HospitalInspections.org

Based on records reviewed (R.R), Do Not Resuscitate (DNR) Policies and Procedures, it was determined that the facility failed to ensure that patients or their representatives formulate advance directive and comply with these directives related to written DNR or "Do Not Intubate" (DNI) orders in accordance to the patient's signed consent for DNR or DNI for 2 out of 8 records reviewed (R.R #40 and #41 ).

Findings include:

According to the facility's policies and procedure related to the DNR or DNI order reviewed on 08/21/2024 at 10:00 AM it states in page #2 items #6, #9 and #12 "The DNR/DNI consent must include the name and signature of the physician who directed the patient and/or family member, guardian, or caretaker. The physician will document the taking of consent and place the medical order in the clinical record. The consent, the order, and the progress note must be signed by the primary physician. The primary physician will document the patient's DNR/DNI status in his or her progress note on a daily basis. The professional nurse will document the DNR/DNI order in the clinical record and activate the corresponding care plan.


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 08/21/2024 from 9:00 AM till 1:00 PM:

1.R.R #40 is a 75-year-old male who was admitted on 08/04/2024 with a diagnosis of Left Lare Pleural Effusion. On 08/21/2024 at 9:47 AM the record was reviewed with the Infection Control Coordinator (employee #20). It was found that the patient's representative signed a DNR consent on 08/14/2024 at 13:47 PM. Evidence was found of the physician's written DNR order on 08/14/2024 at 17:50 PM. There is 4-hour difference from the DNR consent and the DNR order.

No evidence was found in the physician progress note of the justification the DNR/DN and patient or relative orientation.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 AM and the following was found:

a. The nurse failed to identify the patient treatment Kardex that patient have a DNR/DNI order.
b. The nurse failed to document the activation of the plan of care for DNR.
c. On 08/14/2024, the nurse failed to document in the nurse's progress note that patient sign a DNR consent, on 3-11 shift, and 11-7 shift,
d. On 08/15/2024 the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on the three shift (7-3, 3-11, 11-7).
e. On 08/16/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on the 7-3 shift, 3-11 and 11-7 shift.
f. On 08/17/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on three shift (7-3, 3-11, 11-7).
g. On 08/18/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on the 3-11 and 11-7 shift.
h. On 08/19/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on the 7-3 shift, 3-11 and 11-7 shift.
i. On 08/20/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on the 7-3 shift, 3-11 and 11-7 shift.

2. R.R #41 is a 92-year-old female who was admitted on 08/04/2024 with a diagnosis of Enterocolitis. On 08/21/2024 at 11:30 AM the record was reviewed with the Infection Control Coordinator (employee #20). It was found that the patient's representative signed a DNI consent on 08/06/2024 at 6:54 AM. Evidence was found of the physician's written DNI order on 08/13/2024 at 11:05 AM. There is 3 days of difference from the DNR consent and the DNR order.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 11:30 AM and the following was found:

a. The nurse failed to document the activation of the plan of care for DNR.
b. On 08/10/2024, the nurse failed to document in the nurse's progress note and in the flow sheet that patient sign a DNR consent, on 7-3 shift, 3-11 shift, and 11-7 shift,
c. On 08/11/2024, the nurse failed to document in the nurse's progress note and in the flow sheet that patient continues with a DNR order on 11-7 shift.
d. On 08/12/2024, the nurse failed to document in the nurse's progress note and in the flow sheet that patient continues with a DNR order on 11-7 shift.
e. On 08/13/2024, the nurse failed to document in the nurse's progress note and in the flow sheet that patient continues with a DNR order on 3-11 shift.
f. On 08/14/2024, the nurse failed to document in the nurse's progress note and in the flow sheet that patient continues with DNR order 7-3 shift, 3-11 shift, and 11-7 shift,
g. On 08/15/2024 the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on 11-7 shift.
h. On 08/16/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on 3-11 and 11-7 shift.
i. On 08/17/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on 3-11 shift.
j. On 08/18/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on the 11-7 shift.
k. On 08/19/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on the 7-3 shift, 3-11 and 11-7 shift.
l. On 08/20/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on the 7-3 shift, 3-11 and 11-7 shift.

Based on records reviewed (R.R) and review of restrain protocol and policies and procedure with the nurse supervisor (employee #15) and Infection Control Officer (employee #20), it was determined that the facility failed to ensure that restraint be used when less restrictive interventions be ineffective to protect the patient from harm for 1 out of 1patient in restraint. (R.R. #45).

Findings include:

The facility ' s policy and procedure related to Protocol of Patient in Restriction or Seclusion reviewed on 08/21/2024 at 2:00 PM in the part VI state:

Preventive techniques for non-violent or non-self-destructive behavior:
Estimate and attempt to correct possible causes of agitation or confusion. Conditions such as hypoxia, hypoglycemia, acute alcohol or drug intoxication, or brain trauma may present as confusion, combativeness, or agitation.

Promote rest, make adjustments to the temperature, noise, or light in the room. Provide a calm environment. Use simple instructions. Speak in a soothing tone of voice. Avoid using body language. Review medications for possible adverse effects. Place patient near the nursing station. Meet patient needs such as pain, comfort, hydration, or hygiene. Involve family members.

If after implementing the preventive measures mentioned above, there is no positive response, proceed to initiate the restriction protocol based on the behavior presented by the patient: Agitated, hostile, aggressive behavior that endangers the safety of the patient or others. Confused or disoriented patient whose level of agitation or mobility exposes him to harm himself, other people, or property. Attempt to interrupt or discontinue medical treatment.

Management of the patient with non-violent behavior: Initiation of restraint: There must be a written or telephone order, which must be countersigned by the physician within the next 24 hours. When the physician in charge of the patient is not available at the time the need for restraint is determined, the nursing staff in charge initiates the intervention and obtains the order within the first hour. The patient evaluation is performed face to face by the physician in charge of the patient, resident physician, and intern physician. The nursing professional is responsible for educating the family member and documenting it in the medical record.

Monitoring: The nursing professional is responsible for monitoring the restrained patient every two hours. From the beginning of the restraints, evaluations are performed on each shift to identify changes in the patient's behavior that allow the discontinuation of the restraints. Care plans are activated.

Documentation: The beginning of the restraint is documented in the record by the physician in charge or delegate. The medical order has a duration of 24 hours. The medical record includes the following: Alternative methods used before reaching the restriction. Specific description of the behavior or condition that justifies the restriction. Signs or symptoms and diagnosis of the patient upon admission. Results obtained from the security measures applied to the patient with the purpose of maintaining his health, his personal well-being and respecting his dignity. Notification of the use of restriction or seclusion from the physician in charge of the patient. Date and time of the beginning of the restriction. Review of the Care Plan. Results of attempts to discontinue the restriction.

Renewal of the restriction protocol: The renewal of the restriction is documented in the record by the responsible physician or his delegate as well as the inmates. The medical order has a duration of 24 hours. If it is necessary to continue with the restrictions, a new order for the same is issued every 24 hours.

1.R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. According to the record review performed on 08/21/2024 at 1:43 PM with nurse supervisor (employee #15), it was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.

On 08/14/2024 at 17:01 PM the physician ordered Restraint Monitoring every 2 hour.
On 08/15/2024 at 9:38 PM the physician ordered Restraint Monitoring every 2 hour.
On 08/18/2024 at 20:10 PM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.
On 08/19/2024 at 14:26 PM, the physician ordered Restraint Monitoring every 2 hour.
On 08/20/2024 at 5:07AM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.
On 08/21/2024 at 7:29 AM the physician ordered Restraint Initial now, every 8-hour, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.

Evidence was found that the registered Nurse initiate the restraint monitoring on 08/14/2024 at 20:00 PM and continue monitoring every 2 hours, except on 08/16/2024 at 8:55 AM that was performed 2 hour 55 minutes, on 08/17/2024 at 6:00 AM that was performed 3 hours, On 08/18/2024 that was not performed since 2:00 AM until 8:00 AM, on 08/19/2024 since 10:00 AM until 14:00 PM.

The registered nurse (RN) failed to document the sign and symptom or patient behavior before restraint, failed to document the less restrictive interventions or alternative measure before restraint.

The RN progress note lacks documentation that patient was restraint, the reason for restraint, the patient behavior for restraint, physician notification before restraint, mechanism for restrain.

No evidence was found related to physician evaluation face to face before restraint.

No evidence was found related to less restrict measure to be performed before restraint the patient.

a.The facility failed to meet their restraint policy and procedure.
b. The RN failed to document the sign and symptom or patient behavior before restraint.
c. The RN failed to document the less restrictive interventions or alternative measure before restraint.
d. The RN failed to document that physician was notified and evaluate patient before restraint.
e. The RN failed to activate the restraint plan of care.
f. The RN failed to document in the nursing Progress Note and in the nursing flow sheet that patient was in restraint and the patient behavior justification for continue restraint and the constant observation and intervention to the patient in the nursing progress note in each 7-3, 3-11 and 11-7 shift.
g. The RN failed to document in the restraint monitoring sheet the patient assessment on 08/18/2024 at 4:00 AM and at 6:00PM, on 08/19/2024 at 12:00 PM.
h. The RN failed to document the patient, or their relative orientation related to the restraint when started.
i. The RN continue restraint patient without a physician order on 08/15/2024, on 08/16/2024, on 08/17/2024, and on 08/19/2024.
j. The physician on charge of patient failed to perform a comprehensive face to face assessment that justified the use of restraint in the patient.
k. The physician failed to write a new physician order every 24 hours for the continue or renew the restraint order.
l. The Physician failed to document in the progress note the daily justification for continue the restraint.

Based on records reviewed (R.R) and review of restrain protocol and policies and procedure with the nurse supervisor (employee #15) and Infection Control Officer (employee #20), it was determined that the facility failed to ensure that restraint plan of care was activated and reviewed in each nurse shift for 1 out of 1 patient in restraint. (R.R. #45).

Findings include:

The facility' s policy and procedure related to Protocol of Patient in Restriction or Seclusion reviewed on 08/21/2024 at 2:00 PM in the part VI state:

Preventive techniques for non-violent or non-self-destructive behavior:
Estimate and attempt to correct possible causes of agitation or confusion. Conditions such as hypoxia, hypoglycemia, acute alcohol or drug intoxication, or brain trauma may present as confusion, combativeness, or agitation. Promote rest, make adjustments to the temperature, noise, or light in the room. Provide a calm environment. Use simple instructions. Speak in a soothing tone of voice. Avoid using body language. Review medications for possible adverse effects. Place patient near the nursing station. Meet patient needs such as pain, comfort, hydration, or hygiene. Involve family members.

If after implementing the preventive measures mentioned above, there is no positive response, proceed to initiate the restriction protocol based on the behavior presented by the patient: Agitated, hostile, aggressive behavior that endangers the safety of the patient or others. Confused or disoriented patient whose level of agitation or mobility exposes him to harm himself, other people, or property. Attempt to interrupt or discontinue medical treatment.

Management of the patient with non-violent behavior: Initiation of restraint: There must be a written or telephone order, which must be countersigned by the physician within the next 24 hours. When the physician in charge of the patient is not available at the time the need for restraint is determined, the nursing staff in charge initiates the intervention and obtains the order within the first hour. The patient evaluation is performed face to face by the physician in charge of the patient, resident physician, and intern physician. The nursing professional is responsible for educating the family member and documenting it in the medical record.

Monitoring: The nursing professional is responsible for monitoring the restrained patient every two hours. From the beginning of the restraints, evaluations are performed on each shift to identify changes in the patient's behavior that allow the discontinuation of the restraints. Care plans are activated.

Documentation: The beginning of the restraint is documented in the record by the physician in charge or delegate. The medical order has a duration of 24 hours. The medical record includes the following: Alternative methods used before reaching the restriction. Specific description of the behavior or condition that justifies the restriction. Signs or symptoms and diagnosis of the patient upon admission. Results obtained from the security measures applied to the patient with the purpose of maintaining his health, his personal well-being and respecting his dignity. Notification of the use of restriction or seclusion from the physician in charge of the patient. Date and time of the beginning of the restriction. Review of the Care Plan. Results of attempts to discontinue the restriction.

Renewal of the restriction protocol: The renewal of the restriction is documented in the record by the responsible physician or his delegate as well as the inmates. The medical order has a duration of 24 hours. If it is necessary to continue with the restrictions, a new order for the same is issued every 24 hours.

1.R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. According to the record review performed on 08/21/2024 at 1:43 PM with nurse supervisor (employee #15), it was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.

On 08/14/2024 at 17:01 PM the physician ordered Restraint Monitoring every 2 hour.
On 08/15/2024 at 9:38 PM the physician ordered Restraint Monitoring every 2 hour.
On 08/18/2024 at 20:10 PM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.
On 08/19/2024 at 14:26 PM, the physician ordered Restraint Monitoring every 2 hour.

On 08/20/2024 at 5:07 AM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/21/2024 at 7:29 AM the physician ordered Restraint Initial now, every 8-hour, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.

Evidence was found that the registered Nurse initiate the restraint monitoring on 08/14/2024 at 20:00 PM and continue monitoring every 2 hours, except on 08/16/2024 at 8:55 PM that was performed 2 hour 55 minutes, on 08/17/2024 at 6:00 AM that was performed 3 hours, On 08/18/2024 that was not performed since 2:00 AM until 8:00 AM, on 08/19/2024 since 10:00 AM until 14:00 PM.

The registered nurse (RN) failed to document the sign and symptom or patient behavior before restraint, failed to document the less restrictive interventions or alternative measure before restraint.

The RN progress note lacks documentation that patient was restraint, the reason for restraint, the patient behavior for restraint, physician notification before restraint, mechanism for restrain.

No evidence was found related to physician evaluation face to face before restraint.

No evidence was found related to less restrict measure to be performed before restraint the patient.

a. The facility failed to meet their restraint policy and procedure.
b. The RN failed to document the sign and symptom or patient behavior before restraint.
c. The RN failed to document the less restrictive interventions or alternative measure before restraint.
d. The RN failed to document that physician was notified and evaluate patient before restraint.
e. The RN failed to activate the restraint plan of care.
f. The RN failed to document in the nursing Progress Note and in the nursing flow sheet that patient was in restraint and the patient behavior justification for continue restraint and the constant observation and intervention to the patient in the nursing progress note in each 7-3, 3-11 and 11-7 shift.
g. The RN failed to document in the restraint monitoring sheet the patient assessment on 08/18/2024 at 4:00 AM and at 6:00 AM, on 08/19/2024 at 12:00 PM.
h. The RN failed to document the patient, or their relative orientation related to the restraint when started.
i. The RN continue restraint patient without a physician order on 08/15/2024, on 08/16/2024, on 08/17/2024, and on 08/19/2024.
j. The physician on charge of patient failed to perform a comprehensive face to face assessment that justified the use of restraint in the patient.
k. The physician failed to write a new physician order every 24 hours for the continue or renew the restraint order.
l. The Physician failed to document in the progress note the daily justification to continue the restraint.

Based on records reviewed (R.R) and review of restrain protocol and policies and procedure with the nurse supervisor (employee #15) and Infection Control Officer (employee #20), it was determined that the facility failed to ensure that restraint be used in accordance with a physician order for 1 out of 1 patient in restraint. (R.R. #45).

Findings include:

1.R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. According to the record review performed on 08/21/2024 at 1:43 PM with nurse supervisor (employee #15), it was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.

On 08/14/2024 at 17:01 PM the physician ordered Restraint Monitoring every 2 hour.
On 08/15/2024 at 9:38 PM the physician ordered Restraint Monitoring every 2 hour.
On 08/18/2024 at 20:10 PM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.
On 08/19/2024 at 14:26 PM, the physician ordered Restraint Monitoring every 2 hour.
On 08/20/2024 at 5:07 AM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.
On 08/21/2024 at 7:29 AM the physician ordered Restraint Initial now, every 8-hour, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.

Evidence was found that the registered Nurse initiate the restraint monitoring on 08/14/2024 at 20:00 PM and continue monitoring every 2 hours, except on 08/16/2024 at 8:55 AM that was performed 2 hour 55 minutes, on 08/17/2024 at 6:00 AM that was performed 3 hours, on 08/18/2024 that was not performed since 2:00 AM until 8:00 AM, on 08/19/2024 since 10:00 AM until 14:00 PM.

The registered nurse (RN) failed to document the sign and symptom or patient behavior before restraint, failed to document the less restrictive interventions or alternative measure before restraint.

The RN progress note lacks documentation that patient was restraint, the reason for restraint, the patient behavior for restraint, physician notification before restraint, mechanism for restrain.
No evidence was found related to physician evaluation face to face before restraint.
No evidence was found related to less restrict measure to be performed before restraint the patient.

a. The facility failed to meet their restraint policy and procedure.
b. The RN failed to document the sign and symptom or patient behavior before restraint.
c. The RN failed to document the less restrictive interventions or alternative measure before restraint.
d. The RN failed to document that physician was notified and evaluate patient before restraint.
e. The RN failed to activate the restraint plan of care.
f. The RN failed to document in the nursing Progress Note and in the nursing flow sheet that patient was in restraint and the patient behavior justification for continue restraint and the constant observation and intervention to the patient in the nursing progress note in each 7-3, 3-11 and 11-7 shift.
g. The RN failed to document in the restraint monitoring sheet the patient assessment on 08/18/2024 at 4:00 AM and at 6:00 AM, on 08/19/2024 at 12:00 PM.
h. The RN failed to document the patient, or their relative orientation related to the restraint when started.
i. The RN continue restraint patient without a physician order on 08/15/2024, on 08/16/2024, on 08/17/2024, and on 08/19/2024.
j. The physician on charge of patient failed to perform a comprehensive face to face assessment that justified the use of restraint in the patient.
k. The physician failed to write a new physician order every 24 hours for the continue or renew the restraint order.
l. The Physician failed to document in the progress note the daily justification for continue the restraint.

Based on records reviewed (R.R) and review of restrain protocol and policies and procedure with the nurse supervisor (employee #15) and Infection Control Officer (employee #20), it was determined that the facility failed to ensure that restraint order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy for 1 out of 1 patient in restraint. (R.R. #45).

Findings include:

The facility ' s policy and procedure related to Protocol of Patient in Restriction or Seclusion reviewed on 08/21/2024 at 2:00 PM in the part VI state:

Preventive techniques for non-violent or non-self-destructive behavior:
Estimate and attempt to correct possible causes of agitation or confusion. Conditions such as hypoxia, hypoglycemia, acute alcohol or drug intoxication, or brain trauma may present as confusion, combativeness, or agitation. Promote rest, make adjustments to the temperature, noise, or light in the room. Provide a calm environment. Use simple instructions. Speak in a soothing tone of voice. Avoid using body language. Review medications for possible adverse effects. Place patient near the nursing station. Meet patient needs such as pain, comfort, hydration, or hygiene. Involve family members.

If after implementing the preventive measures mentioned above, there is no positive response, proceed to initiate the restriction protocol based on the behavior presented by the patient: Agitated, hostile, aggressive behavior that endangers the safety of the patient or others. Confused or disoriented patient whose level of agitation or mobility exposes him to harm himself, other people, or property. Attempt to interrupt or discontinue medical treatment.

Management of the patient with non-violent behavior: Initiation of restraint: There must be a written or telephone order, which must be countersigned by the physician within the next 24 hours. When the physician in charge of the patient is not available at the time the need for restraint is determined, the nursing staff in charge initiates the intervention and obtains the order within the first hour. The patient evaluation is performed face to face by the physician in charge of the patient, resident physician, and intern physician. The nursing professional is responsible for educating the family member and documenting it in the medical record.

Monitoring: The nursing professional is responsible for monitoring the restrained patient every two hours. From the beginning of the restraints, evaluations are performed on each shift to identify changes in the patient's behavior that allow the discontinuation of the restraints. Care plans are activated.

Documentation: The beginning of the restraint is documented in the record by the physician in charge or delegate. The medical order has a duration of 24 hours. The medical record includes the following: Alternative methods used before reaching the restriction. Specific description of the behavior or condition that justifies the restriction. Signs or symptoms and diagnosis of the patient upon admission. Results obtained from the security measures applied to the patient with the purpose of maintaining his health, his personal well-being and respecting his dignity. Notification of the use of restriction or seclusion from the physician in charge of the patient. Date and time of the beginning of the restriction. Review of the Care Plan. Results of attempts to discontinue the restriction.

Renewal of the restriction protocol: The renewal of the restriction is documented in the record by the responsible physician or his delegate as well as the inmates. The medical order has a duration of 24 hours. If it is necessary to continue with the restrictions, a new order for the same is issued every 24 hours.


1.R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. According to the record review performed on 08/21/2024 at 1:43 PM with nurse supervisor (employee #15), it was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.
On 08/14/2024 at 17:01 PM the physician ordered Restraint Monitoring every 2 hour.
On 08/15/2024 at 9:38 PM the physician ordered Restraint Monitoring every 2 hour.
On 08/18/2024 at 20:10 PM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.
On 08/19/2024 at 14:26 PM, the physician ordered Restraint Monitoring every 2 hour.
On 08/20/2024 at 5:07 AM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/21/2024 at 7:29 AM the physician ordered Restraint Initial now, every 8-hour, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity.

Evidence was found that the registered Nurse initiate the restraint monitoring on 08/14/2024 at 20:00 PM and continue monitoring every 2 hours, except on 08/16/2024 at 8:55 AM that was performed 2 hour 55 minutes, on 08/17/2024 at 6:00 AM that was performed 3 hours, on 08/18/2024 that was not performed since 2:00 AM until 8:00 AM, on 08/19/2024 since 10:00 AM until 14:00 PM.

The registered nurse (RN) failed to document the sign and symptom or patient behavior before restraint, failed to document the less restrictive interventions or alternative measure before restraint.

The RN progress note lacks documentation that patient was restraint, the reason for restraint, the patient behavior for restraint, physician notification before restraint, mechanism for restrain.
No evidence was found related to physician evaluation face to face before restraint.
No evidence was found related to less restrict measure to be performed before restraint the patient.

a. The facility failed to meet their restraint policy and procedure.
b. The RN failed to document the sign and symptom or patient behavior before restraint.
c. The RN failed to document the less restrictive interventions or alternative measure before restraint.
d. The RN failed to document that physician was notified and evaluate patient before restraint.
e. The RN failed to activate the restraint plan of care.
f. The RN failed to document in the nursing Progress Note and in the nursing flow sheet that patient was in restraint and the patient behavior justification for continue restraint and the constant observation and intervention to the patient in the nursing progress note in each 7-3, 3-11 and 11-7 shift.
g. The RN failed to document in the restraint monitoring sheet the patient assessment on 08/18/2024 at 4:00 AM and at 6:00 AM, on 08/19/2024 at 12:00 PM.
h. The RN failed to document the patient, or their relative orientation related to the restraint when started.
i. The RN continue restraint patient without a physician order on 08/15/2024, on 08/16/2024, on 08/17/2024, and on 08/19/2024.
j. The physician on charge of patient failed to perform a comprehensive face to face assessment that justified the use of restraint in the patient.
k. The physician failed to write a new physician order every 24 hours for the continue or renew the restraint order.
l. The Physician failed to document in the progress note the daily justification for continue the restraint.

Based on thirteen medical record review for Isolation, DNR and restraint with the Infection Control Officer (employee #20), Nurse supervisor (employee #13, #14, #15), it was determined that the facility failed to ensure that the nursing staff develops, and keeps current, nursing care plans for each patient for 13 out of 13 medical records review with respect to the nursing plan of care component for isolation, restraint and DNR. (RR #33, RR #34, #35. #36, #37. #38. #39, #40, #41, #42, #443, #44, and #45).

Findings include:

1. R.R #33 is an 82-year-old male who was admitted on 08/16/2024 with a diagnosis of Congestive Heart Failure (CHF) and High Blood Pressure (HBP). On 08/20/2024 at 11:30 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered on 08/19/2024 at 14:03 PM Isolation Precaution for Klebsiella in urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan.

2. R.R #34 is a 74-year-old female who was admitted on 08/15/2024 with a diagnosis of Pneumonia, and Urine Tract Infection (UTI). On 08/20/2024 at 11:35 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered Contact Isolation on 08/19/2024 at 8:30 AM for Klebsiella Pneumonia and Schizophrenia Coli in gastrostomy and in urine.

However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient's representative signed a Do Not Resuscitate (DNR) consent on 08/16/2024 at 12:41 AM. Evidence was found of the physician's written DNR order on 08/16/2024 at 12:45 AM.

However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan.

3. R.R #35 is a 61-year-old female who was admitted on 08/09/2024 with a diagnosis of Lung Cancer with Metastasis. On 08/20/2024 at 1:30 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14.
It was found that the physician ordered on 08/09/2024 at 2:43 PM Protective Isolation due to Immunocompromise status of the patient. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan.

4. R.R #36 is a 92-year-old female who was admitted on 08/04/2024 with a diagnosis of Enterocolitis. On 08/20/2024 at 2:47 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 08/04/2024 at 12:23 PM Contact Isolation due to Clostridium Difficile.

However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient's representative signed a Do Not Intubate (DNI) consent on 08/16/2024 at 10:20 AM. Evidence was found of the physician's written DNI order on 08/16/2024 at 8:19 AM. However, no evidence was found that the Registered Nurse (RN) activate the DNI Care Plan.

5. R.R #37 is a 65-year-old male who was admitted on 07/26/2024 with a diagnosis of Sepsis. On 08/202024 at 3:00 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 07/29/2024 at 12:03 PM Isolation due to Klebsiella Pneumonia, Pseudomonas Aeruginosa in ulcer culture.
However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient's representative signed a DNR consent on 08/08/2024. Evidence was found of the physician's written DNR order on 08/08/2024 at 15:21 PM.
However, no evidence was found that the Registered Nurse (RN) activate the DNR Care Plan.

6. R.R #38 is a 35-year-old female who was admitted on 08/09/2024 with a diagnosis of Matrix Cancer. On 08/20/2024 at 3:30 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 08/09/2024 at 1:00 PM Protective Isolation. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan.

7. R.R #39 is a 79-year-old male who was admitted on 07/11/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). On 08/21/2024 at 8:44 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14.
It was found that the physician ordered on 07/19/2024 at 14:05 PM Isolation due to Pseudomonas Aeruginosa and Candida Albica in Urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan.

8. R.R #40 is a 75-year-old male who was admitted on 08/04/2024 with a diagnosis of Left Lare Pleural Effusion. On 08/21/2024 at 9:47 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the patient's representative signed a DNR consent on 08/14/2024 at 13:47 PM. Evidence was found of the physician's written DNR order on 08/14/2024 at 17:50 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan.

9. R.R #41 is a 92-year-old female who was admitted on 08/04/2024 with a diagnosis of Enterocolitis. On 08/21/2024 at 11:30 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the patient's representative signed a Do Not Intubate (DNI) consent on 08/06/2024 at 6:54 AM. Evidence was found of the physician's written DNI order on 08/13/2024 at 11:05 AM. However, no evidence was found that the Registered Nurse (RN) activate the DNI Care Plan.

10. R.R #42 is a 44-year-old female who was admitted on 08/13/2024 with a diagnosis of Covid 19. On 08/21/2024 at 10:44 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 08/13/2024 at 20:47 PM Droplet Isolation due to Covid. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan.

11. R.R #43 is a 72-year-old male who was admitted on 06/27/2024 with a diagnosis of Pleural Effusion and CHF. On 08/21/2024 at 10:09 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the patient's representative signed a DNR consent on 06/28/2024 at 2:34 PM. Evidence was found of the physician's written DNR order on 06/28/2024 at 14:38 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan.

12. R.R #44 is a 90-year-old male who was admitted on 08/17/2024 with a diagnosis of Altered Mental Status. On 08/217/2024 at 3:12 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #13. It was found that the patient's representative signed a DNR consent on 08/17/2024 at 12:52 PM. Evidence was found of the physician's written DNR order on 08/17/2024 at 12:05 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan.

13. R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. On 08/21/2024 at 1:43 PM the record was reviewed with the Infection Control Coordinator (employee #20) and with nurse supervisor (employee #13). It was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. The RN initiate the restraint monitoring on 08/14/2024 at 20:00 PM. However, no evidence was found that the Registered Nurse (RN) activate the Restrain Care Plan.

Based on thirteen medical records reviewed (R.R) for Isolation, DNR and restraint with the Infection Control Officer (employee #20), Nurse supervisor (employee #13, #14, #15), it was determined that the facility failed to ensure medical record be complete, dated, in writing or electronic form by the person responsible for service provided for 13 out of 13 records reviewed. (RR#33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44 and #45)

Findings include:

1. R.R #33 is an 82-year-old male who was admitted on 08/16/2024 with a diagnosis of Congestive Heart Failure (CHF) and High Blood Pressure (HBP). On 08/20/2024 at 11:30 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered on 08/19/2024 at 14:03 PM Isolation Precaution for Klebsiella in urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:30 AM and the following was found:

a. The nurse failed to document the activation of the isolation Care Plan.
b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution
c. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with Isolation.

2. R.R #34 is a 74-year-old female who was admitted on 08/15/2024 with a diagnosis of Pneumonia, and Urine Tract Infection (UTI). On 08/20/2024 at 11:35 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered Contact Isolation on 08/19/2024 at 8:30 AM for Klebsiella Pneumonia and Schizophrenia Coli in gastrostomy and in urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient's representative signed a Do Not Resuscitate (DNR) consent on 08/16/2024 at 12:41 AM. Evidence was found of the physician's written DNR order on 08/16/2024 at 12:45 AM.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:35 AM and the following was found:

a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan.
b. The nurse failed to document the activation of the isolation Care Plan.
c. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution
d. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR.
e. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR.
f. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order and Isolation.

3. R.R #35 is a 61-year-old female who was admitted on 08/09/2024 with a diagnosis of Lung Cancer with Metastasis. On 08/20/2024 at 1:30 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered on 08/09/2024 at 2:43 PM., Protective Isolation due to Immunocompromise status of the patient. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 1:30 PM and the following was found:

a. The nurse failed to document the activation of the isolation Care Plan.
b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution
c. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with Isolation.

4. R.R #36 is a 92-year-old female who was admitted on 08/04/2024 with a diagnosis of Enterocolitis. On 08/20/2024 at 2:47 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor (employee #15). It was found that the physician ordered on 08/04/2024 at 12:23 PM Contact Isolation due to Clostridium Difficile. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient's representative signed a Do Not Intubate (DNI) consent on 08/16/2024 at 10:20 AM. Evidence was found of the physician's written DNI order on 08/16/2024 at 8:19 AM. However, no evidence was found that the Registered Nurse (RN) activate the DNI Care Plan.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:35 AM and the following was found:

a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan.
b. The nurse failed to document the activation of the isolation Care Plan.
c. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution
d. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR.
e. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR.
f. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order and Isolation

5. R.R #37 is a 65-year-old male who was admitted on 07/26/2024 with a diagnosis of Sepsis. On 08/202024 at 3:00 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 07/29/2024 at 12:03 PM Isolation due to Klebsiella Pneumonia, Pseudomonas Aeruginosa in ulcer culture. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient's representative signed a DNR consent on 08/08/2024. Evidence was found of the physician's written DNR order on 08/08/2024 at 15:21 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR Care Plan.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:35 AM and the following was found:

a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan.
b. The nurse failed to document the activation of the isolation Care Plan.
c. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution.
d. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR.
e. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR.
f. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order and Isolation

6. R.R #38 is a 35-year-old female who was admitted on 08/09/2024 with a diagnosis of Matrix Cancer. On 08/20/2024 at 3:30 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 08/09/2024 at 1:00 PM, Protective Isolation. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:35 AM and the following was found:

a. The nurse failed to document the activation of the isolation Care Plan.
b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution.
c. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with Isolation.

7. R.R #39 is a 79-year-old male who was admitted on 07/11/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). On 08/21/2024 at 8:44 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee (#14). It was found that the physician ordered on 07/19/2024 at 14:05 PM Isolation due to Pseudomonas Aeruginosa and Candida Albica in Urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:35 AM and the following was found:
a. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution.
b. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with Isolation

8. R.R #40 is a 75-year-old male who was admitted on 08/04/2024 with a diagnosis of Left Lare Pleural Effusion. On 08/21/2024 at 9:47AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the patient's representative signed a DNR consent on 08/14/2024 at 13:47 PM. Evidence was found of the physician's written DNR order on 08/14/2024 at 17:50 PM.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 AM and the following was found:

a. The nurse failed to identify the patient treatment Kardex that patient have a DNR/DNI order.
b. The nurse failed to document the activation of the DNR (Dead Process) Care Plan.
c. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR.
d. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR.
f. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order.

9. R.R #41 is a 92-year-old female who was admitted on 08/04/2024 with a diagnosis of Enterocolitis. On 08/21/2024 at 11:30 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the patient's representative signed a Do Not Intubate (DNI) consent on 08/06/2024 at 6:54 AM. Evidence was found of the physician's written DNI order on 08/13/2024 at 11:05 AM.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 Am and the following was found:

a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan.
b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR.
c. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR.
d. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order.

10. R.R #42 is a 44-year-old female who was admitted on 08/13/2024 with a diagnosis of Covid 19. On 08/21/2024 at 10:449 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 08/13/2024 at 20:47 PM, Droplet Isolation due to Covid. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:30 AM and the following was found:

a. The nurse failed to document the activation of the isolation Care Plan.
b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution.
c. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with Isolation.

11. R.R #43 is a 72-year-old male who was admitted on 06/27/2024 with a diagnosis of Pleural Effusion and CHF. On 08/21/2024 at 10:09 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the patient's representative signed a DNR consent on 06/28/2024 at 2:34 PM. Evidence was found of the physician's written DNR order on 06/28/2024 at 14:38 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 AM and the following was found:

a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan.
b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR.
c. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR.
d. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order.

12. R.R #44 is a 90-year-old male who was admitted on 08/17/2024 with a diagnosis of Altered Mental Status. On 08/217/2024 at 3:12 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #13. It was found that the patient's representative signed a DNR consent on 08/17/2024 at 12:52 PM. Evidence was found of the physician's written DNR order on 08/17/2024 at 12:05 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 AM and the following was found:

a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan.
b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR.
c. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR.
d. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order.

13. R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. On 08/21/2024 at 1:43 PM the record was reviewed with the Infection Control Coordinator (employee #20) and with nurse supervisor (employee #13). It was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. The RN initiate the restraint monitoring on 08/14/2024 at 20:00 PM. However, no evidence was found that the Registered Nurse (RN) activate the Restrain Care Plan.

Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 AM and the following was found:

a. The nurse failed to document the activation of the Restraint Care Plan.
b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the Restraint.
c. No evidence was found documented in the physician progress the face-to-face comprehensive assessment that justify the restraint order
d. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with restraint order.

Base on observation tour with the Infection Contro Officer employee #20, it was determined that the facility failed failed to ensure that all drug and biological be kept in a secure area and locked.

Finding include:

During the initial tour with the Infection Contro Officer employee #20 in the 8th floor, 7th floor, 6th floor and 5th floor on 08/20/2024 and 08/21/2024 from 9:00 AM till 3:00 PM, it was observed the following

1. The medication room door was unlocked in the 8th floor, 7th floor, 6th floor and 5th floor.
2. Over the crash cart of the 8th floor, 7th floor, 6th floor and 5th floor was observed a tray of crash cart drower with medication used if two patient was in arrest without security.

Based on observational tour and interview with the Radiology Supervisor (employee #4) and Director of Nursing (DON) (employee #1), it was identified that facility failed to ensure the area is equipped with all required emergency ancillary equipment required in the event of an emergency.

Findings include:

1. During observational tour at the radiology department on 08/21/2024 at 2:00 PM it was informed by the Radiology Supervisor (employee #4) that they perform diagnostic procedures to pediatric patients. Radiology Supervisor (employee #4) stated that the department perform approximately 13 cases every month.

2. When asked to the Radiology Supervisor (employee #4) on 8/21/2024 at 2:20 PM if they had a pediatric emergency crash cart at this area, she said that they do not have a pediatric emergency crash cart in the area because when pediatric cases went to the area hospital pediatric healthcare personnel who transport the patient accompanied and stay at bedside with the patient and they bring an emergency case where there is all the equipment that they were going to need in an event of an emergency.

3. Radiology Supervisor (employee #4) and DON (employee #1) on 8/21/2024 at 2:50 PM stated that they understand that it is necessary to have available a pediatric emergency crash cart stocked with emergency medical equipment, supplies and drugs needed in the event of an emergency.

DON (employee #1) stated on interview on 8/21/2024 at 3:15 PM that having their own pediatric emergency crash cart on this area, this allows facility to be responsible for this crash cart content and equipment. DON also stated on interview on 8/21/2024 at 3:25 PM that nursing department had a nurse assigned to radiology department that is going to be the person in charge of this responsibility along by the pharmacy personnel department.

Based on the observational tour of the facility's kitchen that prepares the patient's meals, review of menus, policies/procedures and interview, it was determined that the facility failed to maintain entry and exit doors in good condition, stainless steel tables in good condition, meat walking freezer and refrigerator in good condition, chemicals and disinfectants used labeled indicating contents and percent of dilution, ceiling tiles free of humidity, appliances in good condition, walls and floors clean and in good condition, bathroom ceilings areas free of humidity and housekeeping areas in good condition.

Findings include:

1. The following was found during the observational tour of the kitchen service with and administrative dietitian (employee #3) of the hospital on 08/20/2024 from 9:30 AM till 11:50 AM:

a. Two doors located at the diet department (one for the staff entrance and the other where tray carts and provisions and merchandise is received) were observed with peeling paint in need of cleaning and maintenance.

b. At the room assigned for meat handling and storage two stainless steel tables used to cut meat products and defrosts meat were observed deteriorated with corrosion rust and stains.

c. A food processor was observed store on one of the tables located at the room assigned for meat handling, this appliance is observed corroded. It was asked to the administrative dietitian (employee #3) on 08/20/2024 from 9:35 AM if this appliance is in use, and she stated that this appliance is not use and can be taken out the area. Facility failed to ensure that kitchen environment is free of unnecessary items.

d. Walking freezer and refrigerator used to storage meat was observed with rust on the floor and on areas at the entrance door and on the areas where this appliance is embedded.

e. A chemical store in a bottle with spray dispenser without a label who indicate the content, percent of dilution and the date when it was prepared was observed located in a table at the room assigned for meat handling and storage.

Administrative dietitian (employee #3) stated on interview on 08/20/2024 from 9:55 AM that the chemical that this bottle contains is Arrex a chemical use for sanitizing and disinfect.

f. A bottle dispenser with a pink solution inside without a label who indicate the content, percent of dilution and the date when it was prepared was observed located in a table at the room assigned for meat handling and storage.

Administrative dietitian (employee #3) stated on interview on 08/20/2024 from 9:59 AM that the liquid that this bottle contains is soap.

g. At the room assigned for vegetable handling and storage it was observed black mold on two ceiling tiles located at the entrance of the walking refrigerator where vegetables are store.
h. An ice machine was observed located on the kitchen production area; the legs of the ice machine were observed corroded with rust.

i. A corner of a wall in the hallway used to transport food tray carts and receive provisions and merchandise, were observed broken with pieces of ceramic tiles hanging, a metal cover was located on this corner to protect the ceramic tiles that was observed dented and loose.

j. The floor of the hallway area located in the area of the door where the kitchen staff enter to the kitchen is observed in need of cleaning.

k. Ceiling tiles located in the toilet cubicle of the kitchen women bathroom were observed with damp appearance and full of black mold. Two additional ceiling tiles located in the kitchen women bathroom were observed with damp appearance and brown spots.

l. In the kitchen housekeeping room was observed a hole on the ceiling where the acoustic tile was located. It was informed by the administrative dietitian (employee #3) on 08/20/2024 from 10:59 AM that she notifies environmental maintenance department that there is a leak in this area on 07/10/2024. She said that environmental maintenance department inform her that there is a broken pipe that cause the leak and that they need to fix first the broken pipe and then proceed to replace the ceiling tile.

m. A floor cleaning bucket located in the kitchen housekeeping room was observed with a lot of rust on the handle, springs and other metal components of the bucket. In this area a floor mop is storage with the head up instead of on a down position. Keep floor mop with the head up when not in use, promotes that waste that could be accumulated on the head of the mop pass to the mop pole and be contact with housekeeping personnel hands and gloves.


47384


n. During the visual inspection of the kitchen on 08/20/2024 to from 9:00 AM through 9:45 AM and staff interview it was noticed that 3 compartment sink was not prepared as sanitation regulations require. It was observed that the staff working the sink did not have knowledge of the temperatures required in the different sinks' compartments. In turn, it was requested that the concentration of sanitizer be taken on the third compartment and the concentration measurement read 600 ppm and the requirement is 200 ppm. Overuse of the sanitizing agent could be harmful.

The facility does not have written policies regarding the use of the three-compartment sink.

Tests to equipment, interviews and observations made during the survey for Life Safety from fire with a facility Engineering Director (employee #24), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101 and an Immediate Jeopardy was identified.



Based on a recertification survey, observation with emergency Engineering Director (employee #24) and Safety Officer (employee #22), on 08/22/2024 at 11:45 AM it was determined that the facility failed to prevent patients from harm. This constitutes an Immediate Jeopardy to 71 out of 154 patients admitted at the facility.


IJ began: 08/22/2024 at 11:45 AM through 2:30 PM

Facility Notified: 08/22/2024 at 2:42 PM IJ template provided to the facility.

Removal Plan Received: 03/20/2024 at 6:30 PM

Accepted by surveyor: 08/22/2024 at 6:40 PM

Based on tests to equipment, interviews and observations made during the survey for Life Safety from fire with a facility Engineering Director (employee #24), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed from 08/20/2024 through 08/22/2024 from 8:00 AM till 4:00 PM with the facility Engineer (employee #24); for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form (K0223, K0291, K0293, K0324, K0345, K0363, K0751, K0791, K911 and K0923).

Based on observations made during the physical environment survey with the Operating Room Manager (employee #6) and Associate Director of Nursing (employee #26), it was determined that the structure of this facility was not maintained to protect and safeguard supplies and equipment to ensure safety.

Findings include:

1. During the tour made in the holding area on 08/20/2024 at 9:20 AM through 4:00 PM, the following was found:

a. On 08/20/2024 at 9:33 AM, six expired #6 suction catheters were observed in the surgical cabinet 06/15/2024.

2. During the tour made in recovery area on 08/20/2024 at 9:20 AM through 4:00 PM, the following was found:

a. On 08/20/2024 at 9:41 AM, a metal table with stains was observed in cubicle #1.

b. On 08/20/2024 at 9:50 AM, a lack of paint on the walls was observed in the isolation room.

c. On 08/20/2024 at 10:10 AM, a stained acoustics, broken window operator, chipped door frame area, stained window frame area and lack of paint were observed in cubicle #10.

d. On 08/20/2024 at 10:25 AM, a chipped door frame area, stained acoustics, and stained metal table were observed in cubicle #11 and #12.

e. On 08/20/2024 at 10:35 AM, a broken window operator and stained window frame area were observed in cubicle #13 and #14.

3. During the tour made in recovery phase II area on 08/20/2024 at 9:20 AM through 4:00 PM, the following was found:

a. On 08/20/2024 at 10:51 AM, a stained acoustic was observed.

4. During the tour made in the crash cart located in the hallway between the waiting and recovery area on 08/20/2024 from 9:20 AM to 4:00 PM the following was found:

a. On 08/20/2024 at 11:02 AM, one #16 nasogastric tube and two #10 suction tubes were noted to expire on 10/10/2023.

b. On 08/20/2024 at 11:03 AM, seven expired #6 suction probes were observed 06/15/2024.

5. During the tour made operating room area on 08/20/2024 from 9:20 AM to 4:00 PM the following was found:

a. On 08/20/2024 at 11:04 AM, the air duct was observed in room #1 with dust and fourteen 2-0 Prolene sutures (18" 45cm) that expired on 06/30/2024.

b. On 08/20/2024 at 1:49 PM, a surgical cabinet without a handle on the door was observed in room #7.

c. On 08/20/2024 at 2:56 PM, two ceiling lights were observed, one with no metal with dust and the other detached with dust, crack was also found in the ceiling of room #3.

d. On 08/20/2024 at 3:24 PM, surgical sink with stains was observed between rooms #3 and #4.

6. During the tour made at the instrument washing room area on 08/20/2024 from 9:20 AM to 4:00 PM the following was found:

a. On 08/20/2024 at 11:14 AM, an air duct with dust, a stained floor and malfunctions were observed when opening and closing the door.

b. On 08/20/2024 at 11:27 AM, two 0.45% sodium chloride 1000 ml and six 1.5% glycine irrigation ups 3000 ml were observed expired 06/2024.

7. During the tour made at the emergency room area on 08/21/2024 from 9:20 AM to 4:00 PM the following was found:

a. On 08/21/2024 at 9:45 AM, the temperature and relative humidity record was observed in the altered medicine room from January to July 2024.

i. Appropriate temperature value 70°F - 75°F

January 51.0- 68.2
February 66.0- 67.8
March 64.9- 69.1
April 65.0- 69.1
May 67.0- 69.6
June 66.2- 69.4
July 67.1- 69.8

ii. Appropriate humidity value 30% - 60%

January 61.0%-69.1%
February 72%-61.1%
March 74%-63%
April 74%-64%
May 73%-61%
June 69%-61%
July 72-61%

b. On 08/21/2024 at 1:38 PM, it is observed that the nursing staff they did not carry out the high and low control levels, cleaning of the glucometer and staff signature.

iii. Cleaning and disinfection not carried out in the following days:

January 31, 2024
March 22, 2024
March 23, 2024

iv. Control solution tests every 12 hours daily at 7:00AM and 7:00PM

Triage:
July 9, 2024- signature missing
July 11, 2024- signature missing
July 14, 2024- 7:00PM missing
July 25, 2024- 7:00PM missing
August 7, 2024- 7:00PM missing
August 16, 2024- 7:00PM mssing
August 18, 2024- 7:00 PM missing

Emergency Room:
July 14, 2024- 7:00PM missing
July 15, 2024- signature missing
July 17, 2024- signature missing
July 20, 2024- signature missing
July 23, 2024- 7:00PM missing
August 10, 2024- 7:00PM missing

Anexo 3:
July 18, 2024- 7:00AM and 7:00PM missing
July 24, 2024- 7:00PM missing
July 26, 2024- 7:00PM missing

Based on the observational tour with the operating room supervisor (employee #6), associate director of nursing (employee # 26) and emergency room supervisor (employee#7) interview, it was determined that the facility failed to provide standards for infection control related to adequate infection control standards at the surgery ward, ambulatory ward and emergency ward.

Findings include:

1. During the observational tour with the operation room supervisor (employee #6) on 08/20/2024 through 08/22/2024 at 9:00AM to 4:00PM, to the medicine ward, and ambulatory ward the following was found:

a. On 08/20/2024 at 9:27AM, observed unlabeled primary and secondary lines in holding area in cubicles #1, #2, #3, #4.

b. On 08/20/2024 at 3:20PM, a nurse anesthetist (employee #12) in room #4 was observed putting on gloves on two occasions without washing her hands.

c. On 08/21/2024 at 2:16PM, it was observed in outpatient surgery room #3 that a nurse anesthetist (employee #11) was administering intravenous medication without wearing gloves.

d. On 08/22/2024 at 8:44AM, an unidentified open vial of Valium 50 mg/10 ml was observed.

e. On 08/22/2024 at 8:52AM, nursing staff of emergency room (employee #8), (employee #9) and (employee #10) observed gel nails in accordance with policies/procedures and administrative order #284.

Based on observational tour, at the radiology and nuclear medicine department, the 8th floor, 7th floor, 6th floor and 5th floor on 08/20/2024 throught 08/21/2024 from 9:50 PM through 4:00 PM, it was determined that the facility fail to include methods for preventing and control the transmission of infections, including maintaining clean and sanitary environment within those hospital areas.

Findings include:

1. During observational tour at the ambulatory radiology and nuclear medicine area the following was observed:

a. Eight wooden chairs located at the waiting room inside the department were observed with the fabric upholstery torn and worn.

b. The mattress of a stretcher located in the area where nuclear medicine procedures were performed is observed torn, worn and broken.

c. A wooden counter located near the area where sonographic procedures were performed is observed overawed with items to be used during procedures, with broken Formica, uneven out of square with open doors.

2. During observational tour at the hospital ambulatory radiology area the following was observed:

a. The floor of the room where the CT scanner is located was observed worn out, with dark spots, scratches, with scuffs in areas where there is most traffic.

b. Housekeeping room located inside of the hospital ambulatory radiology area was observed with a lot of rust on the Cross Tee of the ceiling tiles. In this area 2 floor mops were storage with the head up instead of on a down position. Keep floor mops with the head up when not in use, promote that waste that could be accumulated on the head of the mop pass to the mop pole and be contact with housekeeping personnel hands and gloves.


47632


3. During the tour made in the holding area with the Operating Room Manager (employee #6) and associate director of nursing (employee #26) on 08/20/2024 at 9:20 AM through 4:00 PM, the following was found:

a. On 08/20/2024 at 9:33AM, four prepared 9nss sodium chloride serums were observed next to a sharp container.

4. During the tour made in recovery area on 08/20/2024 at 9:20 AM through 4:00 PM, the following was found:

a. On 08/20/2024 at 9:40AM, in the isolation room, a compression stocking machine was observed placed on the floor and a humidifier (Vyaire) empty in the sink.

b. On 08/20/2024 at 10:10AM, window operator observed with dust in cubicle #10.

c. On 08/20/2024 at 10:35AM, observed an empty humidifier (Vyaire) in the sink.

5. During the tour made to the emergency room area on 08/20/2024 through 08/21/2024 from 9:20 AM to 4:00 PM the following was found:

a. On 08/20/2024 at 3:10PM, cables from electrocardiograph machines were observed on the floor of the triage area.

6. During the tour made operating room area on 08/20/2024 from 9:20 AM to 4:00 PM the following was found:

a. On 08/20/2024 at 11:04 AM, the air duct was observed in room #1 with dust.

b. On 08/20/2024 at 2:56 PM, two ceiling lamps were observed, one without metal with dust and the other detached with dust in room #3.


20423


7. During observation tour on the 8th floor, it was observed the following:

a. Nasal canula catheter was observed place in the oxygen meter, room 801 A.
b. The corrugate air hose of the Bi pap was observed unlabeled room 803A.
c. The bed rail was observed with peeling paint room 803A, 808B.
d. The bathroom was observed with broken tile in the shower, room 803.
e. The room walls was observed with waste the double-sided tape room 803, 806.
f. The room walls near the sharp container was observed with hole room and peeling paint 804
g. The room walls was observed with peeling paint, room 804, 806, 807, 808, 809, 810, 811, 812.
h. Nasal canula catheter was observed tied to the bed rail, room 805.
i. Urinal was observed direct in the floor, room 805.
j. Nightstand was observed with broken Formica, room 806.
k. Bedside light cord tied with a piece of blue cloth room 806.
l. The rooms door was observed with peeling paint room 806, 811.
m. The bathroom door was observed with peeling paint room 807.
n. Acoustic with humidity room 807.
o. Broken plug in the wall of room 810.
p. Cleaning cart, with cleaning products in front of the housekeeping room in the hallway and housekeeping room was with the door unlocked.

8. During observation tour on the 7th floor, it was observed the following:
a. The patient bed linen was observed dirty room 700.
b. The non rebreathing mas was observed in the floor, room 701B.
c. The corrugate air hose of the Bi pap was observed unlabeled room 701B
d. Urinal was observed direct in the floor, room 703A, 712A.
e. Oxygen mask attached to the oxygen meter room 703A.
f. Nonsterile glove was observed over the bedroom 703B.
g. Bed linen was observed over the regular trash can room 710, 712.
h. Floor was observed very dirty, room 715.

9. During observation tour on the 6th floor, it was observed the following:
a. Bed linen was observed with blood spot room 600B.
b. The corrugate air hose of the Bi pap was observed unlabeled, and the mask was place over the Bi pap room 600B.
c. Broken toilet paper dispenser room 603.

Based on review of clinical records, policies/procedures and interview with the supervisor of Social Workers (employee #2), it was found that the facility failed to establish timeframe at an early stage of hospitalization to perform the initial assessment of patients who are likely to suffer adverse health consequences upon discharge in absence of discharge planning as well as for other patients upon the request of the patient representative's. This deficient affect 4 out of 15 patients evaluated for discharge planning (RR#32, #46, #47 and #51).

Findings include:

Upon review of the facility's policy control number: DTS-0821-0019 last update on 05/19/2024, on 08/22/2024 at 9:00 AM. Policy stated on the procedures that an interview by social worker or discharge planning personnel must be performed to guarantee necessary interventions for patients to ensure appropriate transition from hospital to private home.

It was identified that facility's policy control number: DTS-0821-0019 include provisions to address cases with psychosocial situations in addition to cases who may need discharge planning process when is identified that may need Home Health Agency, Hospice agency Skilled Nursing SNF's or require post -hospital services (intravenous antibiotic therapy or specialized medical equipment).


1. The surveyor asked to the supervisor of Social Worker (employee #2), on 08/22/24 at 10:15 AM if facility had establish a time frame to perform the initial assessment of patients who are likely to suffer adverse health consequences upon discharge in absence of discharge planning as well as for other patients upon the request of the patient representative's and she stated that for cases who are received by a consult of a physician they establish a 24 hours as the time frame to evaluate the case and begin the discharge planning process. She stated that other cases referred by member of health care personnel or patient's representatives are evaluated but facility had not established a time frame or criteria for establish priorities on those cases. She also stated during interview that discharge planning department screen other cases that based on the diagnosis, they know that must need discharge planning process but that for those cases they had not establish the time frame.

2. RR#32 is a 57-year-old male patient admitted on 07/11/2024 with a diagnosis of Acute Respiratory Failure and Mechanical Ventilation. During the review of the case with supervisor of Social Worker (employee #2), on 08/22/2024 at 11:49 AM it was identified that this patient had a sacral ulcer and a gastrostomy. She stated that since he had been diagnosed with sacral ulcer and was dependent of mechanical ventilator he must need coordination for home care services, ambulance, medical equipment, mechanical ventilation, enteral feeding machine and enteral supplements and nursing services at home.
A case who needs all those services must be consulted accordingly with facility policy DTS-0821-0019 and evaluated at 24 hours. Case was evaluated on 07/26/2024.


3.RR#46 is a 41-year-old female patient admitted on 08/18/2024 with a diagnosis of Diabetes Ketoacidosis Di Novo. During the review of the case with supervisor of Social Worker (employee #2), on 08/22/2024 at 10:00 AM it was identified that this patient had not been evaluated by discharge planning.

It was asked to the supervisor of Social Worker (employee #2), on 08/22/24 at 10:10 AM if this case require evaluation by discharge planning. She stated that since she had been diagnosed with Diabetes Di Novo need coordination for glucometer, assessment post discharge by an endocrinologist and education at home to ensure that acquire knowledge to manage her condition and prevent adverse health consequences occur upon discharge. She also stated that this case it should have been consulted to discharge planning or referred by a health care professional that was participated in her care. However, this consult or referral it was not carried out. Patient was evaluated on 08/22/2024 at 12:10 PM.

4. RR#47 is a 67-year-old female patient admitted on 08/17/2024 with a diagnosis of Infected Ulcers on both Heels. During the review of the case with supervisor of Social Worker (employee #2), on 08/22/2024 at 10:30 AM it was identified that this patient had not been evaluated by discharge planning.

It was asked to the supervisor of Social Worker (employee #2), on 08/22/24 at 10:40 AM if this case require evaluation by discharge planning. She stated that since she had been diagnosed with ulcers, she must need home care services, ambulance and nursing services at home. She also stated that this case it should have been consulted to discharge planning or referred by a health care professional that was participated in her care. However, this consult or referral it was not carried out. Patient was evaluated on 08/22/2024 at 12:16 PM.

5. RR#51 is a 67-year-old female patient admitted on 08/10/2024 with a diagnosis of Infected Sacral Ulcer. During the review of the case with supervisor of Social Worker (employee #2), on 08/22/2024 at 11:00 AM it was identified that this patient had not been evaluated by discharge planning. It was asked to the supervisor of Social Worker (employee #2), on 08/22/24 at 11:05 AM if this case require evaluation by discharge planning. She stated that since she had been diagnosed with sacral ulcer, she must need home care services, ambulance and nursing services at home. Case was evaluated on 08/21/2024.

Based on review of clinical records, policies/procedures and interview with the supervisor of Social Worker (employee #2), it was found that the facility failed to ensure review of the discharge plan, of those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This deficient affect 1 out of 15 cases evaluated for discharge planning (RR#9)

Findings include:

Upon review of the facility's policy control number: DTS-0821-0019 last update on 05/19/2024, on 08/22/2024 at 9:00 AM. Policy stated on the procedures that an interview by social worker or discharge planning personnel must be performed in order to guarantee necessary interventions for patients to ensure appropriate transition from hospital to private home.

It was identified that facility's policy control number: DTS-0821-0019 include provisions to address cases with psychosocial situations in addition to cases who may need discharge planning process when is identified that may need Home Health Agency, Hospice and Skilled Nursing- SNF's or require post -hospital services (intravenous antibiotic therapy or specialized medical equipment).


1. RR#9 is an 82-year-old male patient admitted on 08/09/2024 with a diagnosis of Acute Respiratory Failure and Sepsis. During the review of the case with supervisor of Social Worker (employee #2), on 08/22/2024 at 10:50 AM it was identified that this patient had been hospitalized on 07/31/2024 and was discharged on 08/08/2024 and that discharge planning program evaluate the patient during the previous admission and coordinate ambulance and medical equipment to the patient when was discharge on 08/08/2024. The patient returns to the hospital on 08/09/2024 with a diagnosis of Sepsis and Melena.

2. It was request to the supervisor of Social Worker (employee #2),on 08/22/2024 at 11:20 AM discharge planning process for this case who was readmitted in a very short period after being discharge from the facility in order to identify if they identify if there any situation related with patient post-discharge needs that could impact and provoke patient readmission to the hospital in a very short period after being discharge and this information is not provided.

3. It was asked to the supervisor of Social Worker (employee #2), on 08/22/2024 at 11:45 AM if facility had a mechanism to ensure that in every case that patient was readmitted, and discharge planning program had previously intervened to delineate a discharge planning process and plan were evaluate in order to ensure that the plans are responsive to the patient post-discharge needs.

Supervisor of Social Workers (employee #2), stated on 08/22/2024 at 11:55 AM that discharge planning re-evaluate cases readmitted to the facility, but this criterion was not included in their policies and procedures as a determinant to intervene.

Based on the review of seven records reviewed (R.R), review of policies and procedures and interview with the operating room supervisor (employee #5), it was determined that the facility failed to ensure that outpatients are evaluated and called after 24 hours after the surgery was performed to ensure acceptable standards of practice for 9 out of 16 records reviewed (R.R #16, #17, #18, #19, #21, #23, #26, #27, #28).

Findings include:

Policy and procedures: Seguimiento a paciente ambulatorio reviewed on 08/21/2024 at 2:20PM indicate that the call will be made between twenty-four and forty-eight hours after the patient has been discharged.

1. During the review of nine record (R.R #16, #17, #18, #19, #21, #23, #26, #27, #28) on 08/21/2024 at 9:20 AM through 11:30AM, it was evident that no calls were made more than 24 to 48 hours after the surgeries.

2. The facility did not ensure that nursing staff made follow-up calls to outpatients within 24 to 48 hours.

Based on observational tour and interview with the Nuclear Medicine Supervisor (employee #4) and Director of Nursing (employee #1), it was identified that facility failed to ensure the area is equipped with all required emergency ancillary equipment required in the event of an emergency.

Findings include:

1. During observational tour at the radiologic department on 08/21/2024 at 3:00 PM it was informed by the Nuclear Medicine Supervisor (employee #4) that they perform nuclear medicine diagnostic procedures to pediatric patients. Nuclear Medicine Supervisor (employee #4) stated that the department perform approximately 3 cases every month.

2. When asked to the Nuclear Medicine Supervisor (employee #4) on 8/21/2024 at 3:20 PM if they had a pediatric emergency crash cart at this area, she said that thy do not have a pediatric emergency crash cart in the area because when pediatric cases went to the area hospital pediatric healthcare personnel who transport the patient accompanied and stay at bedside with the patient and they bring an emergency case where there is all the equipment that they were going to need in an event of an emergency.

3. Radiologic Supervisor (employee #4) and Director of Nursing (employee #1) on 8/21/2024 at 3:30 PM stated that they understand that it is necessary to had available a pediatric emergency crash cart stocked with emergency medical equipment, supplies and drugs needed in the event of an emergency.

Director of Nursing (employee #1) stated on interview on 8/21/2024 at 3:50 PM that having their own pediatric emergency crash cart on this area, this allows facility to be responsible for this crash cart content and equipment. Director of Nursing (employee #1) also stated on interview on 8/21/2024 at 3:25 PM that nursing department had a nurse assigned to radiologic department that is going to be the person in charge of this responsibility along by the pharmacy personnel department.

Based on the review of six medical records, policies/procedures, it was determined that the facility failed to ensure that services are provided in accordance with the physician's orders related to how many hours was given, assessment and re-assessment post therapy, physician's lack of written respiratory therapy reorder in accordance to standards of practice, medical orders not according of policies and procedures for 4 out of 6 clinical records reviewed (RR #72, #73, #74 and #75).

Findings include:

Five medical records were reviewed on 08/22/2024 from 8:30 till 12:00 PM of patients who received respiratory therapy with the respiratory therapy assistant employee # 16 and the Infection Control Officer (employee #20) and provided evidence of the following:

1. R.R #72 is an 80-year-old female admitted on 08/09/2024 with a diagnosis of Infected Sacral Ulcer. The record was review on 08/22/2024 at 11:15 AM and was found the following:

a. On 08/14/2024 at 12:41 PM the physician ordered Ipratropium 0.5 milligram (mg) by power nebulizer (PN) every 8 hour.
b. It was found that the physician edits in the electronic record (audit log renovation) the initial physician order on 08/17/2024 at 13:38 PM, on 08/19/2024 at 14:44 PM, and on 08/21/2024 at 14:51 PM.
c. The physician failed to write a new order for the Ipratropium 0.5 mg by PN every 8 hour on 08/17/2024 at 13:38 PM, on 08/19/2024 at 14:44 PM, and on 08/21/2024 at 14:51PM instead of edit.
d. On 08/14/2024, no evidence was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 mg by PN every 8 hour at 15:00 PM.
e. It was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 mg by PN every 8 hour in the electronic flow sheet template, however no evidence was found the documentation of patient lung auscultation pre and post treatment.
f. The electronic template for the documentation of the respiratory therapy treatment provide to the respiratory therapist documented the full assessment of the patient and documented the patient lung auscultation previous the treatment and post treatment.
e. The respiratory therapist failed to document the patient lung auscultation previous the treatment and post treatment.

2. R.R #73 is a 91-year-old female admitted on 08/20/2024 with a diagnosis of Leucopenia. The record was review on 08/22/2024 at 10:05 AM and was found the following:

a. On 08/20/2024 at 10:32 Am the physician ordered Ipratropium 0.5 milligram (mg)by power nebulizer (PN) every 2 hour. At 14:25 PM ordered Nasal Cannula at 3 litter per minute (Lt/min)
b. On 08/19/2024, no evidence was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 milligram by power nebulizer (PN) every 4 hour at 15:00 PM and 19:00 PM.
c. It was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 mg by PN every 2 hour in the electronic flow sheet template, however no evidence was found the documentation of patient lung auscultation pre and post treatment and the use of oxygen by canula nasal at 3lt/min.
d. The electronic template for the documentation of the respiratory therapy treatment provide to the respiratory therapist documented the full assessment of the patient and documented the patient lung auscultation previous the treatment and post treatment.
e. The respiratory therapist failed to document the patient lung auscultation previous the treatment and post treatment.
f. On 08/20/2024 at 19:10 PM the respiratory therapist documented only the post treatment vital sign, failed to document the level of consciousness pretreatment vital sign, oxygen delivery method, the auscultation pre and post treatment.

3. R.R #74 is a 69-year-old female admitted on 08/17/2024 with a diagnosis of Bronchopneumonia (BKP) and Congestive Heart Failure (CHF). The record was review on 08/22/2024 at 9:30 AM and was found the following:

a. On 08/17/2024at 13:03 pm the physician ordered Bilevel positive airway pressure (Bipap) continue with Inspiratory Positive Airway Pressure (Ipap):14, Expiratory Positive Airway Pressure (Epap): 8, Respiratory Rate (RR):14, Fraction of Inspired Oxygen (FiO2): 60%.

It was found that the physician edits the initial physician order on 08/18/2024 at 11:51 AM, Ipap: 12-14, Epap: 6-8, RR: 12-14, FiO2: 100-80%. On 08/21/2024 at 17:26 PM, Ipap: 12-14, Epap: 6-8, RR: 20-14, FiO2: 80-60%.

b. The physician failed to write a new order for the Bipap parameter on 08/18/2024 at 11:51 am
and on 08/21/2024 at 17:26 PM instead of edit
c. On 08/17/2024 at 8:46 AM the physician ordered Ipratropium Bromide 0.5 mg by power nebulizer (PN) every 4 hour.
d. On 08/19/2024, no evidence was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 milligram by power nebulizer (PN) every 4 hour at 15:00 PM and 19:00 PM.
e. It was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 milligram by power nebulizer (PN) every 4 hour in the electronic flow sheet of the Bipap treatment, this electronic template does not provide to the respiratory therapist to document the re-assessment Vital Sign and auscultation post treatment.
f. The respiratory therapist failed to document the respiratory treatment in an electronic flow sheet (Intervention Respiratory Nebulizer treatment)
the patient auscultation of the lung in each treatment provided to the patient.
g. The electronic template for the documentation of the respiratory therapy treatment provide to the respiratory therapist documented the full assessment of the patient and documented the patient lung auscultation previous the treatment and post treatment.
h. The respiratory therapist failed to document the patient lung auscultation previous the treatment and post treatment.

4. R.R #75 is a 64-year-old male admitted on 08/19/2024 with a diagnosis of Chest Pain. The record was review on 08/22/2024 at 11:30 AM and was found the following:

a. On 08/20/2024 at 22:58 PM the physician ordered Ventury Mask at 50% and at 12:29 PM the physician performed a telephonic ordered Ipratropium 0.5 mg by PN every 4 hour. At 14:25 PM.
b. The physician failed to counter sign the telephonic order.
b. On 08/21/2024, no evidence was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 mg by PN every 4 hour at 11:00 AM and 15:00 PM. On 08/22/2024 at 3:00 AM.
c. It was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 mg by PN every 4 hour in the electronic flow sheet template, however no evidence was found the documentation of patient lung auscultation pre and post treatment.
d. The electronic template for the documentation of the respiratory therapy treatment provide to the respiratory therapist documented the full assessment of the patient and documented the patient lung auscultation previous the treatment and post treatment.
e. The respiratory therapist failed to document the patient lung auscultation previous the treatment and post treatment.
f. No evidence was found in the electronic flow sheet the documentation of patient use of oxygen by Ventury mask at 50% on 08/21/2024 at 19:00 PM, at 23:00 PM and on 08/22/2024 at 3:00 AM.