HospitalInspections.org

Based on the review of documents, observations and interviews from 8/15/11 through 8/17/11 from 9:00 am till 4:00 pm, it was determined that the Governing Body failed to carry out its responsibility for the operation and management of the hospital. It did not provide the necessary oversight and leadership as evidenced by the lack of compliance with: (42 CFR 482.12) Governing Body, (42 CFR 482.28) Food and Dietetic Services and (42 CFR 482.41) Physical Environment.

Based on the observational tour of the facility's kitchen that prepares patient's meals, review of menus and policies/procedures, temperature verification and interview on 8/15/11 from 10:00 am till 11:45 am and on 8/16/11 from 10:00 am till 11:15 am, it was determined that the facility failed to store, maintain and prepare food in a safe and sanitary manner related to freezer temperature, prepared and refrigerated foods on trays without dates when prepared and defrosted and failed to ensure that food arrives at patient's rooms at the appropriate temperatures, the facility failed to ensure that menus provided by the hospital are nutritionally balanced and meet the special needs of the patients, the facility failed to ensure that menus reach recommended dietary allowances for dietary fiber and the facility failed to ensure that patients receive appropriate fluids and food with nothing per mouth (NPO) orders. All of the above findings makes this condition "Not Met".

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Safety Officer (employee #4), review of policies and procedures, incident and accident reports and interview from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well being of patients receiving services related to all maintenance closets found unlocked, operating suites #1, #2 and #3 walls and ceilings are not monolithic, the roof is in need of repairs, the kitchen food storage area is not properly maintained, there is a large accumulation of old wood located near the garbage dumpsters, the smoke barrier doors located near the lower ward closed too fast when released from hold open devices, the facility is in need of repairs and paint of the exterior and interior of the hospital, it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to a broken public phone in the waiting area of the emergency room, garbage container without foot operated lids in the medication preparation room, the storage room located at the back of the pharmacy department and the small room located near patient's rooms #8 and #9 did not have appropriate temperature for stored products and air conditioner consoles were leaking, beds, crash carts, stands and crib were found with rust but no evidence was found of periodic maintenance, it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff related to handicapped bathrooms, handicapped parking, ramps are not appropriately designed, the operating room department is not appropriately designed, Cidex OPA is not used in an appropriate manner, the emergency room does not have a decontamination room, crash cart accessibility, the facility failed to evaluate safety aspects for patients, staff and visitors related to the lack of a security guard and areas not covered by cameras, two outside metal garbage containers did not have the lids on, biohazardous room was not ventilated properly, the facility does not have a dedicated morgue, the facility does not have an accessible entrance protected from the weather by canopy or roof overhang, the laundry room is not properly designed and the shower head in the laboratory department was found with a small leak and the shower head is too small for its purposed use and failed to ensure that applicable provision of the 2000 edition of Life Safety Code of the NFPA 101 are met: K0018, K0027, K0033, K0046, K0050, K0051, K0052, K0067, K0069, K0130 and K0147. These findings make this condition "Not Met".

Based on records reviewed and interview with the medical director (employee #6) , it was determined that the facility failed to ensure that patient's necessary medical information are included in cases transferred from the Intensive Care Unit to the Medicine Ward for one out of eleven records reviewed (R.R #13).

Findings include:

R.R #13 is a 73 years old male admitted on 2/23/11 with a diagnosis of Sepsis Secondary to Prostatitis to the Intensive Care Unit. The patient was ordered bed rest with side rails up and oxygen by nasal cannula at 2 liters. The patient was receiving care at the intensive care unit until 2/27/11 when the physician ordered the patient transferred to the medicine ward at 2:30 pm. The physician's transfer order only stated that the patient must be transferred to the medicine ward and with previous physician's orders to be resumed. The Medical Director (employee #6) stated during interview on 8/16/11 at 2:38 pm that the physician who takes the responsibility of the transfer of a patient from the Intensive Care unit to medical-surgical wards must place new orders based on the patient's status at the time of the transfer and to review the previous orders. The facility failed to ensure the continuity of the patient's health care information during the transfer process, necessary to facilitate the transition from a previous level of care to another as provided by the health care professional.

Based on records reviewed (R.R) and Do Not Resuscitate (DNR) Policies and Procedures and interview, 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 with the patient's signed consent for DNR or DNI for one out of one records reviewed (R.R #22).

Findings include:

1. The facility failed to inform patients or their representatives that they have the right to formulate advance directives and comply with these directives related to DNR order requests as reviewed on 8/16/11 at 12:20 pm:
a. R.R #22 is an 85 years old male who was admitted on 11/30/10 with a diagnosis of Acute Coronary Syndrome. On 8/16/11 at 12:20 pm the record was reviewed. It was found that the physician ordered a DNR on 12/3/10 at 11:10 am and reviewed the order in accordance with the facility's policies and procedures every 24 hours on 12/4/10 at 11:00 am, on 12/5/10 at 11:00 am, on 12/6/10 at 11:00 am, on 12/7/10 at 3:00 pm and 12/8/10 at 1:00 pm. The nurse's progress notes performed on 12/5/10 at 3:00 pm, on 12/6/10 at 3:00 pm and at 11:00 pm stated that the patient has an DNR order. The anticipated directives education sheet provided evidence that the patient was oriented related to CPR on 11/3/10 at 8:30 pm and on 12/3/10 at 11:10 pm the patient or their relatives signed the DNR. However, no evidence was found of the patient or patient relative signature an DNR consent. No evidence was found that the physician oriented the patient and justification of the DNR order in the physician's progress notes. In the event that an emergency arises it is not clear what will happen with the patient since the patient or his relative has not signed the DNR consent, but there is a physician order for the DNR.
2. During the review of the facility's "Do Not Resuscitate Policies and Protocol" on 8/16/11 at 12:20 pm, it was determined that the facility failed to have policies and procedures in place related to:

a. Do Not Intubate (DNI).

Based on records reviewed (R.R), it was determined that the facility failed to promote the patient's right to be free of restraints and failed to continually assess and monitor one out of seven records reviewed (R.R #17).

Findings include:

R.R #17 is a 76 years old female who was admitted on 7/27/11 with a diagnosis of Acute Abdominal Pain. During the record review on 8/16/11 at 8:30 am, it was found that the physician ordered on 7/27/11 at 3:20 pm, on 7/28/11 at 4:00 pm, on 7/29/11 at 4:00 pm, on 7/30/11 at 4:00 pm, on 7/30/11 at 8:00 am, on 7/31/11 at 8:00 am, on 8/1/11 at 8:00 am, restraints to prevent falls, prevent interruption of treatment, high risk of harm to herself, high potential to remove intravenous fluids (IVF'S), equipment and dressings during 24 hours of the left and right arm at the wrist. On 7/29/11 for the 7-3 shift the restraint assessment was left in blank, the nurse's progress note from 7/29/11 at 7:00 am stated that the patient was restrained of the upper extremities with episodes of disorientation and 3-11 shift the nurse documents in the restraint assessment sheet that the patient was free of restraints and on the 11-7 shift the nurse documents restraint assessment every 2 hour. On 8/2/11 for the 3-11 shift the restraint assessment was left in blank. No evidence was found that the patient's plan of care related to the restraints was activated by the registered nurse on 7/27/11.

Based on seven medical records reviewed, review of policies and procedure (P&P) related to restrain protocol, it was determined that the facility failed to ensure that the order for the use of restraints is never used as on a "as needed basis" (PRN) for one out of seven records reviewed (R.R #17).

Finding included:

1. R.R #17 is a 76 years old female who was admitted on 7/27/11 with a diagnosis of Acute Abdominal Pain. During the record review on 8/16/11 at 8:30 am, it was found that the physician ordered on 7/27/11 at 3:20 pm, on 7/28/11 at 4:00 pm, on 7/29/11 at 4:00 pm, on 7/30/11 at 4:00 pm, on 7/30/11 at 8:00 am, on 7/31/11 at 8:00 am and on 8/1/11 at 8:00 am, restraints to prevent falls, prevent interruption of treatment, high risk of harm to herself, high potential to remove intravenous fluids (IVF'S), equipment and dressings during 24 hours of the left and right arm at the wrist. On 7/29/11 for the 7-3 shift the restraint assessment was left in blank and for the 3-11 shift the nurse documents on the restraint assessment sheet that the patient was free of restraints and on 11-7 shift the nurse documents restraint assessment every 2 hours. On 8/2/11 for the 3-11 shift the restraint assessment was left in blank. However no evidence was found related to the physician's order to discontinue the restraint and no evidence was found related to a new order to restart the patient's restraints when the patient was previously released.

2. The facility's restraint policies and procedure reviewed on 8//16/11 at 9:30 am states that if the patient has no alteration of behavior after an order is placed shall not exceed 24 hours and the nurse may discontinue the restriction. If the patient returns to relapse behavior, the restriction can be placed back within 24 hours and this is covered by the medical order (this policy does not meet with the restraint regulation at 482.13 (e)(5)).

Based on the review of quality assurance activities with the quality assurance officer (employee #8), it was determined that the facility failed to ensure that one or more specific quality improvement projects are undertaken each year.

Findings include:

1. The facility failed to provide evidence on 8/17/11 at 10:24 am of performance improvements projects currently underway, as well as those completed in the prior year.

2. Performance improvement activities reviewed on 8/17/11 at 10:40 am, conducted by the facility according with their types of services do not include improvement projects as required by 482.21 (d) standard of QAPI Condition of Participation.

Based on the review of nineteen medical staff credential files, it was determined that the facility failed to examine credential files (C.F) to ensure that medical staff have updated Health Certificates and Cardio-pulmonary Resuscitation Certificates (CPR) for twelve out of nineteen credential files reviewed (C.Fs #1, #2, #3 #5, #7, #8, #9, #10, #12, #13, #14 and #18).

Findings include:

1. During the review of nineteen medical staff credential files on 8/17/11 from 10:30 am the following was found:

a. Ten out of nineteen medical staff credential files provided evidence of expired Health Certificates for C.Fs #1, #2, #5, #7, #9, #10, #12, #13, #14 and #18.

b. Six out of nineteen medical staff credential files provided evidence of expired cardio- respiratory certificates for C.Fs #2, #3, #7, #8, #10 and #14.

Based on nursing supervisor roster review and interview with the Director of Nursing (DON) (employee #2), it was determined that the facility failed to provide 24-hour registered nursing supervision during night shifts.

Findings include:

1. During nursing supervisor roster review on 8/15/11 at 10:00 am, the following was found from 8/1/11 through 8/15/11:

a. On 8/1/11, 8/2/11, 8/3/11, 8/4/11, 8/5/11, 8/6/11, 8/7/11, 8/8/11, 8/9/11, 8/10/11, 8/11/11, 8/12/11, 8/13/11, 8/14/11 and 8/15/11 the facility did not have a registered nurse covering the 11:00 pm till 7:00 am supervisory shift from Monday to Friday.
b. On 8/6/11, 8/7/11, 8/13/11, 8/14/11 the facility did not have a registered nurse supervising from the 3:00 pm till 7:00 am supervisory shift from Saturday to Sunday.
c. During interview with the Director of Nursing (DON) (employee #2) on 8/15/11 at 10:10 am, she stated that they have a nursing supervisor on-site at the hospital from Monday through Sunday from 7:00 am till 11:00 pm, but from 11:00 pm till 7:00 am there is an on-call for Saturday and Sunday from 3:00 pm till 7:00 am they do not have an available nursing supervisor and nursing personnel are oriented to call the on-call nursing supervisor in the event of a situation or an emergency.

Based on the review of thirteen nursing credential files (C.F), it was determined that the facility failed to ensure that three personnel have updated CPR, two personnel did not have updated health certificates in accordance with state and local laws for five out of thirteen C.Fs (C.Fs #1, #2, #7, #9 and #13).
Findings include:

1. Thirteen nursing credential files were reviewed with the Director of Nursing (D.O.N) (employee #2) on 8/15/11 at 2:00 pm and provided evidence of the following:

a. Three out of thirteen nursing credential files did not contain updated cardio-respiratory certificates (C.F #7, #9 and #13).

b. Two out of thirteen nursing credential files did not contain evidence of updated annual health certificate (C.F #1 and #2).

Based on the review of eleven medical records and interviews, it was identified that the facility failed to ensure that the nursing staff develops and keeps current, a nursing care plan for patients identified at risk for falls in three out of eleven records reviewed (#5, #8, #10, # 11 and #13).

Findings include:

1. A mechanism to ensure that nursing personnel take provisions in order to prevent falls in patients at risk was not followed nor evidenced. During the survey process on 8/16/11 from 8:45 am through 3:00 pm the following was identified:

a. R.R #13 is a 73 years old male patient admitted on 2/23/11 with a diagnosis of Sepsis Secondary to Prostatitis to the Intensive Care Unit. The patient was ordered bed rest with side rails up and oxygen by nasal cannula at 2 liters. The patient was receiving care at the intensive care unit until 2/27/11 when the physician ordered to transfer the patient to the medicine ward at 2:30 pm. The physician's transfer orders did not include orders or special provisions that specify if the patient could ambulate or needed to remain on bed rest with bathroom privileges. The patient was transferred to the ward and was located at room #2 at 3:45 pm. From 7:00 pm through 8:00 pm the patient received visits from relatives according with documentation of nurse's notes reviewed with the nursing supervisor (employee #7) on 8/16/11 at 9:55 am. At 9:30 pm and according with the incident and accident reports reviewed with the nursing supervisor (employee #7) on 8/15/11 at 10:00 am, the patient was found on the floor unresponsive with shortness of breath by the security officer who was giving rounds at the rooms to ensure that the visitors left the hospital. The patient was evaluated by the emergency room physician who intubate the patient and transferred him to the intensive care unit where he was placed on mechanical ventilation. Circumstances where the incident occurred or determination of the time that the patient remained on the floor until he was discovered by the security officer was not included on the incident report, nor determined by the risk management personnel during the analysis of the incident. Fall risk assessment for this patient was not determined after the transfer to the ward to determine changes in medical condition that could put him at risk for falls. The facility failed to promote an assessment and plan of care for this patient who had risk factors to fall in order to maintain or promote the patient's safety.

b. R.R #5 is a 69 years old male admitted on 8/12/11 with a diagnosis of Left Foot Cellulitis and Infected Wound. During the admission, the nurse identified in the nursing history that the patient was at risk for falls due to previous fall history and lack of balance. However the plan of care to deal with this risk was not developed nor documented on the medical record. Provisions to prevent the patient from falling down at the facility was not implemented. The Facility failed to promote risk prevention plan of care provisions in order to promote patient safety.

c. R.R #10 is a 72 years old female admitted on 8/10/11 with a diagnosis of Chronic Liver Disease and Ascites. During admission the nurse identified in the nursing history that the patient was at risk for falls due to muscular weakness, hearing problems, visual problems and had difficultly to ambulate. However the plan of care to deal with this risk was not developed nor documented in the medical record. Provisions to prevent the patient from falling down at the facility was not implemented. The facility failed to promote risk prevention plan of care provisions in order to promote patient safety.

2. The Nursing Supervisor (employee #7) stated during an interview on 8/16/11 at 1:43 pm that when a patient is admitted to the facility nursing personnel assess the patient's needs and health status documenting a nursing history. If the nurse determines that the patient has a risk for falls a green label is included in the treatment kardex, plan of care for fall prevention is developed and implemented and rounds every hour must be performed. She was in agreement with the survey findings for R.Rs #5, #10 and #13 that include evidence that fall prevention protocols are not implemented in cases identified as risk for falls by nursing personnel


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3. Two out of seven records reviewed for care plans on 8/15/11 from 10:30 am till 1:45 pm (R.R #8 and #11) provided evidence that care plans do not have revisions during the patients' hospital stay related to their needs and some do not have evidence of care plans:

a. R.R #8 is a 72 years old male who was admitted on 8/13/11 with a diagnosis of Rectal Bleeding, Diabetes Mellitus and Retinopathy. The patient's record was reviewed on 8/15/11 at 10:35 am and no evidence was found that the patient's nursing care plan was established and implemented according to the patient's needs. No evidence was found of the revision of patients' needs according to the patient's changes during the in-patient stay and discharge.

b. R.R #11 is an 81 years old female who was admitted on 8/13/11 with Congestive Obstructive Pulmonary Disease (COPD). The patient's record was reviewed on 8/15/11 at 10:50 am and no evidence was found that the patient's nursing care plan was established and implemented according to the patient's needs. No evidence was found that the registered nurse activated the plan of care according to the patient's needs during the hospitalization.

Based on records reviewed (R.R) and policies and procedures with the director of nursing (employee #2), it was determined that the facility failed to ensure that telephone orders are signed as soon as possible for three out of seven records reviewed (R.R #8, #10and #12).

Findings include:

1. Evidence was found on 8/15/11 from 10:00 am till 3:00 pm and on 8/16/11 from 9:15 am till 12:00 noon of policies and procedures related to the timeliness of countersignatures when telephone orders are used and it states that the physician has 24 hours to countersign the telephone order.

a. R.R #8 provided evidence of a telephone order placed on 8/13/11 at 8:55 pm, 9:35 pm, 10:15 pm and 10:33 pm, that the physician countersigned the order however no evidence was found of the date and hour of the countersignature.

b. R.R #10 provided evidence of a telephone order placed on 8/13/11 at 9:25 am to discontinue paracentesis, that the physician countersigned the order however no evidence was found of the date and hour of the countersignature.

c. R.R #12 provided evidence of a telephone order placed on 8/14/11 at 5:50 pm for Acetaminophen 500mg orally (PO) 2 tablets every 6 hours, when necessary (prn) for fever more than 38 ºC, that the physician countersigned the order however no evidence was found of the date and hour of the countersignature.

Based on the review of the policies and procedure's manuals, a manual of abbreviations and signature registry provided by the medical record supervisor (employee #20), it was determined that the facility failed to maintain an updated and approved by the Governing Body abbreviations and signature registry and are reviewed and revised as needed.

Findings include:

1. No evidence was found on 8/17/11 at 9:30 am of an abbreviation manual that was updated and approved by the Governing Body and includes the pharmacy supervisor's signature of participation.

2. The signature registry of physicians and other disciplines were reviewed with the Medical Record Supervisor (employee #20) on 8/17/11 at 9:30 am. The signature registry was not updated nor was it approved by the Governing Body.

Based on the review of forty-eight closed and active clinical records, it was determined that the facility failed to ensure that medical staff, nursing personnel and other disciplines maintain legible entries for forty-eight out of forty-eight records reviewed (R.R #1 through #48).

Findings include:

Forty-eight clinical records reviewed from 8/15/11 through 8/17/11 from 9:30 am till 3:00 pm contained portions that are not legible. Most notable were the nurse's notes, signatures (physicians and nurses), physicians progress notes, consults, diagnosis, operative reports, informed consent forms, anesthesia reports and physician's orders.

Based on the eleven medical records reviewed and policies/procedures with the facility's nursing supervisor (employee #7), it was determined that the facility failed to implement physician patient policies/procedures related to physician telephone orders for three out of three medical records reviewed with telephone orders (RR #13, #14 and #15).

Findings include:

1. A mechanism to ensure that procedures related with the transcription of telephone orders by nursing personnel are followed according with facility policies and procedures and current standards of practice were not followed as reviewed on 8/15/11 from 10:55 am till 1:49 pm:

a. During the review of medical records with the nursing supervisor (employee #7) and pharmacist (employee #12) on 8/15/11 from 10:55 am till 1:49 pm, it was found that nursing personnel who receive telephone orders did not repeat the order back to the ordering physician to confirm that the repeat order is complete. The orders were countersigned by the physician but did not have the date or time when signed. This deficient practice was identified on records reviewed #13, #14 and #15.

Based on ten closed records reviewed (R.R), it was determined that the facility failed to ensure that discharge summaries are performed with all pertinent information for two out of ten records reviewed (R.R #44 and #47).

Findings include:

R.R #44 and #47 were reviewed on 8/17/11 from 9:00 am till 1:30 pm and provided evidence that the information sheet used by medical personnel has an area that describes discharge instructions and these spaces were observed in blank. The discharge instruction area has different choices to allow medical personnel to perform check marks for those areas that correspond to the patient. However, according with discharge summary regulations "All patient's medical records must contain a discharge summary. A discharge summary discusses the outcome of the hospitalization, the disposition of the patient and provisions for follow-up care. Follow-up care provisions include any post hospital appointments, how post hospital patient care needs are to be met, and any plans for post-hospital care by providers such as home health, hospice, nursing homes, or assisted living" (R.R #47 with a diagnosis of Acute Bacteremia and R.R #44 with Intrauterine Pregnancy of 38 weeks and Multiple Body Trauma).

Based on observations of the medication storage room with the Pharmacist (employee #12), it was determined that the facility failed to ensure that all drugs and biologicals are maintained
in accordance with applicable standards of practice, consistent with Federal and State Law.

Findings include:

Three opened multiple dose vials of insulin were found in the medication room refrigerator of the medicine ward on 8/15/11 at 9:20 am. All had the date when the vials were opened and must be discarded between 30 days beyond the date of the open vials. However the dates exceeded 28 days that are recommended by the US pharmacopeia reference standards (revised in August 4, 2011) in order to ensure that the drugs are safe for use.

Based on observations of the medication storage room with the Pharmacist (employee #12) and interview, it was determined that the facility failed to ensure that all drugs and biologicals are stored in a proper and safe manner accessible only to authorized personnel.

Findings include:

1. During the initial observational tour with the pharmacist (employee #12) on 8/15/11 from 9:04 am though 11:12 am the following was found:

a. The refrigerator used to store medications at the medicine ward was found without a lock. Medications are available to non authorized personnel.

b. The refrigerator used to store medications located at the second floor medication room
was found without a lock. Medications are available to non authorized personnel.

c. During the medication drug pass on 8/15/11 from 9:00 am till 10:30 am the drug cart was observed with all drawers left unlocked. These drawers are used to store medications, creams and syrups used by patients. Nursing personnel were observed leaving the cart unlocked in the hallway while she was administering medications to patients in their rooms. The nursing supervisor (employee #7) stated during an interview on 8/15/11 at 10:39 am that this cart has a broken lock.

Based on observations, review of policies and procedures and routine equipment testing with the supervisor of the X-ray department (employee #1) and interview, it was determined that the facility failed to ensure that the physicist periodically verifies the badge exposure for radiation exposure.

Findings include:

On 8/15/11 at 2:00 pm the supervisor of the X-ray department (employee #1) provided evidence of the monthly radiation dosimetry report revision of badges used by X-ray department personnel. However, no written evidence was found of routine inspections of the dosimeters for radiation by the physicist. The X-Ray supervisor (employee #1) stated during an interview on 8/15/11 at 2:10 pm that the badge reports are reviewed for the physicist annually.

Based on observations, review of policies and procedures and routine equipment testing with the supervisor of the X-ray department (employee #1), it was determined that the facility failed to ensure that the staff receive on going educational program or personnel meetings.

Findings include:

No evidence was shown on 8/15/11 at 3:00 pm of the on going educational program or personnel meetings from 2008.

Based on the observational tour of the facility's kitchen that prepares patient's meals, review of menus and policies/procedures, temperature verification and interview, it was determined that the facility failed to store, maintain and prepare food in a safe and sanitary manner related to freezer temperature, prepared and refrigerated foods on trays without dates when prepared and defrosted and failed to ensure that food arrives at patient's rooms at the appropriate temperatures.

Findings include:

1. During the kitchen observational tour performed with the kitchen manager (employee #15) on 8/15/11 from 10:00 am till 11:45 am and on 8/16/11 from 10:00 am till 11:15 am the following was observed:

a. Two metal cooking pots with pre-cooked cream of wheat for lunch were observed on 8/15/11 at 10:10 am over the warmer grill of the stove used to place food until the lunch meals are served. The kitchen manager (employee #15) stated during an interview on 8/15/11 at 9:20 am that the food is used for patient's lunch and the cream of wheat was prepared at 9:00 am. The cream of wheat was observed dry from staying over the grill and the grill was cold. Also, the kitchen manager took the temperature of the two pots with cream of wheat and obtained a temperature of 40ºF. The facility failed to store and maintain appropriate temperatures of the food on the grill to ensure that it is used during the appropriate period.

b. Two pre-served trays with approximately 25-30 small plastic individual patient serving trays with beets and apple sauces were observed on 8/15/11 at 10:15 am with labels on the trays (not per individual tray) indicating that they were prepared on 8/15/11.

c. The kitchen was found extremely hot especially near the stoves as determined on 8/15/11 at 10:20 am with the kitchen manager (employee #15). It was found that the air extractors in the window over the stoves and the dish washer sinks did not work which caused the kitchen to be excessively hot.

d. Kitchen personnel (employee #13) was observed on 8/15/11 at 10:25 pm pre-serving approximately 20-25 foam cups with milk for the lunch meal. However, during the procedure employee #9 did not turn off a large ceiling fan. The facility failed to ensure that food is prepared and pre-serving food in a safe and sanitary manner to prevent cross contamination.

e. During observations of the refrigerator on 8/15/11 at 10:30 am three trays with meat were found with labels when prepared (8/14/11) and not the date when to use. The kitchen supervisor (employee #15) stated on 8/15/11 at 10:35 am that the food trays were prepared today for the lunch, however the facility failed to store and maintain the food trays to ensure that they are used during the appropriate period

f. During the food preparation it was observed that the lid of a pot was found without a handle on the stove top with the flame under the pot on 8/16/11 at 11:00 am, the food in this pot was to be used for the lunch time meal. The kitchen supervisor (employee #15) stated during an interview on 8/16/11 at 11:00 am that many of the lids that go on the pots do not have handles and when they need to lift the lids they have to use gloves or a towel.

g. During observations of the anti-freezer refrigerator on 8/15/11 at 10:40 am one tray with three portions of meat and eight whole chickens were found without labels when they were taken out of the freezer to defrost and no date when to use was found. The kitchen supervisor (employee #15) stated on 8/15/11 at 10:35 am that the food tray was prepared today for the dinner meal and tomorrows' menu, however the facility failed to store and maintain the food tray to ensure that it was used during the appropriate period. Also, a tray with seven pre-served cups of nutritional supplement were observed with labels on the trays (not per individual tray) indicating that they were prepared on 8/14/11.

h. During the visit of the dry food storage room on 8/15/11 at 10:50 am with the kitchen supervisor (employee #15), it was found that metal shelves used to store dry food and cans were observed with rust. Also, one can (106 ounces) of pineapple was observed dented.

i. The three compartment sink was observed on 8/15/11 at 11:00 am after the dish washing process. The two first compartments were observed without water and the third compartment was observed with sanitizing solution (iodizing). A kitchen personnel (employee #13) stated during an interview on 8/15/11 at 11:05 am that he washes the pots, pans and utensils in the two first compartments and were empty since the lunch meal was over. The sink with the sanitizing solution was tested by employee #13 with a test strip and he was observed introducing the test strip and lifting it immediately from the water. The test strip vial provided evidence that the sanitizing solution registered 25 ppm and not 50 ppm as required. Review of the test strip vial provided evidence that the test strip is to be placed in the water for 60 seconds and removed from the water with the sanitizing solution. Employee #13 did not know the correct amount of time to leave the test strip in the third sink. The facility failed to ensure that policies/procedures related to the use of the dish washing sanitizing solution is followed according with specifications to ensure correct concentrations and appropriate methods for sanitizing. Also, no evidence was found of the test strip registrations.

j. The food line lunch time meal assembly was observed on 8/15/11 at 11:15 am and provided evidence that the food was on the stove while the kitchen employees were serving the food. The kitchen employees were observed serving the food directly from the pots on the stove and serving the portions of the food on the food trays. Also, all the kitchen employees were observed serving the foods on the food line without gloves. Once the food was prepared at 11:00 am the temperature of the food was appropriate (140ºF-180ºF) according with the registry log. Before the kitchen employees served the staff's food (approximately 30 food trays) the temperature was taken and was found to range from 100ºF-138ºF at 11:15 am. When the kitchen employees began to serve the patient's food trays the temperature of the food was not taken to ensure that it was in the appropriate range and they failed to take the temperature of the cold food (milk). The facility failed to ensure that patient's food is at the appropriate temperature when served (hot and cold). Kitchen employees took the temperature from the pots after the foods was cooked and this was when the temperature reached the appropriate range of 140ºF- 180ºF, but because the facility does not have a steam table and the food sat on the stove from 10:30 am till patient were served at 11:30 am under a low flame, the temperature can not be guarantied and a test tray provided evidence that the food arrived at the patient's rooms at inappropriate temperatures (vegetable omelet - 30ºF, soup at 60ºF and milk 70ºF)

k. During observations of kitchen employee #14 on 8/15/11 at 11:45 am, it was observed that he washed the cutting board in a sink after he cut meat on it. Then he placed a plastic wrapped whole chicken in this sink and then he took the chicken (with the plastic wrap) and placed if on another cutting board. He then removed the plastic and cut the chicken on the cutting board. The facility failed to ensure proper technics to prevent cross contamination related to the chicken in the sink and placing it directly on the cutting board.

Based on the review of documentation, recommended dietary allowances, menus recipes and observational tour of the kitchen with the dietitian and interview, it was determined that the facility failed to ensure that menus reach recommended dietary allowances for dietary fiber and the facility failed to ensure that patients receive appropriate fluids and food with nothing per mouth (NPO) orders.

Findings include:

1. During the review of recommended dietary allowances (RDA's) with the dietitian on 8/16/11 at 11:00 am it provided evidence that menus cycles for 7 days do not meet the RDA for dietary fiber on a weekly basis. The facility must ensure appropriate dietary intake and nutritional status related to food intake and output to ensure that their gastrointestinal system is adequately maintained to avoid using chemical laxatives whenever possible. The facility failed to ensure that residents meet 100% of their RDA of dietary fiber.

2. R.R #28 is a 72 years old female who was admitted on 8/10/11 with a diagnosis of Ascites and rule out of Chronic Liver Disease. The record was reviewed on 8/15/11 at 3:00 pm and provided evidence that the patient was ordered "nothing per mouth" (NPO) since admission on 8/10/11 at 7:00 pm to the medicine ward. The patient was ordered Lasix 20 mg every 8 hours, Aldactone 50 mg orally (po) daily, Vitamin K 10 mg po daily and Protonix intravenous daily. The physician also ordered abdominal pelvic sonogram with doppler and consult to surgery for paracentesis. During patient observations and interview on 8/16/11 at 9:30 am the patient was found in bed, with abdominal pain, her tongue was dry and she said that she was not hungry. The laboratory results provided evidence that the patient's laboratory blood results from 8/11/11, 8/15/11 and 8/16/11 revealed low levels of sodium, potassium and chloride possibly due to dehydration status. The dietitian evaluates the patient on 8/11/11 at 5:40 am and she recommends a diet of 2 grams of sodium, high fiber and fluid intake requirements of less than 1 liter a day. A partial paracentesis procedure was performed on 8/12/11 by a surgeon where 200 cc was removed. On 8/14/11 at 10:15 am the physician orders a liquid diet for the patient. On 8/15/11 at 6:15 pm a consult with a gastroenterologist was ordered to evaluate another paracentesis and a abdominal CT scan. No evidence was found that the facility provided the patient with liquids until 8/15/11. The record review provided evidence that the patient did not receive anything by mouth from 8/11/11 through 8/15/11 because the paracentesis procedure was canceled twice and they were waiting for a gastroenterology consult which caused the patient to be without food or fluids for approximately four days. The Nursing Supervisor (employee #7) of the lower ward stated during an interview on 8/16/11 at 10:30 am that when NPO orders are given for patients not exceed more than 48 hours with food or fluids. Interview with the facility's dietitian (employee #16) on 8/17/11 at 11:00 am provided evidence that the facility does not have established policies/procedures related to patients with NPO orders related to the condition of the patients, their diagnosis and the treatment ordered. She stated that the decision related to the amount of time on the NPO order needs to be determined by the medical staff and the dietary department. The facility failed to establishes criteria related to nutritional risk factors with patients who are NPO.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Safety Officer (employee #4), it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well being of patients receiving services related to all maintenance closets found unlocked, operating suites #1, #2 and #3 walls and ceilings are not monolithic, the roof is in need of repairs, the kitchen food storage area is not properly maintained, there is a large accumulation of old wood located near the garbage dumpsters, the smoke barrier doors located near the lower ward closed too fast when released from hold open devices and the facility is in need of repairs and paint of the exterior and interior of the hospital.

Findings include:

1. All janitor's closets (emergency room and hospital) were visited from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm with the facility's Safety Officer (employee #4). These closets were found with chemicals to clean the facility and equipment and were found unlocked and accessible to non-authorized persons.

2. The operating suites were visited on 8/16/11 from 8:15 am through 9:30 am with the facility's Safety Officer (employee #4) and provided evidence of the following:
a. The walls of operating suites #1 and #2 were not monolithic, they were found with tiles and grout lines between the tiles were not sealed which can allow dirt to enter and does not allow for proper cleaning.
b. The ceilings of operating suites #1, #2 and #3 were found with acoustic ceiling tiles that are washable, however the acoustic tiles are very light weight and will not allow proper cleaning because they move when light pressure is applied during cleaning (some acoustic tiles were found off of their tracks).
c. Operating suites #1, #2 and #3 were found with large garbage containers, in order to open the lids to deposit trash the lids are pushed by hand. Foot (pedal) operated lids are needed to ensure that personnel's gloves are maintained clean.

3. During observations of the roof on 8/16/11 at 2:30 pm, it was determined that the roof was in poor condition, various areas did not have protective sealant (the roof is made of solid cement but some areas were without the protective sealant cover exposing the cement). During observations of the second floor (directly under the roof) on 8/16/11 at 2:50 pm, it was found that ceiling acoustic tiles, walls and floors were stained where the upper ward and administration sections of the buildings meet (over and behind the fire hose), near the administration office, in the hallway of the upper ward and in patient's rooms.

4. During the observational tour of the kitchen with the Safety Officer (employee #4) on 8/15/11 from 10:00 till 11:00 am, the following was found:
a. Metal shelves used in the freezer, refrigerator and dry food storage area were found with rust.
b. Metal shelves used in the freezer, refrigerator and dry food storage area were measured for the height of bottom shelf above the floor and they were found within 12 inches from the floor. To ensure infection control precautions food shall not be within 12 inches from the floor to limit contact with the broom, mop and dirt.
c. The ceiling in the dry food storage room was found with peeling (hanging over the shelves) paint.
d. The metal door located in the dry food storage area was found rusty and in need of maintenance.

5. There is a large accumulation of old wood located near the garbage dumpsters in the parking area as observed on 8/15/11 at 11:50 am with the Safety Officer (employee #4).

6. The smoke barrier doors located near the lower ward was verified with the facility's Safety Officer (employee #4) on 8/15/11 at 2:45 pm. These doors were released from their hold open devices and they closed too fast (approximately one to two seconds) which could harm a patient or visitor passing through these doors if the fire alarm is activated and the doors are released. According with "Americans with Disabilities Act" section 4.13.10 (Door Closers) door closers should be adjusted so that from an open position of 70 degrees, the door will take at least 3 seconds to move to a point 3 inches from the latch.

7. Observations of the exterior of the facility on 8/15/11 from 8:00 am till 3:00 pm with the facility's Safety Officer (employee #4), it was found that the facility is in need of exterior repairs and paint. Exterior walls were found with holes, weeds were growing through the wall and the south wall was found with a build up of mildew. Also, the interior walls of the facility were observed on 8/15/11 from 8:00 am till 3:00 pm with peeling paint and with water damage and in need of repairs and paint.

8. The emergency room area doors that separate staff and patients receiving care from visitors and patients waiting to be seen were observed with the facility's Safety Officer (employee #4) on 8/15/11 at 10:00 am. One set of these doors are located in front of the triage area and the other set is located near the time clock. These doors were found with electronic magnets to keep the doors closed to limit access to the emergency room by unauthorized persons, but the doors are not solid core doors and with a strong push or pull they can be forced opened. In order for these doors to provide security as per their design they need to be repaired or changed to ensure that they can not be opened forcibly.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Safety Officer (employee #4), it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed with the facility's with the facility's Safety Officer (employee #4), from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0018, K0027, K0033, K0046, K0050, K0051, K0052, K0067, K0069, K0130 and K0147).

Based on observations made during the survey for the physical environment with the facility's Safety Officer (employee #4), it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to a broken public phone in the waiting area of the emergency room, garbage container without foot operated lids in the medication preparation room, the storage room located at the back of the pharmacy department and the small room located near patient's rooms #8 and #9 did not have appropriate temperature for stored products and air conditioner consoles were leaking, beds, crash carts, stands and crib were found with rust and no evidence was found of periodic maintenance of this equipment.

Findings include:

1. During the observational tour of the emergency room on 8/15/11 from 8:30 am till 10:00 am the following was found:
a. The public phone in the waiting room did not work.
b. The air conditioner console in the waiting room was found leaking water into a bucket.
c. The medication storage room was found with a large regular garbage container that did not have a foot pedal to operate the lid.

2. The storage room located at the back of the pharmacy department and the small room located near patient's rooms #8 and #9 were visited on 8/15/11 at 3:00 pm and provided evidence that they contained products to be stored at 77 ºF or less, but these rooms were found very warm and did not have air conditioners.

3. During observations of the facility from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm, it was found that air conditioner consoles were leaking, beds, crash carts, stands and crib were found with rust. Evidence was requested related to the periodic maintenance of this equipment but none was provided on 8/17/11 at 10:00 am. The facility failed to ensure that periodic maintenance is performed on equipment based on a scheduled rotation.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Safety Officer (employee #4), review of policies and procedures, incident and accident reports and interview, it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff related to handicapped bathrooms, handicapped parking, ramps are not appropriately designed, the operating room department is not appropriately designed, Cidex OPA is not used in an appropriate manner, the emergency room does not have a decontamination room, crash cart accessibility, the facility failed to evaluate safety aspects for patients, staff and visitors related to the lack of a security guard and areas not covered by cameras, two outside metal garbage containers did not have the lids on, biohazardous room was not ventilated properly, the facility does not have a dedicated morgue, the facility does not have an accessible entrance protected from the weather by canopy or roof overhang, the laundry room is not properly designed and the emergency shower head in the laboratory department was found with a small leak and the shower head is too small for its purposed use.

Findings include:

1. The handicapped toilet located within the emergency room (E.R) was visited on 8/15/11 at 8:45 am with the facility's Safety Officer (employee #4) and the following was found:
a. The grab bar located on the side of the toilet near the door did not have enough space for persons in a wheelchair to maneuver to gain access to the toilets, according with the Americans with Disabilities Act (Ley ADA) requirements, at least 64 square inches is needed.
b. The door of this bathroom did not have the international symbol related to handicapped accessibility.
c. The door of this bathroom did not have a door closer and the exhaust fan did not have a cover.

2. The crash cart of the emergency room was observed between cubicles #4 and #5 on 8/15/11 at 9:00 am with the facility's Safety Officer (employee #4). When patients are in these cubicles the accessibility of the crash cart is reduced and shall be located where it can be easily accessed and is out of the way.

3. During the observational tour of the facility from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm, it was determined that the facility does not have a security guard during the day shift (7:00 am-3:00 pm shift). The Safety Officer (employee #4) was interviewed on 8/17/11 at 10:15 am and he stated that the facility does not employee a security guard for any of the shifts nor for the emergency room. Review of incident and accident reports on 8/16/11 at 1:00 pm provided evidence that there has been various incidents of robbery and multiple victims with gun shots attended at the emergency room. The facility failed to evaluate safety aspects for patients, staff and visitors related to the lack of a security guard and areas not covered by cameras. No evidence was found that the facility weighed risks, evaluated shift coverage or incident events to come up with a plan to protect life and property.

4. The metal ramp located near the CT Scan area and also serves as the exit ramp for the lower ward was visited on 8/15/11 at 11:10 am and the following was found:
a. Portions do not have hand rails. To ensure that persons with impediments on either side of their bodies can safely access this ramp, hand rails are needed on both sides of the ramp according with the "Americans with Disabilities Act" (Ley ADA) requirements.
b. The metal is rusty and lacks maintenance.
c. The support structure of this ramp is not sturdy, when multiple persons cross at the same time.
d. The ramp is too steep at some points (does not comply with the "one to twelve rule"). The height where the ramp begins is 16 inches above the floor but the ramp only extends 8 feet out which causes it to be steep (for every inch in height the ramp should extend out a foot-this ramp should be 16 feet long and not 8 feet long).
e. Portions of the ramp were recently painted, making the ramp slippery when wet.
f. Broken pieces of metal were found with sharp edges on the floor.

5. The emergency room was visited on 8/15/11 at 9:00 am and provided evidence that they do not have a decontamination area according with Guidelines for Design and Construction of Health Care facilities (GDCHCF) chapter 2.1, section 5.1.3.7, number 5 and A5.1.3.7(5). This area should measure at least 80 square feet, there needs to be at least two hand held shower heads, the walls floor and ceiling need to be non-porous (for cleaning) there needs to be an outside door to enter this room and there needs to be a water drain trap to collect the used water. If the facility determines to use an external area for this purpose, it needs to be located within 150 feet from the ambulance entrance, there are water and electrical outlets, the area has to be well lighted and the paved ground needs to be marked off in yellow paint with the word "Decon".

6. The handicapped parking spaces to the side of the hospital were visited on 8/15/11 at 1:15 pm and the following was found:
a. The handicapped parking spaces do not have at least one handicapped sign that indicates "Van Accessible".
b. The handicapped spaces need to be painted again to clearly divide the divisions.
c. The route of travel is not smoothly paved to allow persons in wheelchairs to easily transition from the parking to the building.

7. The operating room department was visited on 8/16/11 from 8:15 am through 9:30 am with the facility's Safety Officer (employee #4) and provided evidence of the following:
a. The male and female personnel dressing room and ambulatory patient's dressing room are not constructed to provide one-way traffic. Staff and patients enter through a door located in a non restricted hallway at the entrance and cross over to the dressing room where they change from their street clothes into their scrubs and patients in operating gowns and then access the same non restricted hallway in their scrubs and gowns and then pass through a door that opens into operating suites #1 and #2 room area (semi-restricted) and patients pass into the recovery room.
b. The facility operates on ambulatory patients but they do not have a designated phase II area. The lounge chairs for this area must be separated by curtains and there needs to be at least four feet between each chair and the seats should be placed to avoid visual contact from patient to patient, there needs to be a bathroom for patients, area for patient's family members and area for nursing personnel to write and have visual contact with patients.
c. The facility has a room next to operating suite #3 that is used to process equipment with Cidex OPA. The exhaust fan in this room is located across from the the Cidex OPA tray which places employees working in this area in the direct line of the ventilated exhaust. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media and no evidence was found that the facility has a spill kit to use if Cidex OPA accidentally falls on the floor or procedures to follow when discarding Cidex OPA down the drain.
d. The housekeeping closet located near the recovery room was visited and provided evidence that it does not have a floor receptor (floor sink). A service sink was found at approximately three feet high (from the floor), which increases the risk of staff hurting themselves when lifting pails filled with dirty water and splashing. A mop hanger is also needed at this closet to ensure proper drying (usually placed over the floor receptor) and a door closer is needed for the door.
e. There are three operating room suites, however only one bucket was found to clean the operating suites, instead of one mop and one bucket per suite (the mops had the suite number on them except for one of them). Also, a separate mop and bucket are needed for the hallways and recovery. Also, no evidence was found of policies and procedures related to mop changes.
f. The room with the autoclave is also used to store the sterilized equipment. This room has one door used to enter dirty equipment and it is also accessed to retrieve sterilized equipment and the room was found with a roof leak.
g. There is a roof leak near the operating suite supervisor office.

8. The cement ramp located in front of the hospital was visited on 8/15/11 at 1:30 pm and the following was found:
a. The ramp is too steep (does not comply with the "one to twelve rule"). The height where the ramp begins is 12 inches above the floor but the ramp only extends 4 feet out which causes it to be steep (for every inch in height the ramp should extend out a foot-this ramp should be 12 feet long and not 4 feet long).
b. The handrails are flat pieces of wood (approximately 1 inch wide by 4 inches in depth). According with the requirements from "Americans with Disabilities Act" (Ley ADA) handrails shall allow persons to grasp it with ease if they have functional limitations in their hands (round tubing measuring between 1 ¼ inches to 1 ½ inches in circumference to ensure graspability).

9. The facility has two outside metal garbage containers located in the parking area as observed on 8/15/11 at 11:45 am with the facility's Safety Officer (employee #4). The containers were found without the lids on and the containers are used to place trash from the hospital and also from the kitchen. Even though the containers are far from the kitchen and hospital, lids are important to reduce areas for rodents and flies to feed.

10. The biohazardous waste storage room located in the parking area was visited on 8/15/11 at 11:55 am with the facility's Safety Officer (employee #4) and it was found extremely hot, is not properly ventilated nor is it properly cooled to protect personnel when entering this room to place waste and to weigh it in the prepared boxes.

11. The facility does not have a dedicated morgue as determined on 8/17/11 at 9:25 am with the facility's Safety Officer (employee #4). The Safety Officer (employee #4) was interviewed on 8/17/11 at 9:30 am and he stated that the facility does not have a morgue, however when patients die at the facility they are taken to any unoccupied room (room doors are not equipped with locks for this purpose) and the air conditioner is placed extremely cold and after the funeral home takes the body, the room is disinfected. He also stated that there have been occasions where the body waits between 4 to 6 hours. The facility failed to ensure that dead bodies are protected and safe guarded until they are taken from the facility and failed to evaluate if a body refrigerator could resolve the situation to store and safe guard dead bodies.

12. During observations of the emergency exit ramp near the nursing station at the lower ward on 8/16/11 at 11:25 am with the facility's Safety Officer (employee #4), it was found that the ramp does not have handrails. According with the requirements from "Americans with Disabilities Act" (Ley ADA) handrails shall be placed on both sides of ramps with round tubing measuring between 1 ¼ inches to 1 ½ inches in circumference to ensure graspability.

13. During observations of the ramp used to enter the emergency room on 8/15/11 at 8:45 am with the facility's Safety Officer (employee #4), it was found that the ramp only has one handrail. The handrail on the left side of the ramp as you go up the ramp was measured for height and was found to be 28 inches high and the handrail is a flat piece of wood (approximately 1 inch wide by 4 inches in depth). According with the requirements from "Americans with Disabilities Act" (Ley ADA) handrails shall be placed on both sides of ramps and the piece of wood will not allow persons to grasp it with ease if they have functional limitations in their hands (round tubing measuring between 1 ¼ inches to 1 ½ inches in circumference to ensure graspability).

14. The handicapped toilet in the isolation room of the emergency room was visited on 8/15/11 at 9:45 am with the facility's Safety Officer (employee #4) and it was found that the toilet was measured at 15 inches high, in order for this bathroom to comply with Americans with Disabilities Act (Ley ADA) requirements for toilet heights, the toilet seat must be between 17 and 19 inches in height from the floor.

15. Observations made from 8/15/11 through 8/17/11 from 8:00 am till 3:00 pm of patients being dropped off to receive services and patients being picked up after receiving these services (medical appointments, laboratory tests, ambulatory surgery and X-rays are some of the services provided at this facility) provided evidence that the main entrance of this hospital is not equipped with a covered entrance to protect patients from the sun and rain to allow patients to be dropped off and picked in a safe and comfortable manner. On 8/16/11 at 11:50 am there was a strong rain storm and patients and visitors were observed getting wet when entering and exiting cars. According to the Americans with Disabilities Act (ADA) section 6.2, "At least one accessible entrance shall be protected from the weather by canopy or roof overhang. Such entrances shall incorporate a passenger loading zone".

16. The hospital's laundry was visited on 8/15/11 at 2:00 pm with the facility's Safety Officer (employee #4) and provided evidence that the flow of dirty linen to the washer machine, to the dryer and then to the clean linen folding table does not move in one direction (from dirty to clean). The dirty linen cart enters through the waiting room of the sonogram department and then passes through the clean area (clothes dryer and table to fold the linen) and then it enters the room that has the washing machines. After the linen are washed they go back to the room with the dryer and when they finish drying they are passed to a table where they are folded. The folding table was found with broken formica, is small and was found with a phone and papers and the wall behind the table has a bulletin board. After the linen are folded they are placed in a bin and then afterwards they are placed in plastic bags. The folding area was found extremely hot and three fans were on and the windows were open (with screens) and the window behind the dryer is facing the parking area. These procedures increases the risk of cross contamination of the clean linen with the dirty linen and the outside environment.

17. The shower head in the laboratory department used in the event of an emergency was observed on 8/15/11 at 2:15 pm with the facility's Safety Officer (employee #4) and it was found with a small leak and the shower head is too small for its purposed use.

Based on the observational tour with the infection control officer (employee #9) and review of policies/procedures (P&P), it was determined that the facility failed to promote sanitary and safe care through its infection control program at the lower ward, upper ward, Intensive Care Unit (ICU), biomedical waste area and Laundry area related to rooms with air conditioners off, equipment with mold, lack of P&P related to the ice maker cleaning, patient cleanser products in a tray used for all patient, broken formica and single dose medications opened available for patient use.

Findings include:

1. During the observational tour with the infection control officer (employee #9) at the upper ward on 8/15/11 from 8:45 am till 9:10 am the following was found:

a. It was observed that the upper ward was closed due to the census, Rooms 201 through 209 were found with their air conditioners turn off.

b. The housekeeping room near room 201 was found with the door closed but without a lock.

c. In the Pantry area a refrigerator for patient's food was found with its edges with mold.

d. In the pantry of the lower ward was observed that the wall behind the sink in cement without tiles.

e. Patient's beds were observed with mold in the bed frame and rails in rooms #202, #203, #208 and #207.

f. In the hallway near the operating room it was observed the acoustic ceiling tiles have black spots with humidity.

2. During the observational tour with the infection control officer (employee #9) at the lower ward on 8/15/11 from 9:15 am till 10:15 am the following was found:

a. It was observed that the shower chair had mold in room #101.

b. The acoustic ceiling tiles in room #102 near the window was observed with a black spot.

c. The housekeeping room near room #102 at the lower ward was found with the door closed but it did not have a lock.

d. Patients' beds were observed with mold on the rails in rooms #104, #105, #108 and #113.

e. The crash cart was observed in the hall way near room #107 and was observed with mold.

f. The facility lacks of policies and procedures related to the cleaning process of the ice maker.

g. The supply room of the isolation room was found without an air condition, the room has an extractor and was turn off. In the room it was observed bed linen, healing product, sterile water, saline solution for irrigation and hydrogen peroxide.

h. The clean material room was found with a tray with wound cleanser product as a bottle of used sterile water for irrigation, used saline solution for irrigation, a bottle of Povidone Iodine 10% solution with a dirty top, Dermal wound cleanser, Cleaning foam, perianal skin cleanser, protective Barrier, all these products were used with multiple patients when according to the infection control standards of practice they are to be used with only one patient.

3. During the observational tour with the infection control officer (employee #9) in the Intensive Care Unit (ICU) lower ward on 8/15/11 from 10:15 am till 10:30 am the following was found:

a. The door to the entrance of the units was observed with peeling paint.

b. The pantry was observed with the nursing personal refrigerator and the patient's refrigerator has all of its edges with mold.

c. In the pantry the counter was observed with broken formica.

d. In the medication room it was found that the medication refrigerator was without a lock and a single dose vial of Diltiazem HCL injection 50 mg/10 ml was open without a label and available for patient use.

4. During observation of the path used by the personnel to move dirty linen to the laundry room it was found on 8/15/11 at 10:30 am that containers with dirty linen are transported through a waiting area used by sonogram patients and it is then passed through the clean area of the laundry (dryer machine and folding table). Then the container is entered into the dirty area of the laundry (washing machine area. After linen are washed they are passed once again through the clean area where they are dried and then folded.

Based on observations made of the surgical department, interview and review of policies/procedures with the Operating Room Manager (employee #3), it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice and patients' care.

Findings include:

1. Observations made of the surgical department on 8/16/11 from 9:30 am till 12:00 noon provided the following evidence:

a. It is required by local law to comply with the guidelines for Design and Construction of Hospital and Health Care Facilities. These guidelines on table 7.2 (ventilation requirements for areas affecting patient care in hospitals and outpatient facilities) requires that the relative humidity must be kept between 30-60 % in the operating suites, the following relative humidity were measured on 8/16/11: in suite #1 the humidity registered 57% at 9:40 am, in suite #2 the humidity registered 57% at 9:55 am, in suite #3 the humidity registered 57% at 10:40 am.

b. The housekeeping maintenance room was observed on 8/16/11 at 10:50 am with three mops and one pail. During interview with the housekeeping personnel (employee #22) he said he has one mop for every suites and a pail for all areas. This procedures does not protect the facility's patients from possible cross contamination from one suite to the another.

c. In the sterile material area the following was observed on 8/16/11 at 11:00 am, no evidence was found of the relative humidity and temperature log.
d. In the minor surgery suites the following was observed on 8/16/11 at 11:30 am: wall paint is cracked and Cidex OPA was found in two plastic trays that are not recommended by the manufacturer.
e. A Nurse (employee #19) was observed entering in the minor surgery suites without a mask on.

f. In the central supply area the following was observed on 8/16/11 at 11:20 am: The autoclave room was also observed used as the sterile supply storage area. After equipment is used in the different suites it is passed through this area with the sterilized supplies. This area was found with four wet ceiling acoustic tiles. The operating supervisor (employee #3) was interviewed on 8/16/11 at 11:25 am and she stated that when it rains the acoustic tiles get wet. This procedures does not protect from possible cross contamination from the central supply to the autoclave.

Based on the review of nine medical records and policies/procedures of the operating room with the Operating Room Manager (employee #3), it was determined that the facility failed to execute complete surgery informed consents that includes name of physician, possible procedure complications, name of anesthesiologist authorized to administer the treatment and the name of physician that took the consent for three out of nine records reviewed (R.R #9, #12 and #25).

Findings include:

1. During the review of seven records on 8/16/11 from 9:40 am till 2:30 pm, the following was determined:

a. R.R #25 provided evidence that the surgical procedure consent form lacks the name of anesthesiologist authorized to administer the treatment, the name of physician that took the consent.
b. R.R #9 provided evidence that the surgical procedure consent form lacks the name of anesthesiologist authorized to administer the treatment, lack of the hour that the consent was taken and did not include possible procedure complications.

b. R.R #12 provided evidence that the surgical procedure consent form did not include the name of anesthesiologist authorized to administer the treatment and lacks the date and hour when the consent was taken.

Based on documents reviewed with the Operating Room Supervisor (employee #3), it was determined that the facility failed to ensure that the operating room log registry is complete.

Findings include:

A surgery registration log book and recovery room registration log book were observed on 8/16/11 at 2:00 pm with incomplete spaces and spaces left in blank.

Based on the review of nine medical records to evaluate anesthesia services with the Operating Room Manager (employee #3), it was determined that the facility failed to ensure that informed consent forms are properly executed for three out of nine records reviewed (R.R #9, #12 and #21).

Findings include:

1. During the review of nine medical records on 8/16/11 from 9:30 am till 2:30 pm the following was found:

a. R.R #9 provided evidence that the surgical procedure consent form lacks the name of anesthesiologist authorized to administer the treatment and type of anesthesia given to the patient.
b. R.R #12 provided evidence that the surgical procedure consent form lacks the name of anesthesiologist authorized to administer the treatment, type of anesthesia given to the patient and did not include possible procedure complications.

c. R.R #21 provided evidence that the surgical procedure consent form lacks did not include possible procedure complications.

Based on nine medical records reviewed (R.R), policies/procedures manual and the observational tour with the emergency room (E.R) nursing supervisor (employee #17) and interview, it was determined that the facility failed to follow infection control standards to prevent cross contamination, failed to ensure the patient's condition at the moment of transfer according to the patient's needs and failed to ensure that the condition at the moment of the transfer instead of a risk related to the health conditions on two out six records reviewed (R.R #39 and #41)

Findings include:

1. The following was observed in the emergency room on 8/15/11 from 8:30 am till 10:00 am related to infection control procedures:

a. During the observation tour of the medication room on 8/15/11 at 8:45 am the registered nurse (employee #21) was observed preparing medications and intravenous bags. The RN was observed touching the lid of the garbage container with her hands when she threw trash in the container. Self closing (foot pedal) garbage containers are needed to ensure that personnel do not have to touch the lids when opening and trash located in the container is separated for the environment.

b. One full sharp container was found inside the biohazardous trash container near observation cubicle #2 on 8/15/11 from 8:30.

c. One empty gallon of Metricide was observed inside the regular trash container in the observation room near isolation room on 8/15/11 at 8:35 am. The ER supervisor (employee #17) stated on 8/15/11 at 8:35 am that the empty gallons of Metricide solutions was discarded in the biohazardous trash container.

d. One plastic bags with respiratory equipment were observed at cubicle #2 without the patient's name, a label with the date and time when started. Also, the patient in this cubicle did not have an order for respiratory therapy. The ER supervisor (employee #17) stated on 8/15/11 at 8:40 am that respiratory therapy equipment is managed and changed by respiratory personnel according with respiratory therapy policies and procedures.

e. The crash carts with cardiac monitor/defibrillator was found with rust in the observation area on 8/15/11 at 9:15 am

2. One out of six transfers of closed records provided evidence that the physician failed to document the correct hour at the moment that the patient was transferred and disposition of the patient (R.R #41).

a. R.R #41 is a 16 years old male who visited the emergency room on 6/8/11 at 3:10 am with Mayor Depression and Suicidal Ideas. The triage was performed at 3:10 am and the patient was categorized as "urgent". The record was reviewed on 8/17/11 at 9:30 am and provided evidence that the ER physician evaluates the patient related to suicidal ideas with left wrist laceration and ordered treatment at 3:40 am. The patient's condition was observed and was transferred to another facility on 6/8/11 at 5:40 pm. The transfer sheet was reviewed and provided evidence that the physician did not document the hour when the patient was transferred. For the disposition of the patient in the medical record, the physician documented that the patient was transferred on 6/8/11 at 8:50 am, but it is not until 5:40 pm that a E.R registered nurse documents that the patient was transferred. The facility failed to ensure that the patient's condition was re-evaluated by an E.R physician at the moment that the patient was transferred to the other facility to verify if the patient's needs had changed from 8:50 am (hour of the transfer note) till 5:40 pm (when the patient was actual transferred) which is a span of almost 9 hours (the physician who tranferred the patient at 8:50 am and signed the note did so before the patient was actual transferred).

3. One out of six closed clinical records were reviewed for transfer procedures on 8/17/11 from 9:00 am till 1:30 pm for emergency room services did not provide evidence that the physician documented the condition at the moment of the transfer for R.R #39. The patient was evaluated and stabilized with a diagnosis of Head Trauma with Multiple Body Trauma after the initial evaluation of the emergency room visit.

Based on the review of six respiratory therapists credential files (C.F) with the Director of the Nursing (employee #2), it was determined that the facility failed to ensure that six out of six respiratory therapists personnel meet the qualification specified and consistent with State laws related to certificate of health, annual evaluations and competencies and Hepatitis B vaccines (C.Fs #1, #2, #3, #4, #5 and #6).

Findings include:

1. Two out of six respiratory therapists credential files reviewed on 8/17/11 at 11:30 am provided evidence of expired cardio respiratory certifications (CPR) (C.F #2 and #4).

2. Six out of six respiratory therapists credential files reviewed on 8/17/11 at 11:30 am did not have evidence of updated annual evaluations and competencies related to her functions of clinical assistance (C.F #1, #2, #3, #4, #5 and #6).

3. Three out of six respiratory therapists credential files reviewed on 8/17/11 at 11:30 am did not have evidence of Hepatitis B vaccine (C.F #2, #3 and #5).

Based on the review of seven 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 the physician's lack of written respiratory therapy notes in accordance with standards of practice related to the type and amount of diluent and the unit of concentration of the medication provided for one out of seven clinical records reviewed (R.R #22).

Findings include:

1. Seven medical records were reviewed on 8/16/11 from 8:30 am till 3:00 pm and on 8/17/11 from 8:45 am till 11:30 am of patients who received respiratory therapy and provided evidence that the respiratory therapy order lacked the type and amount of diluent of the therapy and lack of unit dose of the respiratory therapy.

a. R.R #22 is an 86 years old male admitted on 8/17/11 with a diagnosis of Bronchopneumonia. The record review was performed on 8/17/11 at 8:45 am with the Respiratory Therapist Supervisor (employee #10) and provided evidence that the physician ordered on 7/30/11 at 11:50 am Atrovent 2.5 /3 normal Saline (NSS) every 4 hours. On 8/4/11 at 8:45 am Atrovent /3 NSS every 4 hours was ordered. On 8/9/11 at 7:55 am the physician ordered Atrovent 2.5/3 every 4 hours. On 8/13/11 at 8:30 am the physician ordered Atrovent 2.5/3 ml every 6 hours. However the physician failed to write a complete physician order related to the unit dose of the Atrovent and failed to identify the amount and type of diluent. Facility policies and procedures reviewed on 8/17/11 at 11:00 am stated that the written order for aerosolized drug therapy should contain: therapeutic order, dose, hour, bronchial dilator, diluent and the number of days to be managed. Evidence was found of the incomplete patient's assessment after respiratory therapy treatments and of incomplete patient's assessment for initial respiratory therapy treatments.

Based on the review of eleven medical records and interviews, it was identified that the facility failed to provide necessary care and services to monitor, document and implement fall prevention risk assessments, plan of care and surveillance for record review (R.R) #13 that required patient safety provisions to avoid an accident.

Findings include:

1. A mechanism to ensure that proactive measures are implemented in order to prevent falls for patients at risk was not followed nor evidenced. During the survey process on 8/16/11 from 8:45 am through 3:00 pm the following was identified:

a. R.R #13 is a 73 years old male patient admitted on 2/23/11 with a diagnosis of Sepsis Secondary to Prostatitis to the Intensive Care Unit. The patient was ordered bed rest with side rails up and oxygen by nasal cannula at 2 liters. The patient was receiving care at the intensive care unit until 2/27/11 when the physician ordered to transfer the patient to the medicine ward at 2:30 pm. The physician's transfer orders did not include orders or special provisions that specify if the patient could ambulate or needed to remain on bed rest with bathroom privileges. The patient was transferred to the ward and was located at room #2 at 3:45 pm. From 7:00 pm through 8:00 pm the patient received visits from relatives according with documentation of nurse's notes reviewed with the nursing supervisor (employee #7) on 8/16/11 at 9:55 am. At 9:30 pm and according with the incident and accident reports reviewed with the nursing supervisor (employee #7) on 8/15/11 at 10:00 am, the patient was found on the floor unresponsive with shortness of breath by the security officer who was giving rounds at the rooms to ensure that the visitors left the hospital. The patient was evaluated by the emergency room physician who intubate the patient and transferred him to the intensive care unit where he was placed on mechanical ventilation. Circumstances where the incident occurred or determination of the time that the patient remained on the floor until he was discovered by the security officer was not included on the incident report, nor determined by the risk management personnel during the analysis of the incident. Fall risk assessment for this patient was not determined after the transfer to the ward to determine changes in medical condition that could put him at risk for falls. The facility failed to promote an assessment and plan of care for this patient who had risk factors to fall in order to maintain or promote the patient's safety. This record was reviewed as a closed record in order to determine exactly what happen in the incident and if the facility set priorities for its performance and improve the management of the patient at risk for falls after the incident. However, the facility failed to take measures to ensure that fall prevention protocols are followed according with facility policies. Surveillance of cases identified at risk for falls to determine if nursing personnel operationalized fall prevention protocols (plan of care and rounds) are not performed.

b. The Nursing Supervisor (employee #7) stated during an interview on 8/16/11 at 1:43 pm that when a patient is admitted to the facility, nursing personnel assess the patient's needs and health status by documenting it in the nursing history. If the nurse determines that the patient is at risk for falls a green label is included in the treatment kardex, plan of care for fall prevention is developed and implemented and rounds every hour must be performed.

Based on observations of the medication drug cart with the nursing director (employee #11) and interview, it was determined that the facility failed to ensure that drugs and biologicals are stored and protected in a proper manner related to medications not secured in the medication cart and failed to follow nursing staff competence for Medication Administration for two out of two patients observed.

Findings include:

1. During the observational tour of the ground floor ward on 8/15/11 at 9:10 am with the nursing director (employee #2), the medication cart was observed unattended while the nurse (employee #18) was in patient's rooms.

a. Medication drug carts were observed unlocked and unattended while a nurse administered medications to the patient at the medicine II ward room #10-6 at 9:10 am.

2. The following was observed during the medication administration on 8/15/11 from 9:15 am through 9:30 am related to medication administration:

a. During observations in rooms #1-04 and #1-05 of the medication administration (oral route) performed on 8/15/11 at 9:15 am through 9:30 am, accompanied by a Registered Nurse (RN) (employee #18) she was observed serving medications for patients and signed the medication administration record (MAR) before given the medications to the patient. RN #18 failed to follow professional standards of practice related to medication administration by not waiting until the medications are administered to the resident before signing the MAR.

Based on facility menus cycles reviewed and interview with the Dietitian (employee #16), it was determined that the facility failed to ensure that menus provided by the hospital must be nutritionally balanced and meet the special needs of the patients.

Findings include:

During the review of the facility's established menus on 8/16/11 at 9:00 am and review of the food served for this menus, it provided evidence that the food served was not the same as the programed menus. The facility's dietitian (employee #16) was interviewed on 8/16/11 at 11:00 am and she stated that the changes were due to the lack of food available for the menus because the food shipment arrived late. This was also observed for the menus from the previous weeks. The facility failed to ensure that programed menus with established Recommended Dietary Allowances (RDA) that are calculated for their patient's and when changes are made to the menus this may change the RDA.