:00 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0046 and K0051).

Based on observations made during the follow-up survey for the physical environment with the facility's Engineer (employee #1), it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to emergency room (E.R) roof leaks, no evidence was found that the biomedical technician verified the function of the negative pressure of the isolation rooms and no evidence was found of the cisterns' cleaning or periodic bacteriology tests.

Deficiencies Not Corrected

Findings include:

1. The E.R was visited during the follow-up visit on 11/9/11 from 9:30 am till 10:20 am and provided evidence of the following:
a. A 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.
b. Two small storage rooms in front of the nursing station were found during the follow-up visit on 11/9/11 at 9:35 am 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 will need to 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.

2. The adult and pediatric isolation rooms of the emergency room were visited during the follow-up survey on 11/9/11 at 9:40 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 on 11/9/11 from 9:30 am till 12:00 noon with the facility's Engineer (employee #1) 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. 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.

3. Written evidence about bacteriological tests and cleaning of the water cistern was requested on 11/9/11 at 2:00 pm during the follow-up survey. 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 follow-up survey for the physical environment with the facility's Engineer (employee #1), 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, 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 is not properly maintained, the fifth floor hallway only has one handrail along one side of the hallway and no evidence was found of the elevator recall.

Deficiencies Not Corrected

Findings include:

1. The handicapped toilet rooms (male and female) located at the waiting area of the emergency room were visited during the follow-up survey on 11/9/11 at 9:50 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 handicapped female toilet located within the emergency room (E.R) near cubicle #10 was visited during the follow-up survey on 11/9/11 at 9:45 am 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.
3. The bathroom located at the back of the pediatric emergency room was visited during the follow-up survey on 11/9/11 at 9:55 am and provided evidence that it does not have an emergency call system.
4. The pediatric emergency room was visited during the follow-up survey on 11/9/11 at 9:40 am and provided evidence that cribs #6 and #9 do not have nursing call systems.
5. The emergency room was visited during the follow-up on 11/9/11 at 10:05 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.

6. During observations of the handicapped ramps used to access the sidewalk of the emergency room during the follow-up visit on 11/9/11 at 9:30 am, 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).

7. The laboratory department was visited during the previous survey and no evidence was found during the follow-up survey on 11/9/11 at 11:20 am with the facility's Engineer (employee #1) that the "chemical room" was repaired for the following:

a. 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.

8. The handicapped toilet room (male and female) located at the fifth floor was visited during the previous survey and no evidence was found during the follow-up survey on 11/9/11 at 11:20 am with the facility's Engineer (employee #1) of the following repairs:
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.
9. The hallways of the fifth floor were visited during the previous survey and no evidence was provided during the follow-up survey on 11/9/11 at 11:00 am with the facility's Engineer (employee #1) that handrails were placed on both sides 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.

10. The elevators were visited during the follow-up survey on 11/9/11 at 10:35 am with the facility's Engineer (employee #1) 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).

11. The operating room department was visited during the follow-up survey on 11/9/11 from 4:00 pm through 4:30 pm with the facility's Engineer (employee #1) 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. Split unit air conditioners are not recommended in operating 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).

12. Observations made during the follow-up survey on 11/9/11 from 8:00 am through 5:00 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".

13. The handicapped toilet rooms (male and female) located at the X-ray department was visited during the follow-up survey on 11/9/11 at 9:20 am 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 follow-up survey for the physical environment with the facility's Engineer (employee #1), it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area and observation areas which are not equipped with an air disinfection system (such as ultraviolet lights).

Deficiencies Not Corrected

Findings include:

The emergency room was visited during the follow-up survey on 11/9/11 at 9:30 am with the facility's Engineer (employee #1) and provided evidence that the waiting 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 triage room has an ultraviolet lamp, however 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 during the follow up visit, 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, sharp containers without security racks, expired medication, multiple dose vial opened more than 28 days, respiratory equipment exposed to the environment, Intravenous bags without labels with the patient's name.

Deficiency Not Corrected

Findings include:

1. During the observational tour with the infection control officer (employee #8) at the Seventh floor Pediatric ward on 11/9/11 from 9:00 am till 9:30 am the following was found:

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

b. It was observed in the medication refrigerator, a vial of Humuline N opened available for patient use since 10/5/11. The Association for Professional in Infection Control and Epidemiology (APIC) and United States Pharmacopeia (USP) recommend that opened or puncture multiple dose vials be used for no more than 28 day.

c. It was observed that the metal cabinet has mold in the drawers.
d. In the treatment room, it was found that the sharp containers of the crash cart were without security racks.
e. It was observed that respiratory equipment were not placed in plastic bags between patient use exposing them to the environment, in rooms #7-146 B and #7-149 B.

2. During the observational tour with the infection control officer (employee #8) at the Seventh floor Nursery and Neonatal Intensive Care Unit ward on 11/9/11 at 10:15 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.
3. During the observational tour with the infection control officer (employee #8) at the Seventh floor housekeeping room in the area of the Delivery room on 11/9/11 at 10:20 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.
4. It was observed on 11/9/11 at 10:30 am in the hallway near the delivery ward a biohazardous waste storage room with the door closed but it was not locked.
5. During the observational tour with the infection control officer (employee #8) at the Sixth floor Intensive Care Unit on 11/9/11 at 10:35 am, the following was found:
a. It was observed that on the glucometer cart the biohazardous trash container was without a lid.
5. During the observational tour with the infection control officer (employee #8) at the Fifth floor Medical/Surgical ward on 11/9/11 at 10:45 pm, the following was found:
a. It was observed that the intravenous bag lacks the patient name in rooms #5-142 B, #5-144 B, #5-146 A, #5-150 A, #5-151 A, #5-152 B, #5-153 B and #5-161 B.
b. It was observed that the metal cabinet in the bathroom of room #5-133 had mold.
c. It was observed that the mattresses were broken in room ' s # 5-135 A and B #5-148 A, #5-154 A, #5-160 B, and #5-161 A.

Based on the follow up visit, observations made of the surgical department located on third floor, interview and review of policies/procedures with the Operating Room Manager (employee #12), it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice and patient care.

Deficiencies Not Corrected

Findings include:

1. Observations made of the surgical department on 11/09/11 from 9:30 am till 11:45 am provided the following evidence:

a. 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" (ADA Law) 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).

b. 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 September 20 to 30, October and November 4 to 6, evidence of temperature and humidity were taken at the Recovery room, Operating rooms suites #1, #2 and #3, Medical surgical sterile room and material storage. The log form provided evidence that the temperature was maintained from 58.2?F to 70.5?F and the relative humidity was maintained at 37.0.7% through 74.1 %. The facility's policies and procedures reviewed on 11/09/11 at 9:30 am states that the temperature parameters are maintained at 68? F to 73? F and the relative humidity at 30% 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 11/09/11: in suite #1 the temperature registered 61.5?F and humidity 66 % at 2:55 pm, in suite #2 the temperature registered 63.0 ?F and humidity 77 % at 2:45 pm, in suite #3 the temperature registered 64.4?F and humidity 72 % at 2:50 pm. and on Sterile room the temperature registered 67.5?F and humidity 48 % at 2:50 pm. 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.

c. 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 outpatient surgery needs. No evidence was provided of the hospital's outpatient surgical services quality. The nurse manager (employee #12) was interviewed on 11/09/11 at 11:00 am and she stated "I did not perform the post-operative calls for the outpatients these are made in accordance with the patients needs".
The facility prepared a post-operative follow up call form for 24 and 72 hours to evaluate the patients the next day of the surgery. No evidence was provided by the nurse manager (employee #12) related to the post-operative calls. Also, the post-operative patient from the prison visits the emergency room afther surgery when thre is complications. The facility's personnel do not have access with the prison personnel. The secretary of the surgeon (employee #38) calls the prison when there is any complications and the prison guard is oriented about the post-operative complications and is instructed to visit the operating department or visit the emergency room. However, the facility failed to ensure and follow up for the health and the safety of post-operative patients.

d. On 11/09/11 at 1:30 pm the operating room nurse manager (employee #12) did not provided evidence of cleaning and disinfecting registry log of the operating room suites. The operating room nurse manager (employee #12) was interview on 11/09/11 at 1:35 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".

e. The housekeeping maintenance room was visited on 11/09/11 at 2:55 pm and was observed with seven mops, two yellow mops, two red mops and three blue 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. 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. The housekeeping maintenance room was observed unorganized and deteriorated with black stains, humid and dust. The door was maintained 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.

f. In the operating room suite #3 the following was observed on 11/09/11 at 2:45 pm: The plastic mattress of the operating room bed was observed 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 mold. The large lamp of operating room #2 did not have the electric bulb. The operating room nursing director (employee #12) was interview on 11/09/11 at 2:45 pm and she stated, "I have requested the bulb when it broke, however they have not replaced it yet, this operating room is not used for surgical interventions now, we are using operating rooms #1 and #3." No evidence of documentation when the operating room director requested the bulb.

g. Toxic solutions room was visited and the following was observed on 11/14/11 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, April, 2011. No evidence was found in the housekeeping maintenance room that the mop and pail area 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.

Based on follow up visit review of seven medical records and policies/procedures of the operating room with the Operating Room Manager (employee #12), 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 five out of seven records reviewed (R.R #7, #8, #9, #11 and #12).

Deficiencies Not Corrected

Findings include:

1. During the review of seven records on 11/09/11 from 3:35 pm till 4:15 pm, the following was determined:

a. R.R #7 provided evidence that the surgical procedure consent form lacks the risks and benefits.

b. R.R #8 provided evidence that the surgical procedure consent form lacks the risks and benefits.
c. R.R #9 provided evidence that the surgical procedure consent form did not include the risks and benefits and hour when the physician that took the consent.
d. R.R #11 provided evidence that the surgical procedure consent form did not include the risks, benefits, alternatives and other information when the physician that took the consent.
e. R.R #12 provided evidence that the surgical procedure consent form did not include the risks, benefits, the date and the hour when the physician that took the consent.

Based on follow up visit, documents reviewed with the Operating Room Manager (employee #12), it was determined that the facility failed to ensure that the operating room log registry is complete.

Deficiencies Not Corrected

Findings include:

A surgery registration log book was observed on 11/09/11 at 10:00 am. with incomplete spaces and spaces in blank. The last date registry on the log book was performed in October 28, 2011.

Based on the review of policies and procedures and observations with the supervisor of the Respiratory Therapy Department (employee #11) during the follow up visit, 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 three out of three patient's rooms using respiratory equipment (in patient's rooms #7-146 B, #7-149 and #7-150) and failed to perform policies and procedures related to respiratory therapy needs updating the care plan.

Deficiency Not Corrected

Findings include:

1.During the observational tour on 11/9/11 from 9:00 am with the infection Control officer (employee #8), patient's sleeping rooms #7-146 B, #7-149 and #7-150 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 #7-146 B, #7-149 and #7-150.

2. The Respiratory Therapy Department was visited with the respiratory therapist supervisor (Employee #11) and the space used to disinfect and store clean mechanical ventilators was observed on 11/9/11 at 2:40 pm. 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 three medical records and policies/procedures during the follow up visit, 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 three out of three clinical records reviewed (R.R #3, #6 and #18).

Deficiency Not corrected

Findings include:

1. Three medical records were reviewed on 11/9/11 from 2:00 pm till 3:30 pm and provided evidence that respiratory therapists do not administer respiratory therapy treatment in accordance with the physician's order for three out three records reviewed with respiratory therapy.

a. R.R #3 is a 96 years old female admitted on 10/24/11 with a diagnosis of Diverticulitis and Hyponatremia. The record review was performed on 11/9/11 at 2:20 pm with the Respiratory Therapist Supervisor (employee #11) and provided evidence that the physician ordered on 10/30/11 at 4:00 pm Albuterol 0.3 ml/ 3 ml NSS by power nebulizer (PN) every 4 hours. The Respiratory therapy medication sheet from 11/01/11 provide evidence that the treatment was administered at 8:50 am, however no evidence was found of the next dose until 4:00 pm (seven hour later). On 11/2/11 the treatment was administered at 4:00 am then at 9:30 am (one hour a half (1.5) later. On 11/2/11 at 1:00 pm the physician ordered Albuterol 0.5 ml / 3ml NSS every 4 hour. However, evidence was found that the patient received treatment on 11/2/11 at 7:10 pm with Albuterol 0.3 ml the next treatment was administered on 11/3/11 at 1:20 am (2 hour 10 minute later). On 11/4/11 the respiratory therapy medication sheet provide evidence that the treatment was administered at 9:28 am then at 4:00 pm (2 hour 30 minute later). On 11/5/11 the respiratory therapy medication sheet provide evidence that the treatment was administered at 4:00 pm, at 8:00 pm without a physician order. The physician reordered respiratory therapy treatment on 11/6/11 at 1:00 pm and the respiratory therapy medication sheet provides evidence that the treatment was administered on 11/7/11 at 1:10 am 12 hour after the physician ordered the treatment.


b. R.R #6 is a 68 years old male admitted on 11/4/11 with a diagnosis of pneumonia. The record review was performed on 11/9/11 at 3:00 pm with the Respiratory Therapist Supervisor (employee #8) and provided evidence that the physician ordered on 11/4/11 at 1:00 pm Albuterol 0.3 ml/ 3 ml NSS by power nebulizer (PN) every 4 hours. The Respiratory therapy medication sheet from 11/6/11 provided evidence that the respiratory treatment was administered at 1:00 pm, however evidence was found that the next treatment was administered on 11/7/11 at 12:55 am 11 hour and 55 minute later. The physician respiratory therapy order was renewed on 11/8/11 at 5:40 pm However the respiratory therapy medication sheet provide evidence that the treatment was administered 11/8/11 at 12:20am, at 4:10 am, at 9:30 am, at 2:20 pm without a physician order.

c. R.R. #18 is a 54 years old female admitted on 10/31/11 with a diagnosis of Urinary Tract Infection (UTI). The record review was performed on 11/9/11 at 3:30 pm with the Respiratory Therapist Supervisor (employee #8) and provided evidence that the physician ordered on 11/3/11 at 3:00 pm Albuterol 0.3 ml/ 3 ml NSS by power nebulizer (PN) every 4 hours and on 11/7/11 at 2:30 pm the physician place an order of Proventyl 0.3 ml/ 3ml every 8 hr. The Respiratory therapy medication sheet from 11/3/11 provided evidence that the respiratory treatment was administered at 5:00 pm, however evidence was found that the next treatment was administered on 11/8/11 at 12:45 am. The facility failed to provide respiratory therapy according to physician order.