HospitalInspections.org

Based on the review of hospital licenses/certifications, it was determined that the facility failed to ensure that it is in compliance with Federal and State laws related to an expired Sanitary license.

Findings include:

During the review of the facility's licenses/certifications on 8/30/12 at 2:30 pm, it was identified that the facility's Sanitary license expired on July 15, 2012. The facility provided evidence that they submitted and paid for the Sanitary inspection and license on June 20, 2012, but they have not arrived to perform the inspection and give them the license.

Based on the review of medical records, personnel credential files, documents, preventive maintenance documentation, observations, tests and interviews on 8/21/12 from 10:00 am 4:00 pm and from 8/28/12 through 8/30/12 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: Governing Body (42 CFR 482.12), Patients Rights (42 CFR 482.13), Food and Dietetic Services (42 CFR 482.28), Physical Environment (42 CFR 482.41), Discharge Planning (42 CFR 482.43) and Emergency Services (42 CFR 482.55).

Based on the review of institutional plan documents, it was determined that the facility failed to ensure that the institutional plan provides for capital expenditures for at least a three year period including the operating budget year.

Findings include:

The facility's institutional plan was reviewed on 8/30/12 at 2:00 pm and provided evidence of the annual operating budget. However, no evidence was provided of a plan for capital expenditures for at least a 3-year period which includes anticipated income and expenses.

Based on observations, interviews, medical records reviewed and review of policies and procedures and documentation related to exercising rights, informed consent, notice of rights, grievances and restraints and seclusion process on 8/21/12 from 10:00 am till 3:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:00 pm on the third floor Medicine ward, Medicine/Surgical Ward, Central Medicine Ward and Intensive Care Unit with the quality assurance officer (employee #9), it was determined that the facility failed to protect and promote patient's rights related to the notice of rights requirements, inform consent, failed to ensure that pain assessment and management are performed for patients with difficulty communicating or cognitive and sensory impairment, failure to address patients expectations of care and services in a consistent manner, failure to ensure that policies and procedures related with restriction protocol are followed, failure to ensure that policies and procedures related with advance directives for DNR orders are followed, which makes the Patient's Rights Condition of Participation "Not Met".

Based on records reviewed (R.R) and Policies and Procedures and interview, it was determined that the facility failed to have a mechanism in place to ensure that information related with patient's rights is informed to patients, or when appropriate to patient's representatives before providing care or stopping care for three out of three records reviewed (R.R) #9, #36 and #38.

Findings include:

1. The following was found during records reviewed with the nursing supervisor (employee #16) and admission department personnel (employee #19) on 8/21/12 at 11:53 am:

a. R.R #9 is an 87 year old male admitted to the medicine ward on 8/13/12 with a diagnosis of Pneumonia. Information related to patients' rights as hospital patients was not informed until 8/17/12 four days after admission. The nursing supervisor (employee #16) stated during an interview that information related with patients' rights and other accompanying documentation that supports the continued need for inpatient services (patient rights, visiting hours) must be informed upon admission. However due to the lack of personnel in the admission department this documentation was provided to patients several days after admission.

b. R.R #36 is a 91 year old female admitted to the medicine ward on 8/20/12 with a diagnosis of Pneumonia. Information related to patients' rights as hospital patients was left in blank. The nursing supervisor (employee #16) stated during an interview on 8/21/12 at 10:47 am that information related with patients' rights as hospital patient must be provided upon admission. However due to the lack of personnel in the admission department this documentation was provided to patients after they were admitted, personnel then visited the patient in her room.

c. R.R # 38 is a 60 year old female who was admitted to the hospital on 8/8/12 and then transferred to the intensive care unit on 8/13/12 with a diagnosis of Respiratory Failure. Information related to patient rights as hospital patients was left in blank. The nursing supervisor (employee #7) stated during an interview on 8/21/12 at 11:12 am that information related with patient rights as hospital patient must be provided upon admission. However due to the lack of personnel in the admission department this documentation was provided to patients after they were admitted, personnel then visited the patient in her room.

2. On 8/21/12 at 11:49 am the admission department personnel (employee #18) was found in front of room #206. She stated on 8/21/12 at 11:50 am that she was in charge of informing patients about their rights as hospital patients and delivered accompanying documentation that supported the continued need for inpatient services that must be informed upon admission. She also stated that due to the lack of personnel in the admission department this documentation was provided to patients after they were admitted, personnel then visited the patient in their rooms. She also stated that she had about 20 patient admission package information to inform to patients and completed it this morning.

Based on grievance records reviewed and Policies and Procedures and interview, it was determined that the facility failed to address patients expectations of care and services in a consistent manner.

Findings include:

1. From March/2012 through July/2012 five complaints regarding housekeeping services from the Oby-Gyn ward, third floor Medicine ward and Medicine/Surgical Ward were filed by patients. Housekeeping services intervene in the management of those complaints however the follow-up of this service provided in these areas where patients filed the complaints were not performed on an ongoing basis. Evidence that housekeeping services encouraged and involved all personnel concerning the patient grievances during this period of time was not found documented as evidenced on 8/29/12 at 9:50 am.

2. From January/2012 through July/2012 thirty-two complaints regarding services provided in the emergency room were filed by patients. Twenty-eight of these complaints were related with patient care and treatment services. Each complaint was managed according with facility grievance policies and protocols, however evidence that the facility developed corrective action plans which include all personnel and services concerning grievances was not found documented as evidenced on 8/29/12 at 9:57 am.

3. From January/2012 through July/2012 the facility followed-up on cases that eloped or left against medical advice from the emergency room department. They contacted by phone the patients to inquire why they eloped or left the emergency room against medical advice, approximately 33 % of the cases informed that they left the facility due to bad patient care and treatment services provided. Evidence that the facility develop corrective action plans
according with the information provided by patients who left the emergency room
was not found documented as evidenced on 8/30/12 at 10:20 am.

Based on records reviewed (R.R) and Policies and Procedures and interview, it was determined that the facility failed to ensure that pain assessment and management are performed for patients with difficulty communicating or cognitive and sensory impairment for one out of one record review (R.R) #28.

Findings include:

1. A mechanism to ensure that pain protocols and tools by which pain can be better recognized in non-communicative patients was not promoted, nor followed according with the following findings discussed with the nurse supervisor (employee #16) and quality assurance officer (employee #9) on 8/21/12 at 11:53 am:

a. R.R #28 is a 66 year old female admitted to the facility on 7/16/12 with a diagnosis of Intestinal Obstruction, the patient has a history of Cancer and suspected liver neoplasia. The patient was receiving care at the facility and his health care declined and needed to be intubated on 7/18/12 and connected to a mechanical ventilator. On 8/21/12 the patient was observed with a urine catheter with gross hematuria. The nursing supervisor (employee #16) was asked on 8/21/12 at 10:00 am if personnel performed the pain assessment and management due to her history of Cancer and gross hematuria and she stated that the pain assessment protocol was activated when the patient refers pain, if the patient does not refer pain, personnel do not activate provisions for assessment and management included in the pain assessment protocol.

b. The quality assurance officer (employee #9) stated on 8/21/12 at 1:00 pm that the facility's pain protocol does not include provisions to perform assessment in patients with difficulty communicating or with cognitive and sensory impairment, she also stated that they use the Wong-Baker scale which does not include provisions to assess pain in patients with difficulty communicating or cognitive and sensory impairment.

Based on records reviewed (R.R) and Policies and Procedures, it was determined that the facility failed to have a mechanism to ensure that inform consent forms taken before procedures or treatments include all relevant facts and information at the time the consent is taken for three out of three R.R #6, #28 and #37.

Findings include:

1. The following findings related with the inform consent form procedures was discussed on 8/21/12 at 11:53 am with the quality assurance officer (employee #9):

a. R.R #28 is a 66 year old female admitted to the facility on 7/16/12 with a diagnosis of Intestinal Obstruction. The patient was intubated and receiving Mechanical Ventilation. On 8/10/12 the patient was sent to the operating room to perform a tracheostomy and her sister signed the consent for the procedure. However the consent lacked the date, hour taken and risks of the procedure.

b. R.R #37 is a 74 year old male admitted to the intensive care unit on 8/18/12 with a diagnosis of Respiratory Failure and Congestive Heart Failure. The patient was intubated and receiving Mechanical Ventilation. A bronchoscopy was performed on the patient on 8/21/12 at 8:00 am. A relative signed the consent for the procedure, however the consent lacked the date, hour taken and risks of the procedure.


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c. R.R #6 is an 80 year old male admitted to the facility on 8/24/12 with a diagnosis of Bilateral Hip Pressure Ulcer. On 8/27/12 the patient was sent to the operating room to perform a cleaning and debridement of both hip pressure ulcer and the patient's relative signed the consent for the procedure. However the surgery consent was left in blank by the physician and the anesthesia consent lacked the type of anesthesia to be given to the patient.

Based on three medical records reviewed (R.R) with "Do Not Resuscitate" (DNR) orders and "Do Not Intubate" (DNI), review of DNR and DNI protocols and policies/procedures, it was determined that the facility failed to ensure that policies and procedures related to advance directives for DNR and DNI orders are followed for one out of three records reviewed with DNR and DNI orders (R.R #28).

Findings include:

R.R #28 is a 66 year old female admitted to the facility on 7/16/12 with a diagnosis of Intestinal Obstruction, the patient has a history of Cancer and suspected liver neoplasia. The patient was receiving care at the facility and his health care declined and needed to be intubated on 7/18/12 and connected to a mechanical ventilator. A consent to "Do Not Resuscitate" and "No Mechanical Ventilation" was found signed by a patient's relative on 7/24/12 in the event that the patient extubated or needed cardiopulmonary resuscitation. However the physician's signature was not found documented on the consent form.

Based on records reviewed (R.R) with the quality assurance officer (employee #9), it was determined that the facility failed to promote the patient's right to be free of restraints in two out of three records reviewed (R.R #40 and #43).

Findings include:

1. R.R #40 is a 76 years old male who was admitted on 8/24/12 with a diagnosis of Neurologic Deficit and General Weakness. The record review was performed on 8/28/12 at 9:45 am with the quality assurance officer (employee #9) and provided evidence that the physician placed a telephone order on 8/28/12 at 1:40 am for restrictions. The patient was maintained on restrictions on 8/28/12 and 8/29/12, based on a telephone order. No evidence was found of the information in the physician's progress notes related with the patients restrictions orders and justification for the restriction. The facility failed to comply with restriction protocol which establishes that patient restrictions must be justified based on a decisional algorithm which includes a complete assessment and evaluation of the patient.

2. R.R #43 is a 68 years old male who was admitted on 8/15/12 with a diagnosis of Bronchopneumonia. The record review was performed on 8/29/12 at 1:20 pm with the quality assurance officer (employee #9) and provided evidence that the physician placed a telephone order on 8/19/12 at 11:45 am for restrictions. The patient was maintained on restrictions on 8/18/12 and 8/19/12, based on a telephone order. No evidence was found of the information in the physician's progress notes related with the patient's restriction orders and justification for the restriction. The facility failed to comply with restriction protocol which establishes that patient restriction must be justified based on a decisional algorithm which includes a complete assessment and evaluation of the patient.

Based on observations and review of quality assurance activities with the Quality Assurance Officer (employee #9), it was determined that the facility failed to act upon indicators for which there is evidence that it will improve patient health outcomes.

Findings include:

The facility participates with a Quality Improvement Professional Research Organization in partnership improvement projects to improve patient health outcomes. Quality Indicator information of patients treated for acute myocardial infarction, heart failure, pneumonia or having surgery were transmitted as part of the project. During the first trimester of year 2012 (January through March) the facility had a lower percentage related with Surgical Improvement Project, Pneumonia Project, Acute Myocardial Infarction and Heart Failure when compared with a national database and other hospitals in the geographical area. No discussion or analysis of reasons or plans to improve were evidenced and the facility failed to focus attention on these quality issues. Quality partnership improvement project results were reviewed with the Quality Assurance Officer (employee #9) on 8/30/12 from 10:15 am till 11:30 am.

Based on the review of pharmacy quality reports with the Pharmacist (employee #21), it was determined that the facility failed to use data collected to identify opportunities for improvement and changes that will lead to improvement.

Findings include:

1. A mechanism to ensure that the safe and appropriate use of medications and medication related services are promoted was not followed nor performed. The following findings were identified with the Pharmacist (employee #21) on 8/30/12 at 11:45 am:

a. Pharmacy Services reports revealed that they identified a pattern of irregularities in the process of medication preparation and distribution since May/2012 where nursing personnel use the emergency floor stock system instead of unit dose system. When medication therapies are ordered after regular working hours, personnel can use the floor stock system to begin the therapy, but when pharmacy services are available they have the responsibility to prepare and distribute drugs. However they identified that nursing personnel continue to use the floor stock system once the pharmacy served and delivered the medications to the unit dose system. These irregularities were identified by pharmacy personnel when they delivered the unit dose system to hospital areas. However, it is not clearly documented if the irregularities were investigated and analyzed by pharmacy personnel and the nursing personnel, in order to resolve the situation. The facility failed to follow pharmaceutical policies and procedures in order to minimize drug duplicity and minimize errors.

Based on the review of quality assurance activities with the quality assurance officer (employee #9), it was identified that the facility failed to include contracted services in the Quality Assessment and Performance Improvement (QAPI) program to maintain on-going quality assurance as established by the hospital's governing body and promotes quality assurance activities focused on patient health outcomes.

Findings include:

1. The facility's hospital-wide quality assurance activities master plan was reviewed with the quality assurance officer (employee #9) on 8/30/12 at 10:00 am and the following was identified:

a. Food and Dietetic Services, Housekeeping Services, Nuclear Medicine and Rehabilitation Services are contracted services that do not submit quality indicators data in order to be evaluated for the performance of their services.

Based on seventeen records reviewed with the operation room supervisor (employee #4), discharge planning supervisor (employee #6) and respiratory therapy supervisor (employee #15), it was determined that the facility failed to ensure that the medical history and physical examination (H&P) is completed and documented by a physician for each patient no more than 30 days before or 24 hours after admission or registration for two out of seventeen medical record R.R #7 and #8.

Findings include:

1. R.R #7 is a 66 years old female admitted to the facility on 8/27/12 with a diagnosis of Perforated Diverticulosis Transverse Colon. During the record review performed on 8/28/12 at 11:30 am it was found that the patient entered the operating room on 8/27/12 to perform a partial colostomy and requiring anesthesia services however the H&P was not performed by the patient's physician, it was left in blank.

2. R.R #8 is a 62 years old female admitted to the facility on 8/25/12 with a diagnosis of closed left ankle fracture. During the record review performed on 8/29/12 at 10:45 am, it was found that the patient needed surgery on 8/27/12 to repair the ankle fracture requiring anesthesia services, however the H&P was not performed by the patient's physician, it was left in blank.

Based on the review of clinical records and policies/procedures with the director of nursing (DON) (employee #7), it was found that the facility failed to ensure that two out of twelve records reviewed (R.R #8 and #25) have developed, updated and implemented nursing care plans.

Findings include:

1. Two out of twelve records reviewed for care plans from 8/29/12 through 8/30/12 from 9:30 am till 3:30 pm with the DON (employee #7), provided evidence that care plans do not have written evidence of revisions during the patients' hospital stay related to their needs:

a. R.R #8 is a 62 years old female who was admitted on 8/25/12 at 4:14 pm with Diabetes Mellitus, Neuropathy, High Blood Pressure and Arterial Disease, no evidence was found of the standardized plan of care in accordance with her health condition. No evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay. The facility used a standardized plan of care, however no evidence was found that the facility's nurses individualized the plan of care according to the patient's needs. No evidence was found of goals and objectives established to coordinate patients' nursing care.

b. R.R #25 is a 66 years old male who was admitted on 8/24/12 at 7:30 am with Acute Gastritis, Dehydration, Urinary Tract Infection and Paraplegic, no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay. The facility used a standardized plan of care, however no evidence was found that the facility's nurses initiated the plan of care and individualized the plan of care according to the patient's needs. No evidence was found of goals and objectives established to coordinate patients' nursing care.

Based on the review of the policies and procedure's manual, a manual of abbreviations and personnel signature registry provided by the medical record administrator (employee
#25), 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 8/30/12 at 10:30 am of an abbreviation manual that was approved by the Governing Body and includes the pharmacy supervisor's signature of participation.

2. The signature registry of physicians and other disciplines (nursing, dietitian, respiratory therapist) were reviewed with the Medical Record Administrator (employee #25) on 8/30/12 at 10:30 am. The signature registry was not updated nor was it approved by the Governing Body.

Based on the observational tour of the medical records department through the central file area with the Medical Record Administrator (employee #25) and interviews, it was determined that the facility failed to properly secure the central file of the medical records department, it is completely full to capacity and completed clinical records within 30 days following discharge.

Findings include:

1. The central file of active records was visited on 8/30/11 from 9:30 am till 10:45 am and was found completely full to capacity (second floor). The physical area does not have extra space available for new records to be filed. Approximately 10,000 to 15,000 admitted and emergency room clinical records were observed over different counter tops and tables without being filed because there is not enough space for storage. Approximately 500 emergency room clinical records were observed over the shelves near the entrance of the medical record room without being filed.

2. Approximately 28 boxes were found on 8/30/12 at 10:30 am with clinical records directly on the floor in a hallway near metal storage cabinets waiting to be moved to a contracted storage area. The Medical Record Administrator (employee #25) stated on 8/30/12 at 10:35 am that all of the boxes on the floor are from the past two years (2010 and 2011) and were prepared with the record numbers and then are sent to the storage area.

3. The incomplete medical record report reviewed on 8/30/12 at 2:30 pm revealed that there are 1,207 incomplete records over 30 days by the physician, nursing staff and other disciplines. There is an average of 652 monthly discharges.

Based on the observational tour of the medical record department with the Medical Record Administrator (employee #25), it was determined that the facility failed to ensure that unauthorized individuals gain access to the record department and that the records are protected.

Findings include:

On 8/29/12 at 11:30 am the medical record department was visit with the in-service training coordinator (employee #39) and it was found that the entrance door of the medical records department was not locked and did not prevent unauthorized access. On 8/30/12 at 9:30 am the medical record department was visited again and the front door was left open during the entire survey and the door was not label with a sign for "authorized personnel only". Medical records for admitted and emergency room patients were observed over different counter tops and tables without being filed because there is not enough space to store them near the entrance door.

Based on the review of fifty-eight closed and active clinical records with nursing personnel and the Medical Record Administrator (employee #25), it was determined that the facility failed to ensure that medical staff, nursing personnel and other disciplines maintain legible entries for fifty-eight out of fifty-eight records reviewed (R.R #1 through #58).

Findings include:

Fifty-eight clinical records reviewed from 8/21/12 from 10:00 am till 3:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm contained portions that are not legible. Most notable were the physician's progress notes, nurse's notes, signatures (physicians and nurses), consults, diagnosis, operative reports, informed consent forms, anesthesia reports, discharge summary and physician's orders.

Based on the review of twelve records reviewed (R.R), it was determined that the facility failed to ensure that 4 out of 12 records contain appropriate documents related to consult evaluations and appropriate findings by clinical and others staff involved in the care of the patient (R.R #8, #15, #16 and #17).

Findings include:

1. R.R #8 was reviewed on 8/29/12 at 8:10 am and failed to provide evidence on a consult requested by the Generalist to Orthopedist on 8/25/12 at 3:50 pm and consultation report to the Cardiologist did not have the reason for the request of the consultation, the physician ' s license number and the physician ' s signature.

2. R.R #15 was reviewed on 8/21/12 at 2:00 pm, ten consults were requested on different days and failed to provide evidence on the requested consults of consultant and or service, reason for the request, attending signature, license number, date and hour when notified and to whom it was notified. One consult request on 8/14/12 to a Pneumologist was performed by the physician on 8/19/12 at 6:35 pm (four days later).

3. R.R #16 was reviewed on 8/28/12 at 3:00 pm, four consults were requested on different days and failed to provide evidence on the consultation report of the hour of the consult request and the consultant and or service lacks the consult if stat or within 12 or 24 hours. Consult request on 8/24/12 lacks the hour and who notified the consult, record number and physician ' s name. Consult request on 8/26/12 at 12:30 pm lacks the consultant and or service date and hour, signature of attending physician, license number, date, hour and if the consult was stat or within 12 or 24 hours.

4. R.R #17 was reviewed on 8/21/12 at 2:30 pm, three consults were requested on different days and failed to provide evidence on the request of if the consults were notified by, to whom, date and hour, if the consult was stat, of within 12 or 24 hours, the reason for the request of the consultation was only written as " DM decompensated " , lacks the signature of the attending physician, license number, no evidence was found of finding and recommendations, no consultant's signature, date and hour. The consult requested on 8/19/12 at 3:57 am was from the Emergency room department. A consult request on 8/19/12 at 9:20 am lacks the date and hour, consultant and or service and if the consult was stat or within 12 or 24 hours. A consult request for an Infection Disease evaluation lacks the date and the hour when requested.

Based on the review of documents, observational tour with the Pharmacist (employee #21), it was determined that the facility failed to ensure that drug storage areas are administered in accordance with accepted professional principles related with the lack of medication storage in locked areas, an updated pharmacy formulary was not readily available, lack of documentation of information related with patient's weight and history of allergies in the Medication Administration Record (MAR) and lack of air conditioning in the room with the laminar flow.

Findings include:

1. During the initial observational tour with the pharmacist (employee #21) on 8/30/12 from 10:23 am though 11:54 am, the following was observed:

a. At the Gynecology Ward, the medication cart was found open, located at the nursing station and medication located inside were available to non authorized persons.

b. At the Medicine/Surgical Ward, nine out of twelve Medication Administration Records (MARs) reviewed lacked information related to the patient's weight, age and history of allergies.

c. At the Central Medicine Ward, seven out of eight Medication Administration Records (MARs) reviewed lacked information related to the patient's weight, age and history of allergies. The facility failed to keep an update Pharmacy Formulary at the patient's care units.

d. Medication refrigerators located at the Central Medicine, Medicine/Surgical, Gynecology ward and Intensive Care Unit with a large accumulation of ice in the freezer.

e. Temperature of the medication refrigerator located in the off hour medication stock was not taken or documented from 7/1/12 through 7/15/12.

e. A laminar flow device used to prepare chemotherapy was located in the Medicine/Surgical ward medication preparation room. This room did not have a working air conditioning; intravenous bags and other medications were observed located in this area.

Based on the review of documents, with the Pharmacist (employee #21), it was determined that the facility failed to ensure that pharmacy services are actively participating in the
supervision and coordination of all the activities related with pharmaceutical services.

Findings include:

The pharmacy committee is meeting every four months as reviewed on 8/30/12 at 11:50 am.
However, drug administration errors, adverse drug reactions and drug incompatibilities are not presented or discussed as part of the activities performed by the committee. Information related with drug adverse reactions and medication errors are sent directly to the quality assurance committee and are not reviewed by the committee for purposes of identifying causes and developing policies or procedures to prevent occurrences in the future.

Based on the review of medication adverse drug reaction reports with the Pharmacist
(employee #21), it was determined that the facility failed to promote that drug reactions and drug incompatibilities are immediately reported to the attending physician and if appropriate to the hospital-wide quality assurance program.

Findings include:

This facility dispatches approximately 10,905 medications monthly. However from the period of January through July of 2012 no adverse drug reactions were documented. The facility failed to promote the immediate reporting of drug reactions and incompatibilities to the pharmacy department.

Based on blood bank records review, laboratory staff and laboratory director interview on 08/28/2012 at 9:45 AM, it was determined that the laboratory failed to follow written procedures to ensure that the emergency transfusions records were signed by the requesting physician and by the medical technologist.

The findings include:

1. From 12/30/2011 to 03/28/2012, one out the six emergency transfusions records was not signed the requesting physician (patient record 164853 on 12/30/2011).

2. From 12/30/2011 to 03/28/2012, three out the six emergency transfusions records were not signed the medical technologist (patient record 164853 on 12/30/2011, patient record 165454 on 03/28/2012 and patient record 165240 on 03/28/2012).


Based on general immunology quality control records review, laboratory staff and laboratory director interview on 08/28/2012 at 11:00 AM, it was determined that the laboratory failed to ensure that the patient ' s identification number where include in the testing records.

The findings include:

1. From 02/01/2012 to 03/31/2012, the Influenza A & B testing records showed that the laboratory did not include the patient ' s identification number. The laboratory processed 505 patients ' specimens from February to March 2012.

2. From 02/01/2012 to 08/16/2012, the HIV Rapid Unigold testing records showed that the laboratory did not include the patient ' s identification number. The laboratory processed 15 patients' specimens from February to August 16, 2012.


Based on observations and bacteriology general supervisor interview on 8/28/2012 at 9:48 AM, it was determined that the bacteriology area is located in a small physical area, crowded with instruments, devices, materials and other equipment, that does not ensure sufficient work bench space for the patient specimens management and tests performance.

The findings include:

1. The work bench area crowded with instruments (BacT Alert 3D, MicroscanWalk- Away 40 SI, Micro Auto Scan 4, hood), computer devices (two (2) personal computer- HP L1710, ACER, printer Lexmark) and reagents materials.

2. Over the Microscan-Walk Away 40 SI instrument two boxes (NBPC and PBCP identification panel and MicroScan Prompt Incubator system) was observed.

3. This deficiency was cited on last surveys on 1/3/2010 and 01/25/2012.


Based on observations, quality control records, procedures manual review and laboratory testing personnel interview on 08/28/2012 at 10:48 AM, it was determined that the laboratory failed to document correctives actions when the bacteriology refrigerator temperature was outside of the established operating parameters.

The findings include:

1. The laboratory procedures manual establishes that the laboratory must monitor and document the refrigerator temperature in (2° C - 8° C) daily.

2. The bacteriology temperature log sheet did not include the refrigerator temperature range and incubator temperature range.

3. Review of bacteriology quality control records showed that the bacteriology refrigerator was outside of range established (2° C - 8° C) from July 28, 2012 to August 13, 2012 (over 8° C).

4. The laboratory testing personnel confirmed that the laboratory did not document corrective actions when the bacteriology refrigerator was outside of range (2° C - 8° C).


1. Based on observations, quality control records, procedures manual review and laboratory testing personnel interview on 08/28/2012 at 11:18 AM, it was determined that the laboratory failed to perform and document the required preventive maintenance of the laboratory's equipments.

The findings include:

a. The manufacturer manual instructed the laboratory to perform and document the preventive maintenance of the eye wash station and emergency shower (weekly).

b. The laboratory did not perform nor document the weekly preventive maintenance of the eye wash station and emergency shower since January 2011.

c. The laboratory general supervisor confirmed that the laboratory failed to perform the preventive maintenance of the eye wash station and emergency shower since January 2011.

2. Based on observations, quality control records, manufacturer ' s instructions and laboratory general supervisor interview on 08/28/2012 at 11:46 AM, it was determined that the laboratory failed to perform and document the required calibration (annually) of automatic pipettes (MLA).

The findings include:

a. The manufacturer manual instructed that the laboratory performed and documented the calibration of the automatic pipettes annually.

b. The laboratory did not perform the calibration of the automatic pipettes MLA 30µl since March 7, 2010 and MLA 25 µl since April 8, 2011.

c. The laboratory general supervisor confirmed that the laboratory failed to perform and document the calibration of the automatic pipettes annually.

Based on quality control records and laboratory testing personnel interview on 08/28/2012 at 1:12 PM, it was determined that the laboratory failed to test the cell counts patient specimens in duplicate.

The findings include:

1. The laboratory performed the patient ' s cell count (body fluid RBC and WBC) by the hemocytometer.

2. Review of hematology quality control records showed that the laboratory did not tested the cell counts in duplicate. The records showed only one results recorder when the laboratory performed and reported the following cell counts on 6/18/2012 (ARE), 6/19/2012 (BBM), 6/26/2012 (TOR), 8/14/2012 (ARE) and 8/26/2012 (MVA).

Based on the observational tour of the facility's kitchen that prepares patient's meals, review of menus and policies/procedures, temperature verification with the kitchen assistant (employee #26), the liaison (employee #28) between the hospital and the contracted dietary services and the contracted dietary services supervisor (employee #34) and interview on 8/28/12 from 9:30 am till 12:30 pm and on 8/30/12 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 the temperature/humidity of the dry food storage area, the facility failed to ensure that employees follow infection control standards of practice related to glove changes, hand washing, and are assigned specific duties and tasks that do not increase the risk of cross contamination from one task to another, a food storage area did not have temperature and humidity registrations, can food was found dented and a pouch of mayonnaise expired, seven rolls of hand paper were observed on the cabinet shelves of the dry food storage area exposed to the environment of this room, metal carts used by kitchen personnel were found with rust, the kitchen area was found dusty, dirty and with grease, kitchen equipment was found with built up grime, utensils and cooking trays are not stored properly, no evidence was found that the frying oil was changed appropriately, the hand sink at the preparation area was not working and the employee did not wash his hands as needed, inappropriate sanitizer use in the three compartment sink, food servers did not follow appropriate infection control standards, cold food on patient's food trays are not served at the appropriate temperature, flies were observed in the kitchen area, walk-in freezer and refrigerator temperatures are not properly maintained and no evidence was found that the facility is recording the temperature of the automatic food tray washer, kitchen and dietary personnel do not have evidence of the required appropriate training related to food safety and do not have appropriate health certificate documentation regarding throat and fecal cultures or Hepatitis screening and the facility failed to ensure that menus provided by the hospital are nutritionally balanced and meets the special needs of the patients. All of the above findings makes this condition "Not Met".

Based on the observational tour of the facility's kitchen that prepares patient's meals, review of menus and policies/procedures, temperature verification with the kitchen assistant (employee #26), the liaison (employee #28) between the hospital and the contracted dietary services and the contracted dietary services supervisor (employee #34) and interview, it was determined that the facility failed to store, maintain and prepare food in a safe and sanitary manner related to the temperature/humidity of the dry food storage area, the facility failed to ensure that employees follow infection control standards of practice related to glove changes, hand washing, and are assigned specific duties and tasks that do not increase the risk of cross contamination from one task to another, a food storage area did not have temperature and humidity registrations, can food was found dented and a pouch of mayonnaise expired, seven rolls of hand paper were observed on the cabinet shelves of the dry food storage area exposed to the environment of this room, metal carts used by kitchen personnel were found with rust, the kitchen area was found dusty, dirty and with grease, kitchen equipment was found with built up grime, utensils and cooking trays are not stored properly, no evidence was found that the frying oil was changed appropriately, the hand sink at the preparation area was not working and the employee did not wash his hands as needed, inappropriate sanitizer use in the three compartment sink, food servers did not follow appropriate infection control standards, cold food on patient's food trays are not served at the appropriate temperature, flies were observed in the kitchen area, walk-in freezer and refrigerator temperatures are not properly maintained and no evidence was found that the facility is recording the temperature of the automatic food tray washer.

Findings include:

1. During the kitchen observational tour performed with the kitchen assistant (employee #26), the liaison (employee #28) between the hospital and the contracted dietary services and the contracted dietary services supervisor (employee #34) on 8/28/12 from 9:30 am till 12:30 pm and on 8/30/12 from 10:00 am till 11:15 am, the following was observed:

a. During the visit of the dry food storage room on 8/28/12 at 9:45 am with the kitchen assistant (employee #26), it was found that metal shelves used to store dry food and cans were observed with dust. This dry food storage room was located near of kitchen area and it has a thermometer and personnel record the temperature and the relative humidity of this room. The temperature of the room were 61ºF and the relative humidity was 62% on 8/28/12. No evidence was found that the facility has policies/procedures related to the appropriate temperature and humidity for the dry food storage area. The facility is recording temperature/humidity, however they do not know what the established parameters are.

b. During the observational tour of the kitchen food line serving area (where the steam tables are located) on 8/28/12 at 10:30 am, it was observed that there is a side by side refrigerator which contains food to use for the lunch time meal. A large metal tray with 90 small individually served portions (small plastic containers) of green peas and a large metal tray with 90 small individually served portions (small plastic containers) of corn were observed in the refrigerator and were stacked one on top of the other. When the kitchen assistant (employee #26) was asked on 8/28/12 at 10:35 am if the small plastic containers were touching the food above it or below it in the large tray she stated that she did not know but she would call the employee who prepared it. When the kitchen employee (employee #33)who prepared the food trays entered the room, he came in with a pail with dirty water and a dirty mop. Employee #33 had on a pair of gloves and he was asked if the small plastic food containers were separated with a plastic wrap and he said it was and he approached the tray to remove the plastic wrap. Employee #33 was stopped from touching the tray with food because he was touching the mop and pail with the small gloves. He then removed his gloves and tried to touch the tray again and was stopped again because he did not wash his hands. It was also observed that he placed the pail with the dirty water next to clean patient food trays and the handle of the mop was touching the top of the service counter. Employee #33 was asked what were his specific tasks and he replied on 8/28/12 at 10:40 am that he does different tasks, whatever is asked of him which includes cleaning, preparing food for the food serve line, bringing food trays up to the wards, bringing enteral nutrition to the wards and retrieving supplies. The facility failed to ensure that employees follow infection control standards of practice related to glove changes, hand washing, and are assigned specific duties and tasks and these duties do not increase the risk of cross contamination from one task to another.

c. There is a small closet located near the food line service area which was observed on 8/28/12 at 9:45 am stocked with 2 cases of corn flakes, a box of splenda, a box of soda crackers, a case of apple sauce, 50 bags of rice, disposable containers and cooking equipment and the room was found warm. The facility failed to verify the temperature and humidity of this room to ensure that it is appropriate to store food.

d. One can (108 ounces) of sweet cream corn and one can (6 pounds) of green beans were observed dented. Also, one pouch of mayonnaise was observed with an expiration date of 8/11/12.

e. Seven rolls of hand paper were observed on the cabinet shelves of the dry food storage area without a plastic cover protective them from the environment of this room.

f. Metal carts in the kitchen area were observed with the kitchen assistant (employee #26) on 8/28/12 at 9:30 am till 12:30 pm, and were found that these carts are used to move dry food, transport food trays to patient's wards and used in the kitchen to prepare food and were observed with rust.

g. Kitchen equipment (stoves, warmer near to the stove, the wall behind the stove and the fryer) were observed dusty, dirty and with grease on 8/28/12 at 10:35 am. No evidence was found the terminal cleaning of the kitchen and its equipment.

h. Equipment used to prepare food (pots, pans, 6 large trays and other utensils) were observed with an accumulation of built up grime on 8/28/12 at 11:15 am.

i. The food cooker (employee #30) was observed on 8/28/12 at 10:45 am preparing food for the cafeteria and for patient meals, and it was found that there was a plastic container under the food preparation table with clean equipment used to prepared food (scoops, large spoons, ladles, food grater, small pot and lid). The plastic container was found with residual water from the drying process and the container did not have a lid. The facility failed to ensure that the clean equipment used to prepare food is maintained in a safe and sanitary manner to prevent cross contamination.

j. Already cleaned cooking trays were observed on 8/28/12 at 10:45 am stacked upside down one on top of the other and they were found wet with an accumulation of water.

k. The fryer was observed on 8/28/12 at 11:20 am near the stove with fried meat in the metal draining container above the oil. The kitchen assistant (employee #26) stated during an interview on 8/28/12 at 11:25 am that the fryer was used for the cafeteria. She also stated that the oil is changed twice a week regardless of use. According with the food safety magazine (referenced by the FDA), oil used for deep fryers should be changed after three to six uses and this depends on the type of oil used and the frying temperature. The facility failed to ensure that policies/procedures related to oil changes, oil type, temperature, amount and cleaning of the deep fryer.

l. The food cooker (employee #31) was observed on 8/28/12 at 11:25 am preparing food for the cafeteria and patients. When the food cooker was preparing a tray with chicken parmesan he touched the top of the counter on various occasions with his gloved hands than took the cheese and put it on the chicken and then touched the counter again and than put more cheese on top of the chicken and flies were observed in the kitchen area. The facility failed to follow infection control standards related with hand washing while employees prepare and manage food (the hand sink at the food preparation area was not working and personnel had to go to the near the front door to use that sink to wash their hands even though this sink is used to defrost meat).

m. The three compartment sink was observed on 8/28/12 at 10:50 am during the dish washing process. The first compartment was observed with water and soap to wash pots, pans and utensils, the second compartment had water and the third compartment was observed with sanitizing solution. The dish washer (employee #32) stated during an interview on 8/28/12 at 10:55 am that he washes the pots, pans and utensils in the first compartment, rinses in the second sink and then he dunks them in the sanitizing water in the third sink. The dish washer (employee #32) stated that he did not prepare the sanitizer for the third compartment of the sink, but it was done by the food cooker (employee #30). The food cooker (employee #30) stated on 8/28/12 at 10:57 am that he placed an ounce of sanitizer in the sink but he did not know if the concentration was appropriate because he does not have test strips to measure the sanitizer concentration. The facility failed to ensure that policies/procedures related to the use of the dish washing sanitizing solution is followed according with product specifications to ensure its correct concentrations and no evidence was found of test strip registrations.

n. The food line lunch time meal assembly was observed on 8/28/12 at 11:45 am and provided evidence that the food was being served by kitchen employee #38 who was also assigned other the task during the day such as preparing meal cards and administrative tasks. Kitchen employees #38 was observed serving the food without a protective gown or apron after performing these other tasks. After this observation, the contracted dietary services supervisor (employee #34) gave him a plastic apron (plastic aprons are not recommended in the area of the kitchen around heat sources (open flames) and their propensity to leak (not absorbed) if splashed which increases the risk of cross contamination). Also, employee #38 was using a dark blue colored shirt which does not allow visualization when the shirt is dirty or clean and did not wash his hand washing or use hand sanitizer available in this area. When kitchen employee #38 served the portions of the food on the food trays, he touched his nose with his gloved hand and put his hand in his pants pocket and continued serving the food. The facility failed to ensure that employees follow infection control standards of practice related to glove changes, hand washing and are assigned specific duties and tasks and these duties do not increase the risk of cross contamination from one task to another.

o. Once the food was prepared at 11:15 am the temperature of the food was appropriate (140ºF-160ºF) according with the registry log. Before kitchen employee #38 served the patients food (approximately 30 food trays) the temperature was taken of the third floor (sample tray) food and was found that the temperature of the milk was 60ºF at 12:15 pm. When kitchen employee #38 began to serve the patient's food trays, the temperature of the cold 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) and could not guarantee that the food test tray arrived at the patient's rooms at the appropriate temperatures (milk 60ºF).

p. A plastic screen covering a window between the kitchen preparation area and food serving area (steam table) was observed with a space where the plastic did not cover the window completely and left a space and flies were observed in the kitchen area.

2. During the review of the registration log used to record temperatures in the morning and in the afternoon of the kitchen's walk-in refrigerator and freezer with the kitchen assistant (employee #26) and the liaison (employee #28) on 8/28/12 at 12:00 noon the following was determined from the months of June, July and August of 2012:

a. For the month of June 2012, the temperature of the refrigerator in the morning met the temperature criteria of 41ºF or less on eight out of thirty days and in the afternoon five out of thirty days (also, no temperature was recorded on four days in the afternoon). On the days that the temperature did not meet the criteria it ranged from 42ºF to 60ºF.

b. For the month of July 2012, the temperature of the refrigerator in the morning met the temperature criteria of 41ºF or less on two out of thirty-one days and in the afternoon three out of thirty-one days (also, no temperature was recorded for one day in the afternoon). On the days that the temperature did not meet the criteria it ranged from 42ºF to 70ºF.

c. For the month of August 2012, the temperature of the refrigerator in the morning met the temperature criteria of 41ºF or less on four out of thirty days and in the afternoon one out of thirty days (also, no temperature was recorded on two days in the afternoon). On the days that the temperature did not meet the criteria it ranged from 42ºF to 60ºF.

d. For the month of June 2012, the temperature of the freezer in the morning and afternoon did not meet the temperature criteria of 0ºF or less for the entire month (also, no temperature was recorded on three days in the morning and four days in the afternoon). For this month when the temperature did not meet the criteria it ranged from 8ºF to 55ºF. Also, the freezer was reported broken on the 3rd, 4th and 5th of June 2012.

e. For the month of July 2012, the temperature of the freezer in the morning met the temperature criteria of 0ºF or less for one out of thirty-one days and did not met the criteria on any day in the afternoon (also, no temperature was recorded for one day in the afternoon). On the days that the temperature did not meet the criteria it ranged from 5ºF to 34ºF.

f. For the month of August 2012, the temperature of the freezer in the morning met the temperature criteria of 0ºF or less on five out of thirty-one days and did not met the criteria on any day in the afternoon (also, no temperature was recorded for two days in the afternoon). On the days that the temperature did not meet the criteria it ranged from 4ºF to 17ºF.

3. No evidence was found of the temperature registration log of the automatic dish washer located in the kitchen area as reviewed with the kitchen assistant (employee #26) on 8/28/12 at 11:50 am. The facility could not provide evidence that during the wash and rinse cycles of the automatic dish washer that it reaches the appropriate temperature parameters to ensure that patient's food trays are cleaned and sterilized as recommended by the machine's manufacturer.

Based on observations of the kitchen area and the review of twenty-one kitchen personnel credential files with the kitchen assistant (employee #26) and interview, it was determined that kitchen and dietary personnel do not have evidence of the required appropriate training related to food safety and do not have appropriate health certificate documentation regarding throat and fecal cultures or Hepatitis screening.

Findings include:

During the review of twenty-one (21) kitchen personnel credential files on 8/30/12 at 2:00 pm with the kitchen assistant (employee #26), it was found that kitchen personnel failed to receive adequate training to be competent in their respective duties related to food safety procedures. During observations of the kitchen area with the kitchen assistant (employee #26), on 8/28/12 at 11:00 am, she stated that there are two cooks working today in the kitchen and a dish washer is also working in the kitchen, however no one has the training related to food safety as required by the state of Puerto Rico. According with the food code from 2009 (2-101.11) at least one person (dietitian, cooker or supervisor) at all times must be present and that person must have taken and passed the food safety course. Also no evidence was found during credential files reviewed of 21 kitchen personnel that health certificate documentation includes throat and fecal cultures or Hepatitis screening for these personnel (2-201.11).

Based on facility menus cycles reviewed and interview with the kitchen assistant (employee #26), it was determined that the facility failed to ensure that menus provided by the hospital are nutritionally balanced and meets the special needs of the patients.

Findings include:

1. During the review of the facility's established menus on 8/28/12 at 11:30 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 kitchen assistant (employee #26) was interviewed on 8/28/12 at 11:30 am and she stated that the changes were due to the lack of food available for the menus because the food shipment arrived late. No evidence was found of the Recommended Dietary Allowances (RDA) calculations for the three week menus cycle. Also, no evidence was found of the dietitian's signature on the menus and no evidence was found that the changes in the menus were approved by the dietitian. The facility failed to ensure that programmed menus and changed menus have calculations with established Recommended Dietary Allowances (RDA) that are calculated for the regular programmed diet or when changes are made to the menus.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Engineer (employee #1) and interviews on 8/21/12 from 10:00 am till 4:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 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 the minor surgery room which is not properly maintained, cardiac monitors in the emergency room were not set to be heard, the air extractor in the dirty linen room of the emergency room was not working, regular sitting chairs are being used in the shower instead of commodes, return vents in the operating suites found with peeling paint, the janitor's closet of the operating department was found with regular and biohazardous trash, ceiling acoustic tiles in the dry food storage area were detached, a sink did not work in the kitchen, patient's sleeping rooms doors lock from the inside, patient's wards are not maintained appropriately related to cross contamination and accessibility to night lights, fire hose cabinets have glass doors, the elevator did not land flush to the floor, the Neonatal Intensive Care Unit (N.I.C.U), Delivery room and morgue are not appropriately maintained and passageway behind the kitchen is not maintained and used to decrease the risk of cross contamination, the facility failed to follow established procedures for the storage of biohazardous trash related to the maintenance building where the biohazardous trash boxes are placed before they are picked up, this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to biohazardous storage rooms without air extractors, janitor's closets without floor sinks, I.V pumps in the emergency room (E.R) are not properly stored, crash carts in the E.R were left unlocked, a mattress in the operating room (O.R) was ripped, kitchen carts in poor condition, a step ladder with a platform is needed in the dry food storage area, clean food trays were draining on the kitchen floor, the front door of the kitchen was broken, automatic food tray cleaner leaking oil on the floor, the large walk-in freezer and refrigerator area is in need of cleaning, biohazardous storage area, laboratory, medical records department and ward areas are not properly maintained and the oxygen tank on a crash cart did not have a regulator, this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to the Emergency Room (E.R) cubicles with two patients and one call system, lounge chairs in the observation area within four feet, E.R stretchers are placed side by side, handicapped toilets are not appropriately designed, operating room department is not divided into different designated areas (unrestricted, semi-restricted and restricted), the kitchen does not have a grease trap, Intensive Care Unit isolation room does not have negative pressure, inappropriate use of Cidex OPA and the handicapped parking spaces are not appropriately designed, the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas which are not equipped with an air disinfection system; also it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101, cited tags are K0018, K0022, K0025, K0027, K0033, K0046, K0048, K0050, K0051, K0052, K0055, K0062, K0064, K0075, K0130 and K0144. 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 Engineer (employee #1) and interview, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well being of patients receiving services related to the minor surgery room which is not properly maintained, cardiac monitors in the emergency room were not set to be heard, the air extractor in the dirty linen room of the emergency room was not working,
regular sitting chairs are being used in the shower instead of commodes, return vents in the operating suites found with peeling paint, the janitor's closet of the operating department was found with regular and biohazardous trash, ceiling acoustic tiles in the dry food storage area were detached, a sink did not work in the kitchen, patient's sleeping rooms doors lock from the inside, patient's wards are not maintained appropriately related to cross contamination and accessibility to night lights, fire hose cabinets have glass doors, the elevator did not land flush to the floor, the Neonatal Intensive Care Unit (N.I.C.U), Delivery room and morgue are not appropriately maintained and passageway behind the kitchen is not maintained and used to decrease the risk of cross contamination.

Findings include:

1. The minor surgery room of the emergency room was visited on 8/21/12 at 11:05 am with the facility's Engineer (employee #1) and provided evidence of the following:
a. The facility failed to record temperature and humidity for this room to ensure that it complies with appropriate perimeters.
b. The mattress of the treatment bed was found with cracks and ripped which will not allow personnel to properly disinfect the mattress between patients (internal foam aspect of the mattress is porous).
c. As part of their functional plan the minor surgery room places casts on patients, however this area does not have a plastic sink and trap.
d. The front door did not close flush to its frame.
e. This room is located to the side and behind the nursing counter and was found unlocked and accessible to non-authorized persons nor was a coded key pad found to limit access to those persons who do not know the coded sequence.
f. This room was found with one tray with Cidex OPA and this room did not have air extractors or air returns. 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.

2. The emergency room was visited on 8/21/12 from 10:00 am till 12:00 noon with the facility's Engineer (employee #1) and provided evidence that there is an area with three cubicles used to place critical/intensive patients and it is located in front of the nursing station. On 8/21/12 at 11:45 am there were two patients located in this area with cardiac monitors but no nursing supervision was found. The emergency room nursing supervisor (employee #2) was interviewed on 8/21/12 at 11:50 am and stated that personnel at the nursing counter can hear the monitors and nursing personnel are entering constantly to verify the patients. However when the sound of the cardiac monitors were tested by going behind the nursing counter, they could not be heard over the environment noise of the emergency room. The biomedical technician (employee #3) was interviewed on 8/21/12 at 11:55 am and she stated that the volume was too low and she adjusted it so that staff can hear them and she also stated that the alarm will now also ring louder to ensure that personnel at the nursing counter can hear it.

3. The dirty linen storage room located in the emergency room was visited on 8/21/12 at 10:45 am with the facility's Engineer (employee #1) and provided evidence that it had two large hampers full of dirty linen, the air extractor was not working (covered in dust) and was also used to store a foot stool, a long piece of wood, and I.V pole and a role of stretcher paper was found on the floor.

4. The bathrooms located in the observation area of the emergency room (one located near cubicle A-9 and two located near cubicle #6) were observed on 8/21/12 at 10:20 am with regular plastic sitting chairs in the shower area. The facility will need to provide shower commodes to ensure that they can be cleaned properly between patient uses.

5. The operating suites were visited on 8/21/12 from 1:45 pm till 3:00 pm with the facility's Engineer (employee #1) and provided evidence that there are four operating suites. Each operating suite has two return vents located near the floor, however the return vent covers were all found with peeling paint and in need of scrapping to remove the paint or these vent covers need to be replaced with new ones.

6. The janitor's closet of the operating room department was visited on 8/21/12 at 2:35 pm with the facility's Engineer (employee #1) and provided evidence that this closet is also used to store regular garbage (two bags with regular trash were found directly on the floor) and biohazardous trash (six boxes with biohazardous trash were found in this closet). Having regular and biohazardous trash in this closet may cause personnel who clean the operating room suites and department to cross contaminate other areas. This closet also contained mops and pails to clean the operating suites, recovery room and hallways and for contaminated cases, but some of the mops and pails need to be numbered appropriately according to the area of use. Also, the mop used for contaminated cases was found in the condition of being used over a long period of time and no evidence was found of the procedures to follow after it is used.

7. The dry food storage area located near the kitchen was visited on 8/28/12 at 9:35 am and was found with three detached ceiling acoustic tiles which can allow dust and dirt located between the acoustic tiles and the ceiling to fall on the cans of food and other food products. On 8/28/12 at 9:40 am the facility's Engineer (employee #1) called maintenance personnel to replace the acoustic tiles and they finished at 10:20 am, however they failed to cover the shelves with the food cans and cases of food and they all became covered with dust from replacing acoustic tiles and the floor was covered with dust from the cutting of the acoustic tiles.

8. The small sink located at the food preparation table in front of the stove was found not working on 8/28/12 at 10:00 am.

9. The Medicine III ward with twenty-one patient's sleeping beds on the third floor was visited on 8/28/12 from 1:20 pm till 2:00 pm with the facility's Engineer (employee #1) and the following was determined:
a. Patient's sleeping rooms #310, #311, #314, #316, #319 and #321 were visited and provided evidence that they can be locked from the inside by patients. Nursing staff and personnel must have instant access to the patients and their rooms at all times.
b. Two air filters were found on the floor in the hallway in front of patient's rooms restricting the width of the hallway in the event of an emergency.

10. The Medicine II ward with twenty patient's sleeping beds on the second floor was visited on 8/28/12 from 2:05 pm till 2:45 pm with the facility's Engineer (employee #1) and the following was determined:
a. Patient's sleeping rooms #273, #277 and #279 were visited and provided evidence that they can be locked from the inside by patients. Nursing staff and personnel must have instant access to the patients and their rooms at all times.
b. Across from patient room #270 is a storage closet that was found with six ready to use I.V pumps and they were next to the dirty linen hamper which increase the risk of cross contamination.
c. The maintenance cart does not fit into the janitor's closet and is left in the hallway when not used.
d. Two biohazardous and two regular trash containers and three dirty linen hampers were found in the hallway near patient's rooms next to the clean linen cart. The clean linen was out of its plastic protective bag and was exposed to the environment of the hallway which increases the risk of cross contamination.
e. The privacy curtain between the beds in patient's room #279 had a detached track from the ceiling.
f. Regular wood frame seats with a fabric cushions were observed used as shower seats in patient's rooms #276 and #279.
g. All patient's sleeping room windows did not have operators to open and close the windows. Minimum requirements of "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) section 8.2.2.5(1) states if operable windows are provided in patient rooms, operation of such windows shall be restricted to inhibit (should not open wide, a few inches) possible escape or suicide. Appendix A 3.1.1.3 also states that window use is essential in the event of mechanical ventilation system failure.

11. The Medicine/Surgical ward with twelve patient's sleeping beds on the second floor was visited on 8/28/12 from 3:10 pm till 3:30 pm with the facility's Engineer (employee #1) and the following was determined:
a. Patient's sleeping rooms #235, #237, #238 and #239 were visited and provided evidence that they can be locked from the inside by patients. Nursing staff and personnel must have instant access to the patients and their rooms at all times.
b. Twelve night lights above patient's beds are activated by switches and not accessible to all patients lying in their beds. Minimum requirements of "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) section 10.3.5.2(1)(i) states that reading light controls shall be accessible to the patient without having to get out of bed.
c. Patient's rooms #238 and #239 do not have windows that give direct light and air from the outside (they have skylights).
d. The dirty linen closet for this ward did not have an air extractor.
e. The isolation room (#228) was visited and provided evidence that it has an ante-room. The ante-room door that separates this area from the hallway has a large vision panel to look into this area, however the door that protects the patient's sleeping room does not have a vision panel which will allow nursing personnel to check up on the patient without having to place personal protective equipment on and open the door. The vision panel shall be placed in a manner that the patient can not be seen by persons passing by in the hallway, but can be seen by nursing personnel if they enter the ante-room.

12. The Medicine South ward with eight patient's sleeping beds on the second floor was visited on 8/28/12 from 3:35 pm till 4:00 pm with the facility's Engineer (employee #1) and the following was determined:
a. No night lights above patient's beds were found in patient rooms #201, #202, #204 and #205 for patients to use.
b. A regular wood frame seats with a fabric cushions was observed used as shower seats in patient's room #208.
c. The lounge chair in patient's room #208 was found with a ripped vinyl seat cushion.
d. This ward does not have an approved area with air extractors, smoke detectors, with walls and doors protection for the dirty linen and biohazardous waste from this area. The dirty linen and biohazardous waste are placed in a cabinet in the hall.

13. The Central Medicine ward with ten patient's sleeping beds on the second floor was visited on 8/29/12 from 9:05 am till 9:45 am with the facility's Engineer (employee #1) and the following was determined:
a. The dirty linen closet was also found with a commode and mattress.
b. All patient's sleeping rooms were visited and provided evidence that they can be locked from the inside by patients. Nursing staff and personnel must have instant access to the patients and their rooms at all times.
c. Patient's sleeping room windows open wider than two feet. This ward is located on the second floor. Minimum requirements of "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) section 8.2.2.5(1) states if operable windows are provided in patient rooms, operation of such windows shall be restricted to inhibit possible escape or suicide. Appendix A 3.1.1.3 also states that window use is essential in the event of mechanical ventilation system failure.
d. Ten night lights above patient's beds are activated by switches and not accessible to all patients lying in their beds. Minimum requirements of "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) section 10.3.5.2(1)(i) states that reading light controls shall be accessible to the patient without having to get out of bed.
e. The nursing call system was not near patient's bed in room #210.

14. During the observational tour of the entire facility on 8/21/12 from 10:00 am till 4:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm, it was determined that fire hose cabinets have glass doors. The fire hose cabinets are located in stairways or hallways on all floors and some have fire extinguisher. The fire hose cabinets do not require a key to open or a device to break the glass to gain access to the hoses. The glass doors are approximately three feet by three feet in size and pose a potential hazard if broken by accident. The glass is not tempered, laminated or of wire mess to prevent shattering.

15. The second floor (Central Medicine ward) was visited on 8/29/12 at 9:05 am with the facility's Engineer (employee #1) and provided evidence that the elevator did not land flush to the floor of this floor when it opened. The elevator landed approximately two inches higher than the floor of the ward which creates a possible risk for falls.

16. During observations of the second floor Central Medicine ward, it was found that the staircase next to the nursing station leads to the first floor as observed on 8/29/12 at 10:00 am with the facility's Engineer (employee #1). At the bottom of this staircase was found that a floor tile was broken. Also, the exit door in front of this staircase was not working during the inspection and there are other routes that patients and visitors can take to exit the building, however there needs to be a larger sign or barrier in front of this door to ensure that persons do not mistakenly try to exit or enter from this door.

17. The Neonatal Intensive Care Unit (N.I.C.U) and Delivery room were visited on 8/29/12 from 10:00 am till 10:30 am and the following was found:
a. The N.I.C.U has sliding curtains over the windows which can accumulate dust and shall be removed to ensure that the area remains as clean as possible.
b. The air conditioner unit located behind the neonatal bassinets has a drainage tube that exits through the wall. However, the space between the tube and the wall was filled with a foam sealer that is porous and will not allow for proper cleaning.
c. The delivery room was found with a tray with Cidex OPA out in the open on a tray table. 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.
d. Operating suite II was of the delivery room was found with detached floor tiles.

18. The pediatric ward with seven patient's sleeping beds was visited on 8/29/12 from 10:45 am till 11:10 am with the facility's Engineer (employee #1) and the following was determined:
a. Seven night lights above patient's beds are activated by switches and not accessible to all patients lying in their beds. Minimum requirements of "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) section 10.3.5.2(1)(i) states that reading light controls shall be accessible to the patient without having to get out of bed.
b. This ward does not have an approved area with air extractors, smoke detectors, with walls and doors protection for the dirty linen and biohazardous waste from this area. Dirty linen hampers are placed in a cabinet in the hall and there is no place to place biohazardous waste.
c. All patient's sleeping rooms were visited and provided evidence that they can be locked from the inside by patients. Nursing staff and personnel must have instant access to the patients and their rooms at all times.
d. The wall by the side of the bed in room #305 was found with peeling paint and missing patches of paint.

19. Eight patient's sleeping beds on the first floor (Annex) were visited on 8/29/12 from 11:40 am till 12:10 pm with the facility's Engineer (employee #1) and the following was determined:
a. All patient's rooms did not have windows that give direct light and air from the outside.

20. The morgue was visited on 8/29/12 at 2:00 pm with the facility's Engineer (employee #1) and provided evidence of the following:
a. Sheets used to cover a corpse was found on top of a counter, this room did not have a dirty linen container.
b. The floor of this room is porous and can not be cleaned properly. The maintenance supervisor (employee #37) was interviewed on 8/29/12 at 2:10 pm and he stated that they clean the walls with a big sponge with a handle but they do not clean the floor because the cement floor is broken.
c. This room does not have a dedicated mop and pail or a floor sink.
d. The mattress on the stretcher in this room was found ripped and cracked and will not allow for proper cleaning.
e. A log was not found with documented evidence of periodic cleaning and disinfecting of this room.
f. No evidence was found of a registration with the temperature of this room since it is not a refrigerated room, it is cooled by a regular air conditioner and policies and procedures needs to be detailed related to appropriate temperature, amount of time a corpse can be left in this room and cleaning procedures.
g. No evidence was found of the temperature registration for the specimen refrigerator in this room.

21. The passage behind the kitchen area is used by escorts, personnel moving biohazardous trash, regular trash, dirty and contaminated linen, maintenance carts with dirty mops and pails (dirty mops and pails are washed at this passageway), merchandise moves through this area and personnel use it as a short cut to go to the cafeteria as observed on 8/29/12 at 2:30 pm.
This passageway was found with a steadily leaking drain from the roof and air conditioner condensation which directly crossed this traveled passageway and personnel were stepping in it every time they passed this area.
a. On 8/30/12 at 10:30 am operating room personnel (employee #36) was observed crossing this area with shoe covers and scrubs to go to the cafeteria and she stepped directly in the leaking water.
b. On 8/29/12 at 2:45 pm a kitchen personnel (employee #33) was observed tracking through this area with the water on the floor with a large garbage container from the kitchen and went to the cafeteria to remove the trash there. The facility's Engineer (employee #1) stated on 8/29/12 at 2:45 pm that this was not the correct route for him to travel.
c. The frequency of use by a multitude of facility personnel and outside persons using this path of travel needs to be re-evaluated and reorganized and should include the relocation of some area and the implementation and enforcement of strict policies and procedures for the use of this area due to the high risk of cross contamination of personnel and requires the involvement of infection control personnel.


17959


22. The Medicine II was visited on 8/28/12 at 10:05 am and provided evidence that the nursing personnel did not check the cardiac monitor on each shift: 7:00 am till 3:00 pm, on 3:00 pm till 11:00 pm and 11:00 pm till 7:00 am seven days a week according to the facility's policies and procedures. No evidence was found on 7/6/12 and 7/7/12 from 11:00 pm till 7:00 am, 7/9/12 from 7:00 am till 3:00 pm and 3:00 pm till 11:00 pm, on 7/10/12, 7/11/12 and 7/13/12 from 3:00 pm. till 11:00 pm, on 7/15/12 from 7:00 am till 3:00 pm, on 7/21/12 from 3:00 am till 11:00 pm and 11:00 pm till 7:00 am, on 7/24/12 from 7:00 am till 3:00 pm, on 7/25/12 from 3:00 pm till 11:00 pm, on 7/27/12 from 11:00 pm till 7:00 am, on 7/27/12 from 11:00 pm till 7:00 am, on 7/28/12 from 7:00 am till 3:00 pm, on 7/29/12 from 11:00 pm till 7:00 am, on 7/30/12 and 7/31/12 from 7:00 am till 3:00 pm, on 8/1/12 and 8/2/12 from 7:00 am till 3:00 pm and 3:00 pm till 11:00 pm, on 8/3/12 from 7:00 am till 3:00 pm and 11:00 pm till 7:00 am, on 8/4/12 from 11:00 pm till 7:00 am, on 8/8/12 from 3:00 pm and 11:00 pm and 11:00 pm till 7:00 am, on 8/9/12 from 3:00 pm till 11:00 pm, on 8/10/12 from 7:00 am till 3:00 pm, on 8/11/12 from 7:00 am till 3:00 pm and 3:00 pm and 11:00 pm, on 8/13/12 and 8/14/12 from 11:00 pm till 7:00 am, on 8/16/12 from 7:00 am till 3:00 pm, on 8/17/12 and 8/18/12, 8/19/12, 8/20/12 and 8/21/12 from 3:00 pm till 11:00 pm, on 8/23/12 and 8/24/12 from 7:00 am till 3:00 pm, on 8/25/12 from 11:00 pm till 7:00 am, on 8/26/12 from 3:00 pm till 11:00 pm and 11:00 pm till 7:00 am and 8/27/12 from 3:00 pm till 11:00 pm.

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

Findings include:

The Life Safety from Fire survey was performed on 8/21/12 from 10:00 am till 4:00 pm and from 8/28/12 through 8/30/12 from 9:00 am till 3:30 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0018, K0022, K0025, K0027, K0033, K0046, K0048, K0050, K0051, K0052, K0055, K0062, K0064, K0075, K0130 and K0144).

Based on observations made during the survey for the physical environment with the facility's Engineer (employee #1), it was determined that the facility failed to follow established procedures for the storage of biohazardous trash related to the maintenance building where the biohazardous trash boxes are placed before they are picked up.

Findings include:

1. The maintenance department has a small building at the back of the hospital (behind the kitchen) and was visited on 8/29/12 at 1:45 pm with the facility's Engineer (employee #1) and the following was determined:
a. The first room of this small building was found with over a hundred packed cardboard boxes of biohazardous waste waiting to be collected (twice a week) and they were placed directly on the floor and the maintenance supervisor (employee #37) entered this room without appropriate personal protective equipment and this room does not have an air extractor.

2. On 8/30/12 at 9:00 am over a hundred boxes of packed biohazardous waste were placed between the large gate (used to receive merchandise) and the door to enter the cafeteria. These boxes were removed from a room used to store them and then were placed in this location near the gate by an employee of the company paid to dispose of the waste. The area where the biohazardous waste boxes are stored, the transporting of these boxes through the passageway and then left near the open gate needs to be re-evaluated related to cross contamination.

Based on observations made during the survey for the physical environment with the facility's Engineer (employee #1) and interview, it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to biohazardous storage rooms without air extractors, janitor's closets without floor sinks, I.V pumps in the emergency room (E.R) are not properly stored, crash carts in the E.R were left unlocked, a mattress in the operating room (O.R) was ripped, kitchen carts in poor condition, a step ladder with a platform is needed in the dry food storage area, clean food trays were draining on the kitchen floor, the front door of the kitchen was broken, automatic food tray cleaner leaking oil on the floor, the large walk-in freezer and refrigerator area is in need of cleaning, biohazardous storage area, laboratory, medical records department and ward areas are not properly maintained and the oxygen tank on a crash cart did not have a regulator.

Findings include:

1. During the observational tour of the emergency room on 8/21/12 at 10:35 am with the facility's Engineer (employee #1), the biohazardous storage room was visited. This room was found without an air extractor and it had a full large red container with biohazardous waste and two plastic bags with biohazardous waste with one on top of the large red container and the other was on the floor.

2. The janitor's closet located in the emergency room was visited on 8/21/12 at 10:40 am with the facility's Engineer (employee #1) and was found without a floor sink. The sink found in this closet was approximately 3 feet high and is where the dirty water from the mop pails are emptied, which increases the risk of maintenance employees hurting themselves when lifting the pails and increases the risk of dirty water splashing on them which increases the risk of cross contamination. Also, this closet does not have mop hangers to ensure that mops can air dry after they are cleaned. The mop used for contaminated cases was placed directly in the sink. A mop for regular use was found on top of the machine used to provide negative pressure to the isolation room. Mops and pails need to be appropriately labeled and this closet does not have an MSDS (material safety data sheet) for the chemicals used in this closet.

3. The emergency room pantry was visited on 8/21/12 at 10:30 am with the facility's Engineer (employee #1) and provided evidence that there is a cart with ten I.V pumps. The biomedical technician (employee #3) was observed taken an I.V pump from this cart and left the room, she stated on 8/21/12 at 10:35 am that these pumps were verified and are working and ready to use and she was asked by nursing personnel to take one of the I.V pumps to a cubicle. The pumps on the cart were not covered to protect them from the environment of the pantry and the cart was located near the bathroom of this room. Also, a box with twenty I.V pumps was found near the lockers of the emergency room personnel and they were not working properly.

4. The crash cart located near cubicle #6 was observed on 8/21/12 at 10:15 am with the facility's Engineer (employee #1) and it was found unlocked and its contents were accessible to non-authorized persons and the crash cart was placed in an area that was not readily visible by personnel.

5. The operating suites were visited on 8/21/12 from 1:45 pm till 3:00 pm with the facility's Engineer (employee #1) and provided evidence that the mattress on operating suite bed #1 was cracked and ripped and the vinyl seat in operating room #2 was also found ripped and cracked and had three pieces of tape to hold it together. The mattress and seat in these operating rooms can not be cleaned properly between patients due to the porous nature of the foam and padding in the mattress and seat.

6. The kitchen department was visited on 8/28/12 at 9:30 am with the facility's Engineer (employee #1) and provided evidence that the carts used to bring supplies to and from the dry food storage room or other parts of the kitchen was broken and in poor condition. The carts were broken and leaning to the side and gave the appearance that they could fall and the middle shelf of these carts were detached.

7. The dry food storage area located near the kitchen was visited on 8/28/12 at 9:35 am with the facility's Engineer (employee #1) and it was found that the shelves in this room are approximately twelve (12) feet high. The top shelves were observed with cases with cans of food and boxes of food and the room had a common household ladder. An open step ladder with side rails, wheels and a platform as the top step is needed to ensure that personnel can access the top shelves safely. The platform will provide stability when reaching for boxes and the side rails will guide them and give them support on the way down or up.

8. The food tray preparation area was visited on 8/28/12 at 9:50 am with the facility's Engineer (employee #1) and a small closet located in this area was found with a large accumulation of cleaning chemical but this room did not have an air extractor, smoke detector and the door had a louver.

9. Cleaned food trays were observed on 8/28/12 at 9:45 am on a movable metal tray holder. This tray holder with the cleaned drying food trays was found in the food tray preparation area and under the tray holder was found a large puddle of water which accumulated on the floor near the food line assembly area and in the passageway to exit this area to the outside. The placement of the food trays draining on the floor increases the risk for cross contamination due to the close proximity to the food preparation line. Also, some of the food trays were found with areas where they were separating which could allow water to enter inside of them.

10. The front door of the kitchen was observed on 8/28/12 at 10:00 am. This door swings into the kitchen and is made of wood and it was found this the wood was broken and had holes in it which will not allow it to be cleaned properly.

11. The automatic food tray cleaner located in the kitchen area was observed on 8/28/12 at 10:15 am with a puddle of oil under the control panel. The oil fell to the floor and it was found that it originated from the automatic food tray machine cleaner and could be stepped on and spread throughout the kitchen.

12. The front door of the kitchen was observed on 8/28/12 at 10:00 am. This door swings into the kitchen and there is a metal screen door that separates the kitchen area from the working administrative area when the wood door is left in the open position. However the screen door did not close properly which did not allow it to close into its frame. During the observational tour of the kitchen on 8/28/12 at 10:15 am flies were observed near the food preparation table in front of the stove.

13. During the observational tour of the large walk-in freezer and refrigerator located outside of the dietary department on 8/28/12 from 11:00 am till 11:15 am the following was determined:
a. The ceiling light in the hallway in front of the freezer was not working.
b. The bottom shelves were less than 12 inches from the floor. The shelves were measured at eight inches high and will not allow proper cleaning or ensure that food is not touched by mops or brooms when cleaning this area.
c. The area where the walk-in freezer and refrigerator are located is approximately fifty (50) feet from the kitchen's back door. When food is needed to prepare meals a cart is wheel out the back door and it passes down a ramp near the generator past a security gate with lock and down another ramp. The area behind the security gate is where the walk-in refrigerator and freezer are located and was found with broken equipment located at the left of the ramp. This area was also in the need of cleaning and painting and no evidence was found of documented evidence of the cleaning in this area and the floor was dirty and porous and does not allow for proper cleaning.
d. The rooms located to the right of the security gate are used by maintenance personnel for their office, one room is dedicated to store biohazardous waste in boxes waiting to be collected (twice a week) and the back room is used to place dirty and contaminated linen also waiting to be collected (twice a week).
e. Directly behind the back door of the kitchen, in the hallway used by different personnel to access the maintenance department, morgue and cafeteria was found with milk crates (approximately twenty) stacked one on top of the other and were directly on the floor and exposed to the traffic of this area. Some of these crates were also found in the walk-in freezer with preserved cups of milk to be used for patient's food trays.
f. The area to the right of the security gate is used by maintenance personnel to pack biohazardous waste into boxes and to weigh the boxes before they are placed in the room used to store them until they are collected. After biohazardous and regular trash containers are emptied they are stored under an outside roof near this area.
g. The path traveled from the kitchen's back door to the security gate is the same route traveled by escorts, the biohazardous trash, regular trash, dirty and contaminated linen, maintenance carts with dirty mops and pails (dirty mops and pails are washed at an outside floor drain to the left of the security gate), merchandise received and the route traveled by corpses (patients who died during their hospital visit-the morgue is located to the left of the walk-in refrigerator/freezer).
h. The frequency of use by a multitude of facility personnel and outside persons using this path of travel needs to be re-evaluated and reorganized and should include the relocation of some area and the implementation and enforcement of strict policies and procedures for the use of this area due to the high risk of cross contamination of food products and personnel and requires the involvement of infection control personnel.

14. The maintenance department has a small building at the back of the hospital (behind the kitchen) and was visited on 8/29/12 at 1:45 pm with the facility's Engineer (employee #1) and the following was determined:
a. The first room of this small building was found with over a hundred packed cardboard boxes of biohazardous waste waiting to be collected (twice a week) and they were placed directly on the floor and the maintenance supervisor (employee #37) entered this room without appropriate personal protective equipment and this room does not have an air extractor.
b. The back room of this small building is used to place dirty and contaminated linen also waiting to be collected (twice a week). There was about five large dumpter style bins with wheels and this area is completely open to the outside street (only protected by bars).
c. When biohazardous and regular trash containers are filled at the wards, they are lowered to this area and after they are emptied and cleaned they are stored at an outside area near this small building under a zinc roof which did not cover all of the containers and the area was found dirty.

15. During the observational tour of the laboratory department on 8/28/12 from 11:30 am till 12:10 pm, the following was determined:
a. Three sharp containers were found on top of counters, but they were not in safety bases to prevent them from tipping over or falling.
b. The emergency shower and eye wash station was not easily accessible due to boxes on a shelf next to the station and the position of the shower and eye wash.
c. No evidence was found of preventive maintenance performed on the shower and eye wash to ensure that it is working properly during an emergency situation.
c. Ceiling acoustic tiles throughout this area were found loose and not tightly in place to ensure that dust in this space does not fall down to the laboratory area.

16. The Obstetric and Gynecology ward with twenty-four beds was visited on 8/28/12 at 2:50 pm and provided evidence that the janitor's closet does not have a floor sink. The sink found in this closet was approximately 3 feet high and is where the dirty water from the mop pails are emptied, which increases the risk of maintenance employees hurting themselves when lifting the pails and increases the risk of dirty water splashing on them which increases the risk of cross contamination.

17. The medication room located at the Medicine/Surgical ward of the second floor was visited on 8/28/12 at 3:00 pm with the facility's Engineer (employee #1) and provided evidence that medications and intravenous solutions are kept in this room and there is a door in this room that separates the area with the laminar flow hood (used to prepare chemotherapy medications). Both areas in this room were found warm because the air conditioner was not working. The facility failed to ensure a safe temperature to store medications for patient use (on 8/29/12 at 9:00 am the air conditioner in this area was fixed).

18. The second floor (Central Medicine ward) was visited on 8/29/12 at 9:05 am with the facility's Engineer (employee #1) and the following was determined:
a. Kitchen employee #33 was observed on 9:25 am leaving enteral nutrition on the counter of this ward on 8/29/12 at 9:25 am and walked away. It is not until 9:35 am that the enteral nutrition is removed from the counter. The prepared enteral nutrition was exposed to the environment of the hallway and the passing of persons and the name of the patient could be seen.

19. The crash cart located in front of room #208 was found with a type E oxygen cylinder attached to the cart on 8/29/12 at 11:30 am with the facility's Engineer (employee #1) however, it did not have a regulator. To ensure that patients receive immediate care in the event of an emergency the oxygen cylinder shall be attached to the crash cart with a regulator and ready to use in the event of an emergency.

20. The medical record department was visited on 8/30/12 at 9:00 am with the facility's Engineer (employee #1) and the following was determined:
a. Medical records were stacked to within a few inches of the ceiling and boxes of records were found directly on the floor. At least twelve inches of free space is needed between the records and the ceilings to ensure proper air circulation for the smoke detectors.

21. The women's clinic was visited and was found with antibacterial disinfecting product (Abadisin) as observed on 8/30/12 at 9:30 am with the facility's Engineer (employee #1) in the mammogram room, but no evidence was provided about the proper use and storage of this product and the infection control department was not aware of its use in this area. Also, in the sonogram room a treatment tray was found over the biohazardous container (the tray was empty and the room did not have a patient).

22. The general material supply area located at the ground level of the administration building next to the hospital was visited on 8/30/12 at 10:00 am with the facility's Engineer (employee #1) and provided evidence of the following:
a. Materials and supplies in boxes were stacked to within a few inches of the ceiling and recently received boxes of materials were found directly on the floor. At least twelve inches of free space is needed between the boxes and the ceilings to ensure proper air circulation for the smoke detectors.
b. Thirty-seven I.V pumps that are no longer used at the facility were found on the floor and on shelves taken up valuable space in an already small for their needs area.
c. An area where there are file cabinets was found with a large quantity of Christmas decorations being stored in this area taken up valuable space in an already small for their needs area.
d. A small room near the file cabinets was found with no longer used large electrical transformers taken up valuable needed space and part of the wall in this room is open to the outside and shall be sealed to protect the supply area from pests.
e. Exposed light fixtures were found throughout the general material supply department. This department has long fluorescent light bulbs that did not have protective plastic covers over the fixtures or on the light bulbs; as personnel work in this area, these fluorescent light bulbs can break and the small pieces of glass can fall on personnel or into their eyes.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Engineer (employee #1), it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to the Emergency Room (E.R) cubicles with two patients and one call system, lounge chairs in the observation area within four feet, E.R stretchers are placed side by side, handicapped toilets are not appropriately designed, operating room department is not divided into different designated areas (unrestricted, semi-restricted and restricted), the kitchen does not have a grease trap, Intensive Care Unit isolation room does not have negative pressure, inappropriate use of Cidex OPA and the handicapped parking spaces are not appropriately designed.

Findings include:

1. The emergency room was visited on 8/21/12 at 10:10 am with the facility's Engineer (employee #1) and it provided evidence that there are seventeen cubicles and one isolation room. Observation cubicles all contained two patients each. Within these cubicles there was only one nursing call system for both patients and no ceiling mounted curtains to separate the patients in these cubicles to provide privacy during specific procedures or providing aid with personal hygiene.

2. The hospital's emergency room was visited on 8/21/12 from 10:00 am till 12:00 noon with the facility's Engineer (employee #1) and provided evidence that there was one wall oxygen outlet and two type H oxygen cylinders that are in an area that was used to provide respiratory therapy and to administer intravenous medications to patients. There were five lounge chairs placed side by side with little space between them and no curtains were found between the lounge chairs. In order to provide emergency treatment to a patient at least four feet between lounge chairs is needed to accommodate emergency staff and equipment and the curtains are needed to provide privacy during treatment.

3. The hospital's emergency room was visited on 8/21/12 from 10:00 am till 12:00 noon with the facility's Engineer (employee #1) and provided evidence that there is an area near cubicle #6 in the middle of the observation area with four stretchers placed side by side with little space between them and no curtains were found between the stretchers and no call systems. These patients were in this area waiting to be admitted to the hospital's wards and oxygen outlets were observed on the ceiling in this area.

4. The two handicapped toilets (male and female) located within the emergency room (E.R) waiting area were visited on 8/21/12 at 10:00 am with the facility's Engineer (employee #1) and the following was determined related with the "Americans with Disabilities Act" (Ley ADA) requirements:
a. No grab bars were found behind or to the side of the toilets. They can either be placed on both sides of the toilet or on one side and behind the toilet.
b. The handles of the paper dispensers were measured at 60 inches from the floor and are front access dispensers. (Handicapped persons in wheelchairs who can only access the dispenser by reaching in front (due to the space of the bathroom or dispenser placement) shall not be placed above 48 inches from the floor).
c. The doors do not have the international symbol recognized for handicapped use.
d. The drainage tubes under these sinks extend out to eight inches from the wall. In order for persons in wheelchairs to access these sinks without hurting their legs the drain tubes can not extend beyond six inches.
e. The top of the sink in the female bathroom was measured at thirty-five (35) and a half inches above the floor, but in order to be accessible to handicapped persons the height can not exceed thirty-four (34) inches in height.

5. The handicapped toilet (for both male and female patients) located within the emergency room (E.R) observation area was visited on 8/21/12 at 10:25 am with the facility's Engineer (employee #1) and the following was determined related with the "Americans with Disabilities Act" (Ley ADA) requirements:
a. No grab bars were found behind or to the side of the toilets (these toilets did not have any grab bars. They can either be placed on both sides of the toilet or on one side and behind the toilet).
b. The handle of the paper dispenser was measured at 60 inches from the floor and is a front access dispenser. (Handicapped persons in wheelchairs who can only access the dispenser by reaching in front (due to the space of the bathroom or dispenser placement) shall not be placed above 48 inches from the floor).
c. The door did not have the international symbol recognized for handicapped use.
d. The drainage tube under the sink extended out to eight inches from the wall. In order for persons in wheelchairs to access this sink without hurting their legs the drainage tube can not extend beyond six inches.

6. The handicapped toilet (for both male and female patients) and located at the operating room department which patients also use to change from their street clothes into their surgical attire was visited on 8/21/12 at 1:50 pm with the facility's Engineer (employee #1) and was found with only one grab bar behind the toilet (these toilets need two grab bars, they can either be placed on both sides of the toilet or on one side and behind the toilet). Also the toilet seat was measured at fifteen inches above the floor, but to comply with the "Americans with Disabilities Act" (Ley ADA) requirements the toilet seat needs to be between seventeen to nineteen inches in height from the floor in order to ensure that they can get up and sit down with ease.

7. The operating room department was visited on 8/21/12 from 1:45 pm till 3:00 pm and provided evidence of the following:
a. Observations made during the initial tour provided evidence that the operating room department (dressing room-street clothes to operating room attire, pre-induction room, surgical area and recovery room) are not divided into different designated areas (unrestricted, semi-restricted and restricted) with signs at each area indicating the surgical attire required.
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. There is a room located near operating suite #4 and the janitor's closet was found with trays of Cidex OPA. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media and no evidence was found that the facility has a spill kit to use if Cidex OPA accidentally falls on the floor.

8. The handicapped toilet (for both male and female patients) located within the waiting area of the operating room department was visited on 8/21/12 at 2:50 am with the facility's Engineer (employee #1) and the following was determined related with the "Americans with Disabilities Act" (Ley ADA) requirements:
a. One grab bars was found behind the toilet (this toilet only has one grab bars, two grab bars are needed they can either be placed on both sides of the toilet or on one side and behind the toilet).
b. The door did not have the international symbol recognized for handicapped use.
c. The drainage tube under the sink extended out to eight inches from the wall. In order for persons in wheelchairs to access this sink without hurting their legs the drainage tube can not extend beyond six inches.
d. The height of the mirror was measured above forty (40) inches from the lower aspect of the mirror to the floor. In order for handicapped persons to use this mirror the lowest aspect of the mirror can not be higher than forty inches from the floor.

9. During the observational tour of the waiting room of the emergency room on 8/21/12 at 10:00 am with the facility's Engineer (employee #1), it was determined that there are approximately thirty (30) seats for patients and visitors. The seats are not attached to other seats and are not fixed to the floor and are light enough to pick up with ease. Due to the functional plan of an emergency room which attends public which enter directly from the street with physiologic and at times mental diseases with behavior disorders, it is important to reduce environmental risks where loose chairs or other items can be used as weapons or used to take their anger out on which could harm other patients, visitors or personnel. Commonly used at waiting rooms are seats attached to a long base which makes them heavier to move and less likely to be used against persons in this area.

10. The kitchen area was observed on 8/28/12 at 10:25 am without a grease trap. According with the Guidelines for Design and Construction for Health Care Facilities section 2.1-10.1.2.5 paragraph 5 (Drainage systems) (pages 116 and 117) (2006 edition) states "kitchen grease traps shall be located and arranged to permit easy access without the need to enter food preparation or storage areas. Grease traps shall be accessible from outside the building without need to interrupt any services".

11. The Obstetric and Gynecology ward with twenty-four beds was visited on 8/28/12 at 2:50 pm and provided evidence that it does not have a dirty linen or biohazardous closets.

12. The Intensive Care Unit (I.C.U) was visited on 8/29/12 at 10:20 am with the facility's Engineer (employee #1) and it was found that it has a room that is used as an isolation room. However, this room does not have negative pressure or an air disinfecting device to ensure that personnel and visitors are protected from patients on isolation precautions.

13. The Endoscopy department on the first floor was visited on 8/29/12 at 11:30 am with the facility's Engineer (employee #1) and provided evidence that the bathroom does not have a bench or chair where patients can sit down and change their clothes.

14. The cardiovascular non-invasive procedure department was visited on 8/29/12 at 12:00 noon with the facility's Engineer (employee #1) and provided evidence that a small room was found with a tray with Cidex OPA. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media which this room did not have and no evidence was found that the facility has a spill kit to use if Cidex OPA accidentally falls on the floor and the test strips used to verify the strength of the solution expired in 2010.
a. This department did not have a bathroom for patient use.

15. The handicapped parking spaces located in parking lot were visited on 8/29/12 at 1:15 pm with the facility's Engineer (employee #1) and the following was found:
a. The handicapped parking spaces do not have the appropriate handicapped signs and one of these signs must indicate "Van Accessible" and have the appropriate space requirements. The height of the signs shall be high enough so that they can be seen even when cars are parked in these spaces.
b. The path of travel from the handicapped parking spaces through the parking lot, across the street to the hospital is not painted with the appropriate lines to advise persons in cars to be aware of persons crossing.

16. The sterile supply room was visited on 8/30/12 at 1:00 pm with the facility's Engineer (employee #1) and provided evidence that a small room was found with a tray with Cidex OPA. According with the Manufacturers' recommendations, they suggest that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media which this room did not have and no evidence was found that the facility has a spill kit to use if Cidex OPA accidentally falls on the floor.

Based on observations made during the survey for the physical environment with the facility's Engineer (employee #1), it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas which are not equipped with an air disinfection system (such as ultraviolet lights).

Findings include:

The emergency room was visited on 8/21/12 from 10:00 am through 12:00 noon with the facility's Engineer (employee #1) and provided evidence that the waiting area, triage area and the observation area of the emergency room are not equipped with an air disinfection system (for example: Ultraviolet lights). According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) the triage area is the point of entry of undiagnosed and untreated airborne infections and should be designed and ventilated to reduce exposure of staff, patients and families to airborne infectious diseases. Through the facility's infection control program, determinations must be made related to general ventilation and air disinfection similar to inpatient requirements for airborne infection isolation rooms according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". The waiting area and observation area are other areas to provide protection with an air disinfection system.

Based on the observational tour with the Infection Control Officer (ICO) (employee # 11), interviews 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 in the laundry room, central supply department, medicine intensive care unit and X-ray department related to improper infection control procedures and failed to follow infection control standards of practice.

Findings include:

1. The following was observed in the medical-surgical area on the second floor on 8/28/12 from 9:40 am till 11:00 am related to infection control procedures:

a. The supply area of the second floor (medical surgical area) was visited on 8/28/12 at 9:40 am with the ICO (employee #11) and provided evidence that there is a small room divided into four small closets: in one closet a patient ' s walker was observed in the closed designated area to store clean linens, on the second closet designated for dirty linens was observed with one hamper with dirty linens and two IV stands directly on the floor, the third closet was designated for medical/ surgical materials and was observed without a security lock and one wood cupboard was observed near the main entrance and IV fluids were observed in the interior.

b. A patient ' s scale and one regular trash can with mold were observed at the medicine storage area. Three IV stands with two IV pump machines connected to the electrical receptacle were observed in the small closet near the storage designated for dirty linens. This area lacks an identification label.

c. A plastic container with respiratory therapy lines and masks were observed in the medical surgical area without protective covers exposing them when personnel take them out of the container.

d. Sharp containers were observed without security bases during the observational tour of the medicine area, intensive care unit, invasive laboratory, endoscopy area, X-Ray department and nuclear medicine area on 8/28/12, 8/29/12 and 8/30/12 from 9:30 am till 2:00 pm. Security bases and label are needed to protect the sharp containers from unauthorized removal.

e. One vial of Sodium Bicarbonate Injection 1 meq./ml. Lot.89-280 expired on May/1/12 and one vial of Atropine Sulfate Injection (USP) 1 mg. Lot. 87-107-EU expired on March 1/2012 and one Temporary Pacing Catheter tray with shoulder pins (Introducer Kit) Lot. RF0092752 with expiration date of January/2012 were observed on the emergency crash cart at the Invasive Laboratory (Catheterism area).

2. In front of the closet used to place clean linen, operating room scrubs and patient ' s room curtains located outside of the hospital, six large plastic containers were observed, the ICO (employee #11) was interviewed on 8/28/12 at 2:15 pm and she said " The plastic containers are used to deposit biohazardous garbage from the different floors, personnel take the plastic containers and go to the different floors and take a biohazardous plastic bag and put it in the plastic containers and then maintenance personnel take the plastic containers to the designated area and then place the plastic containers in this area " , however it did not contain a plastic bag, and the containers are left outside of the hospital exposed to dust, water, sun, rodent and insects.

3. The following was observed in the intensive adult care unit on 8/21/12 from 10:50 am till 11:58 am related to infection control procedures accompanied by the nursing supervisor (employee #10) and ICO (employee #11):

The following was observed in the supply room of the intensive care unit related to infection control procedures:

a. The supply area lacks an identification label. A narcotic stainless steel case was observed on the right side of the supply room. The main door was observed opened all the time and one carton box of Dextrose 5 %/0.9 % Sodium Chloride Potassium Chloride 20 meq was observed holding the door open.

b. Two commercial large containers without identification label referred by the nursing supervisor (employee #10) used to keep clean linens were observed near the washstand located on the right side of the main entrance door, water when personnel washing their hands was observed on the top of the lid.

c. The door of the refrigerator used to maintain the medications was observed with mold, dust and dirty.

d. One open piggy bag of N/SS .9% 50 ml without an identification label with the date when opened, hour and nurse ' s signature were observed on a plastic tray, the nursing supervisor (employee #10) stated on 8/21/12 at 10:50 am. " the saline solution was used by the nurses to flush the patient ' s IV catheter when the catheter has problems to flow adequately " .

e. Two red blood samples tubes with expiration dates of August 2011, one blue blood samples tube with expiration date of May 2012, two blue blood samples tube with expiration date of July 2012 and one straight Thoracic Catheter expired in May 2011 were observed on the interior of the plastic tray, the cart was no organized and dust was observed on the interior of the tray.

f. Six clean sharps containers directly on the floor were observed under the wash stand used by personnel of the intensive care unit.

g. Fourteen clean suction canisters were observed on the top of the left side of the wash stand exposed to water when nurses washed their hands.

h. One full hand sanitizer bag was observed on the top of the right side of the wash stand which lacks the dispenser. When personnel need to use the hand sanitizer they need to touch the hand sanitizer bag.

i.Two bedpans and a urinal were observed directly on the floor.

j. A large transparent plastic bag on the counter with different sizes of transparent plastic bags (via flex) used to prepare medications and various Intravenous containers 500 ml./50 ml were observed on the last shelf of the wood cabinet, the cabinet did not have doors, however all of the materials used for patients were exposed to dust.

k. On the left side of the room a wood cabinet was observed, the cabinet used to keep the IV solutions was found with dust on the interior of the cabinet. A bottle of Hibiclens, Lot. 002270 with expiration date of 5/30/12 and was maintained on this cabinet. Four packages of diapers were observed on the top of the cabinet.

l. The refrigerator used to maintain the medications used at the intensive care unit lacks a security lock. The refrigerator was observed in a deteriorated condition and was not clean. The door was observed with a broken area on the interior and dirty adhesive tape was observed on broken areas of the door.

m. A bag of 50 ml which contained Diflucan 100 mgs was observed on the first shelf of the refrigerator, however the label lacks the date and the hour when prepared the medication, added by, expiration date, patient ' s name, room number, start time and flow rate. Another bag described as the medication added Diflucan 100 mgs prepared date in April 2011 and the first name of the patient (Luz).

n. A sharp container without a security rack was observed on the table used to maintain the venopuncture tray and destrostix machine.

o. Observations made during the initial tour provided evidence that the emergency call located at the patient ' s bathroom was maintain off at the moment when the test was performed.

p. A nurse ' s locker was located at the second door located on the right side of the patient ' s bathroom. Disinfecting wipes, ornaments, clothes hooks, basins, broom and other items were observed in the nurse ' s locker.

q. The intensive care unit does not have temperature and humidity daily registrations.

r. The intensive care unit ' s refrigerator used to maintain patients ' snacks does not have temperature daily registrations.

s. No evidence was found on 8/21/12 at 11:00 am of the registration log to record temperature for the Intensive Care Unit refrigerator used to maintain patient's snacks during for the dates of January 16, 22 and 30 of 2012. Facility policies and procedures reviewed on 8/21/12 at 11:20 am establishes that the temperature is to be taken daily and needs to be maintained between 36ºF and 46ºF.

t. Facility policies and procedures reviewed on 8/21/12 at 11:20 am establishes that the temperature of the refrigerator used to maintain biological medications is taken daily and is to be maintained between 36ºF and 46ºF. The daily registry was reviewed on 8/21/12 at 12:30 pm and provided evidence that Intensive Care Unit personnel failed to check the temperature daily and the temperature form did not established if the temperature was taken for Fahrenheit or Celsius. The registration log to record temperature for the Intensive Care Unit refrigerator was reviewed from January, February, March, April, May, June, July and August of 2012 and provided evidence that all temperatures were maintain under 18 to 30 degrees but it does not specify Celsius or Fahrenheit. The facility failed to ensure that the temperature registration log is in accordance with established policies and procedures.

u. Two opening boxes of gloves exposed to the environment were observed on the wall near the isolation room.

v. A suction machine, a large hamper used to deposit dirty clothes and linen, electrocardiogram machine, IV stand and a biohazardous trash container without identification labels were maintained in the corridor in front of the isolation room.

w. Two blood sample blue tubes expired since January 2012, five blood sample blue tubes expired since May 2012, one bottle of sterile water for injection expired on November 1, 2012 and one sterile water for injection expired on March 1, 2012 were observed inside of the emergency crash cart.

x. A dirty gauze pad and adhesive tape were observed covering around the air valve suction outlet, the valve lacked the plastic cover and the last inspection according with the inspection label of the suction outlet was performed on 6/17/2005.

y. During the initial tour on the intensive care unit on 8/21/12 at 2:00 pm with the ICO (employee #11) and the Intensive Care Unit Supervisor (employee #10) provided evidence that the patient at room #3, R.R #15 (record review) is a 64 years old female who was admitted by transfer to the Intensive care unit on July 27, 2012 with Renal Failure and Respiratory Failure. The patient has a foley catheter and the foley collection bag provided evidence that the foley catheter #16 was placed on July 12, 2012. According with facility policies and procedures manuals reviewed on 8/21/12 at 2:05 pm, it establishes that in March of 2012 that the foley it to be change every thirty days from the insertion day, dependent on urine changes and appearance or patient symptomatology. The record was reviewed on 8/21/12 at 2:15 pm and provided evidence that the physician did not placed the order to change the foley catheter and the patient exceeded by eleven days since the date of insertion.

The nurse supervisor (employee #10) was interviewed on 8/21/12 at 10:30 am and she stated " The physician (employee #38) ordered to change the foley on 8/21/12 at 3:00 pm by telephone order.

z. The record was reviewed on 8/29/12 at 11:50 am and provided evidence that the Foley catheter was changed on 8/21/12 at 3:00 pm and the urine was observed amber in color. The physician ordered on 8/26/12 at 9:00 am U/C and U/A six days after the Foley catheter was changed. No evidence was found that a urine culture was ordered until 8/26/12 at 9:00 am by the physician to verified possible bacterial infection. The order was taken by the nurse (employee #39) on 8/26/12 at 10:20 am and the urine culture was taken at 2:20 pm. The record was reviewed on 8/29/12 at 10:30 am and provided evidence that the microbiology report for urine culture reported colony count (C/C) over 100,000 CFU/ML (colony for unit per milliliters) and Growth of Yeast like structures.

The nurse supervisor (employee #10) was interview on 8/29/12 at 10:05 am related to the prolonged time to take the urine culture and she stated " The urine culture was not taken because the patient did not present urine output " .

a. The urine output daily form was reviewed on 8/29/12 at 10:21 am and provided evidence that the patient presented a urine output of 75 ml on 8/24/12, 25 ml on 8/25/12 and 25 ml on 8/26/12. The patient received antibiotic therapy treatment of Levaquin 750 mgs IV daily until 8/25/12 and received Fluconazole 50 mgs IV daily until 7/22/12 and Cansidas 50 mgs IV daily until 8/3/12. However, the nurse failed to change the Foley in accordance with policies and procedures of the facility that establishes every professional nurse utilize the judgment dependent on observations and patient symptomatology and should the Foley catheter every thirteen days from the date of insertion.

b. No evidence was found in the patient ' s record when the nurse notified the physician to change the Foley in accordance with policies and procedures of the facility. The physician failed to write the order in accordance with urine catheterization policies and procedures.

The ICO (employee #11) was interviewed on 8/29/12 at 10:25 am related to this case and she stated " I did not know about this case " . No evidence was provided by the ICO of the culture reports.

c. RR #17 is an 81 years old female who was admitted to the Medicine ward on 8/23/12 from the emergency room with a diagnosis of Urinary Tract Infection, Acute Renal Failure and Sepsis. The patient ' s record was reviewed on 8/29/12 at 10:10 am and provided evidence that the Foley catheter was placed at the emergency room on 8/18/12, however, no evidence of the Foley catheter number and the hour when the Foley was placed by the nurse. In Accordance with facility policies and procedures manual reviewed on 8/29/12 at 10:30 am, established on March of 2012 says when the Foley is inserted by the nurse the date, hour and Foley number needs to be placed.

4. The following was observed at the Medicine Ward II on 8/28/12 at 9:45 am related to infection control procedures:

a. A red mop used for the isolation room was observed in the floor sink where dirty mop water is discarded in the housekeeping room.

b. The hand soap dispenser was observed broken.

c. One large and clean sharp container and two small and clean sharp containers were observed directly on the floor of the housekeeping room used by the maintenance employees for patient ' s rooms.

5. The following was observed at the Endoscopy/Gastroscopy and Colonoscopy area on 8/29/12 at 11:20 am with the nurse supervisor (employee #13) and ICO (employee #11) related to infection control procedures:

a. The metal based used to put the Endoscopy/Gastroscopy and Colonoscopy equipment was observed with mold.

b. The curtain used to divide room #1 and recovery area touched the floor and was observed dirty.

c. Two gallons of Enzol, one gallon of Metricide OPA, exposed linen on a supply cart and one gallon of water were observed in the supply room.

d. One carton box of clean plastic containers used to collect specimens during the physician ' s procedures was observed in the room used to clean used tubes of Endoscopy/Gastroscopy and Colonoscopy procedures.

e. The door of the refrigerator used to maintain the medications was observed with mold.

f. One bag of chloraseptic drops, five bottles of Isopropyl rubbing alcohol 70%, two bottles of Povidine Iodine 10 % and two Hydrogen peroxide bottles were observed in the medication stock.

g. Two bottles of Cetacaine Topical Anesthetic Spray were observed in the medication cart with an expiration date of March 2011 and September 2012.

h. Dirty, black and brown stains and deteriorated floor was observed in the Endoscopy/Gastroscopy and Colonoscopy designated area.

6. During the initial tour of the X Ray department on 8/29/12 at 11:50 am with the ICO (employee #11) and the X Ray Supervisor (employee #8) at 11:50 am it was observed that a registered nurse (employee #42) canalized a patient on the left arm previous to realizing a C.T. Scan with contrast, the designated area to perform the canalization procedure was located at the corridor near the internal elevator and the main entrance and exposed the patient to the risk to acquire possible bacterial infection.

7. During the initial tour of the sterile supply area on 8/30/12 at 10:30 am with the ICO (employee #11) and the Operating Room Supervisor (employee #4) at 11:50 am, the following was observed:

a. Cidex OPA was observed in a tray prepared since August 23, 2012 to September 5, 2012 according with the identification label. 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 and lacks Manufacturers' recommendations.

8. During the initial tour on the Nuclear Medicine Department on 8/30/12 at 10:45 am accompanied by the registered nurse (employee #41) a lot of dust was observed on the interior and exterior of the crash cart, suction machine and defibrillator.

a. The suction machine with a serial #101807 lacks the annual preventive maintenance label.

b. The last annual maintenance check of the defibrillator with a serial #101957 was performed in April of 2011.

9. The general storage room located at the basement of the facility was visited on 8/30/12 at 1:45 pm with the ICO (employee #11) and provided evidence that approximately twenty to twenty five IV pump machines out of service, six carton boxes of gift packs used at the nursery department, sharps containers, gallons of water, pre-shaped kits and other materials were observed directly on the floor expose to environment.

10. The general storage area used to clean clothing, linen, blankets, scrubs and others located at the outside of the facility was visited on 8/28/12 at 2:00 pm. The entrance door to the clean clothes room was maintain closed but was observed without a security lock. The area was observed unorganized, deteriorated structure and dust was detected. On the right side a metal open shelve was observed and various patient ' s room curtains and were observed unorganized and without protective plastic covers and various curtains were located on the last shelf touching the floor exposed to dust. In front of the metal desk with an open shelf as observed two mattresses were observed on the top exposed to the environment.

11. Outside near the door of the clean clothes storage was a hand sink for personnel to wash their hands after sorting the dirty linen or used by other maintenance personnel of the facility. In front of the clean clothes room a corridor was observed and six plastic hampers identified with different departments were observed outside of the corridor.

The ICO (employee #11) was interview on 8/28/12 at 2:05 pm and she stated " Maintenance personnel from the different departments have a hamper and when the nurses change the patient beds they placed the linen in the hamper and carry the hamper to this area " .

a. The hampers were maintained outside exposed to the environment, rain, pests and vermin. The facility does not have a dirty laundry room with air extractor (to ensure negative pressure).

Based on the observational tour with the Infection Control Officer (employee #11), interviews and review of policies/procedures (P&P), it was determined that the facility failed to maintain a log of all incidents related to infections to promote sanitary and safe care through its infection control program in the laundry room, medicine intensive care unit, endoscopy area, invasive laboratory, X-Ray department related to improper infection control procedures and failed to follow infection control standards of practice.

Findings include:

The Infection Control Officer (ICO) (employee #11) has statistic information as reviewed on 8/28/12 at 9:20 am related to events in the hospital; however she does not have the capability with her documents to identify specific events that have occurred at the hospital, if further information is required by other departments. No evidence was found that the ICO has an infection control log to document all incidents and take the appropriate measures.

Base on review of policies and procedure, medical records review and interview with the discharge planning supervisor (employee # #6) it was found that the facility failed to establish the criteria to identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge and failed to ensure to have criteria for identifying risks within an early stage of hospitalization for the patient for discharge planning. Failed to ensure that discharge planning has policies/procedures related to a defined time frame to assess patients after the screening. Failed to ensure that discharge planning personnel complete an evaluation and reassess the patients' needs on a timely basis for post-hospital care and are made before discharge to avoid unnecessary delays with the discharge. Failed to ensure that the initial implementation of the patient's discharge plan is performed according to facility policies/procedure. Failed to ensure that ongoing reassessments are performed for patient's needs for factors that may affect continuing of care, which makes the Discharge Planning Condition of Participation "Not Met".

Based on the review of clinical records, policies/procedures and interview with the Discharge planning Supervisor (employee #6), it was found that the facility failed to establish the criteria to identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge and failed to ensure to have criteria for identifying risks within an early stage of hospitalization for the patient for discharge planning for 1 out of 8 records reviewed (R.R #12).

Findings include:

1. During interview with the Discharge planning Supervisor (employee #6) on 8/28/12 at 2:50 pm related to the discharge planning process, she stated that she checks the census every day for new admissions then she performs the discharge planning evaluation for all patients over 65 years old and according with the medical insurance during a 24 hour to 48 hour period from the admission. After the evaluation she performs a re-evaluation of the patients' needs for the next 8 to 10 days.

2. The facility's lacks policies and procedures that establish Discharge Planning time frame for the initial discharge planning assessment and re-assessment after admission as reviewed on 8/28/12 at 2:30 pm. The facility failed to establish psychosocial risk criteria for identifying patients who are likely to suffer adverse health consequences upon discharge without adequate discharge planning.

3. The facility failed to establish a mechanism of screening according to risk criteria as reviewed on 8/28/12 at 3:00 pm. The Discharge planning services failed to perform surveillance of issues which need to be assessed to ensure the quality of care offered to patients. The data was not presented as indicators or information obtained in order to present facility approach of quality improvement and patient health outcomes as the result of the care provided by the service.

4. One out of eight records reviewed (R.R #12) provided evidence that the facility failed to performed an assessment and identified it at an early stage during the hospitalization for a patient who was likely to suffer adverse health consequences upon discharge.
a. R.R #12 is a 37 years old male admitted to the facility on 8/23/12 with a diagnosis of left foot ulcer. During the record review performed on 8/29/12 at 2:00 pm, it was found that the patient was not evaluated by discharge planning since admission. According to an interview with the discharge planning supervisor (employee #6) on 8/29/12 at 2:00 pm, she talked with the physician to perform a referral for home care for wound care upon discharge. However no evidence was found related to this intervention.

Based on records reviewed and the review of policies and procedures related to the Discharge Planning Program and interview with the Discharge Planning Supervisor (employee #6), it was determined that the facility failed to ensure that discharge planning has policies/procedures related to a defined time frame to assess patients after the screening for one out of eight records reviewed (R.R #13).

Findings include:

1. During the review of policies and procedures on 8/28/12 at 2:50 pm with the Discharge Planning Supervisor (employee #6) who performs discharge planning, the following was identified:

a. During interview with the discharge planning supervisor (employee #6) on 8/28/12 at 2:50 pm related to the discharge planning process she stated that Discharge planning evaluations are performed during the 24 to 48 hours after admission for patients with Medicare and Medicare advantage and those patient over 65 years old based on needs identified by screening during admission to the facility, the patient is re-assessed after 8 to 10 days of the initial assessment. Other patients have to be referred by the physician or nurse to be evaluated by the discharge planning program. However, no evidence was found of policies and procedures related to a defined time frame to perform assessments after the referral or screening.

b. RR #13 is a 95 years old female admitted to the facility on 8/19/12 with a diagnosis of left leg cellulites. During the record review performed on 8/29/12 at 2:10 pm, it was found that the patient's discharge evaluation was performed on 8/20/12 and the discharge planning evaluation was left in blank related to the patient's needs or problems identified at the moment of the evaluation. No evidence was found related to the discharge planning follow up or reassessment to identify other patient needs during the admission until 8/29/12 when the physician ordered discharge planning and physical therapy evaluation to be discharged on 8/30/12.

Based on records reviewed and the review of policies and procedures related to the Discharge Planning Program with the Discharge Planning Supervisor (employee #6), it was determined that the facility failed to ensure that discharge planning personnel complete an evaluation and reassess the patients' needs on a timely basis for post-hospital care and are made before discharge to avoid unnecessary delays with the discharge for 1 out of 8 records reviewed (R.R #13).

Findings include:

R.R #13 is a 95 years old female admitted to the facility on 8/19/12 with a diagnosis of left leg cellulitis. During the record review performed on 8/29/12 at 2:10 pm, it was found that the patient's discharge evaluation was performed on 8/20/12; the discharge planning evaluation was left in blank for patient's needs or problems identified at the moment of the evaluation. No evidence was found related to a discharge planning follow up or reassessment of the identified needs or other patient needs during the admission until 8/29/12 when the physician ordered discharge planning and Physical therapy evaluation. On 8/30/12 the patient was discharge and the discharge planning process was delayed.

Based on the review of eight medical records, policies/procedures and interview with the discharge planning supervisor (employee #6), it was determined that the facility failed to ensure that the initial implementation of the patient's discharge plan is performed according to facility policies/procedure for 3 out of 8 records reviewed (R.R #6, #12 and #13).

Findings include:

1. During interview with the Discharge planning Supervisor (employee #6) on 8/28/12 at 2:50 pm related to the discharge planning process she stated that she checks the census every day for new admissions then she performs the discharge planning evaluation for all patients 65 years old and depending on the medical insurance within a 24 to 48 hour period from the admission. After the evaluation she performs a re-evaluation of the patient's needs during the next 8 to 10 days.

2. The facility's lacks policies and procedures that establish Discharge Planning time frame for the initial discharge planning assessment and re-assessment after admission. The facility failed to establish psychosocial risk criteria for identifying patients who are likely to suffer adverse health consequences upon discharge without adequate discharge planning.

3. The facility failed to establish a mechanism of screening according to risk criteria as reviewed on 8/28/12 at 3:00 pm.

4. The Discharge planning services failed to perform surveillance of issues which need to be assessed to ensure the quality of care offered to patients. The data was not presented as indicators or information obtained in order to present facility approach of quality improvement and patient health outcomes as the result of the care provided by the service.

4. Three out of eight records reviewed (R.R #6, #12 and #13) provided evidence that the facility failed to performed an assessment and reassessment for early identification during the hospitalization of patients who are likely to suffer adverse health consequences upon discharge.
a. R.R #6 is an 80 years old male admitted to the facility on 8/24/12 with a diagnosis of Sepsis. During the record review performed on 8/29/12 at 11:15 am, it was found that the patient's discharge planning process was performed on 8/27/12, three days after the patient was admitted.

b. R.R #12 is a 37 years old male admitted to the facility on 8/23/12 with a diagnosis of left foot ulcer. During the record review performed on 8/29/12 at 2:00 pm, it was found that the patient was not evaluated by discharge planning since admission. According to an interview with the discharge planning supervisor on 8/29/12 at 2:00 pm, she spoke with the physician to perform a referral for home care for wound care when discharge. However no evidence was found related to this intervention.

c. R.R #13 is a 95 years old female admitted to the facility on 8/19/12 with a diagnosis of left leg cellulitis. During the record review performed on 8/29/12 at 2:10 pm, it was found that the patient's discharge evaluation was performed on 8/20/12; the discharge planning evaluation was left in blank related to the patient's needs or problems identified at the moment of the evaluation. No evidence was found related to the discharge planning follow up or reassess to identify other needs during the admission until 8/29/12 when the physician ordered discharge planning and Physical therapy evaluation. On 8/30/12 the patient was discharge and the discharge planning process was delayed.

Based on the review of eight medical records, policies/procedures and interview with the discharge planning supervisor (employee #6), it was determined that the facility failed to ensure that ongoing reassessments are performed for patient's needs for factors that may affect continuing of care for 1 out of eight patients admitted to the facility (R.R #13).

Findings include:

1. During interview with the Discharge planing Supervisor (employee #6) on 8/28/12 at 2:50 pm related to the discharge planning process, she stated that she checks the census every day for new admissions, then she performs the discharge planning evaluation for all patients 65 years old and depending on the medical insurance during a 24 to 48 hour period after admission. After the evaluation she performs a re-evaluation of the patient needs within the next 8 to 10 days.

2. Policies and procedures were reviewed on 8/28/12 at 2:30 pm and provided evidence that they do not address the time frame when the reassessments are to be performed.

3.A mechanism to ensure that the discharge planning process is reassessed on an on-going basis was not performed nor followed as found on 8/28/12 from 2:50 pm till 3:30 pm: and on 8/29/12 from 10:00 am till 3:00 pm for one out of eight clinical record reviews which did not reveal a re-assessment (R.R #13).

a. R.R #13 is a 95 years old female admitted to the facility on 8/19/12 with a diagnosis of left leg cellulitis. During the record review performed on 8/29/12 at 2:10 pm it was found that the patient discharge evaluation was performed on 8/20/12 the discharge planning evaluation was left in blank related to the patient's needs or problems identified at the moment of the evaluation. No evidence was found related to a discharge planing follow up or reassess to identified other patient need during the admission until 8/29/12, when the patient that the physician ordered discharge planning and a Physical therapy evaluation. On 8/30/12 the patient was discharged and the discharge planing process was delayed.

Based on observations made of the surgical department, interview and review of policies/procedures with the Operation Room Nurse Supervisor (employee #4), 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. The operating room department was visited on 8/21/12 from 10:20 am till 3:30 pm provided evidence of the following:

a. During the operating room department observational tour on 8/21/12 from 10:20 am till 3:30 pm, it was observed that personnel of the operating room department and personnel of other hospital areas were entering into the different areas, restrictive and semi-restrictive areas of the operating room without traffic control.

b. In the preadmission area, it was observed that there was a paper tape on the floor, the nurse supervisor (employee #4) took them from the floor and put it on a table near the cannulation tray.

c. In the preadmission area, two cannulation trays were observed with non sterile gauze exposure to the environment.

d. In the preadmission area, an I.V pump machine was observed directly on the floor not connected to the electricity to maintain it charged.

e. In the preadmission area, the rail of a stretcher was observed with peeling paint.

f. The recovery area was observed with an emergency cart that was open and it had expired medications and medical/surgical material: one vial of Nitroglycerin in Dextrose 5% 200 mcg/ml with an expiration date of June 2012, two vials of Dobutamine 250 mg/20 ml with an expiration date of 5/1/12, four syringes of Epinephrine 1:10000 with an expiration date 6/1/12, six vials of vasopressin 20 u/ml with an expiration date of July 2012, one vial of Magnesium Sulfate 50% 5 gm/10 ml with an expiration date of July 2012, three bags of 50 ml of D5%W with an expiration date of November 2011, one bag of 50 ml of sodium chlorine with an expiration date of November 2011, one bag of 100 ml of sodium Chlorine 0.9% with an expiration date of December 2011, two bags of 500 ml of D 5%W with an expiration date of January 2012, one bag of 500 ml of Sodium Chlorine at 0.45% with an expiration date of November 2011, one bag of 1000 ml of sodium chlorine at 0.9% with an expiration date of March 2012, four red blood sample tubes with an expiration date of March 2012, three lilac blood sample tube with an expiration date of February 2012, one Foley catheter tray with an expiration date of September 2011, one Urethral catheter tray with an expiration date of October 2011 and one Central Venous Catheterization Kit with an expiration date of October 2011.

g. Cubicle #3 in the recovery room was observed with 4 x 4 non sterile gauze over a non sterile glove box.

h. The crash cart near operating room #1 was observed at 11:10 am without a security lock and with expired medications: one bag of Hespan 6% hetastarch in 0.9% sodium Chloride 500 ml with an expiration date of May 2012, one bag of Ringer Lactated 1000 ml with an expiration date of 8/1/12, one bag of 500 ml of D 5%w/.45 sodium chlorine with an expiration date of 6/1/12, three red tubes of blood sample with an expiration date of March of 2012 and four lilac tubes for blood samples with an expiration date of December 2011.

i. The nurse anesthetist (employee #40) was observed in operating suite #1 (in the restricted area) without a mask on 8/21/12 at 11:15 am.

j. The orthopedic surgeon (employee #42) was observed in the hallway near operating suite #1 (semi restricted area) with a pair of rubber shoes (crock style) without shoe covers on 8/21/12 at 11:15 am.

k. The plastic surgeon (employee #41) was observed in operating suite #4 (in the restricted area) without a mask on 8/21/12 at 11:30 am.

2. The hospital operates on ambulatory patients but the facility does not have a designated phase II area as observed on 8/21/12 at 10:30 am. These patients are located at the pre admission area until the patients are discharged.

3. The room used to process equipment with Cidex OPA was visited on 8/21/12 at 11:50 am and it did not have an exhaust hood: Manufacturers' recommendations suggests that the solution is used in a well-ventilated area and stored 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 accidently falls on the floor.

3. R.R #25 is a 66 years old male admitted to the facility on 8/24/12 with a diagnosis of Acute Gastritis, Dehydration, Urinary Tract Infection and Paraplegic. During the record review performed on 8/28/12 at 11:30 am, it was found that the patient enter the operation room on 8/27/12 to have performed a partial colostomy which required anesthesia services, however the history and physical (H&P) was not performed by the patient's physician, it was left in blank.


20423


Based on the review of eight records and policies/procedures of the operating room with the Operation Room Nursing supervisor (employee #4), it was determined that the facility failed to have complete history and physical work-ups for 3 out of 8 records reviewed (R.R #7, #8 and #25) related to the physician failure to perform the patient's history and physical work-ups.

Findings include:

1. R.R #7 is a 66 years old female admitted to the facility on 8/27/12 with a diagnosis of Perforated Diverticulosis Transverse Colon. During the record review performed on 8/28/12 at 11:30 am, it was found that the patient enter the operation room on 8/27/12 to have performed a partial colostomy which required anesthesia services, however the history and physical (H&P) was not performed by the patient's physician, it was left in blank.

2. R.R #8 is a 62 years old female admitted to the facility on 8/25/12 with a diagnosis of closed left ankle fracture. During the record review performed on 8/29/12 at 10:45 am, it was found that the patient needed a surgical procedure on 8/27/12 to repair the ankle fracture which required anesthesia services, however the H&P was not performed by the patient's physician, it was left in blank.

Based on the review of eight medical records and policies/procedures of the operating room with the Operating Room Supervisor (employee #4), it was determined that the facility failed to execute complete surgery informed consents that includes date, hour, type of surgery, name and signature of the surgeon, name of the anesthesiologist, type of anesthesia given to the patient, record number, benefits of the surgery and surgeon's license number for 1 out of 8 records reviewed (R.R #6).

Findings include:

R.R #6 is an 80 year old male admitted to the facility on 8/24/12 with a diagnosis of Bilateral Hip Pressure Ulcer. On 8/27/12 the patient was sent to the operating room to perform a cleaning and debridement of both hip pressure ulcers and the patient's relative signed the consent for the procedure. However the surgery consent was left in blank by the surgeon.

Based on the review of eight medical records to evaluate anesthesia services with the Operating Room Supervisor (employee #4), it was determined that the facility failed to ensure that informed consent forms are properly executed for 1 out of 8 medical records reviewed (R.R #6).

Findings include:

1. During the review of eight medical records on 8/28/12 from 10:00 am till 12:00 noon, the following was determined:

a. R.R #6 is an 80 year old male admitted to the facility on 8/24/12 with a diagnosis of Bilateral Hip Pressure Ulcer. On 8/27/12 the patient was sent to the operating room to perform a cleaning and debridement of both hip pressure ulcers the anesthesia consent lacked the type of anesthesia to be given to the patient.

Based on the review of nine closed and active records reviewed (R.R), policies/procedures manual, interview and the observational tour with the emergency room nursing supervisor (employee #2) on 8/21/12 from 10:00 am till 3:00 pm and 8/29/12 from 1:30 pm till 3:30 pm, it was determined that the facility failed to comply with procedures related to the integration or coordination between the emergency room and other departments, the emergency room Nursing Supervisor (employee #2), it was determined that the facility failed to comply with revision dates for E.R manuals, policies and procedures related to the compliance with EMTALA requirements, no sign posting at the ambulance entrance and the entrance/waiting area notifying of the rights of the individuals who enter the emergency room (E.R), emergency personnel do not have a plan or assignments for all specific tasks in the event of an emergency, failure to ensure infection control standards of practice, a sharp container was attached to the venopuncture cart with tape, no evidence was found of the policies/procedures for the daily registration of the cleaning and disinfecting of the digital thermometer in the triage room, the minor surgery room is not appropriately maintained related to Cidex OPA use and temperature and humidity, the monitors at the critical care area used to stabilize patients at the ER were not appropriately set for sound, the ER does not count with the help of Licensed Practical Nurses, five crash carts and medications carts were found unlocked and their content accessible to non-authorized persons, medications were found on the top of a medication cart and preserved medications were found in a drawer, patients were disconnected from cardiac monitors without an order from the physician and there are not enough cardiac monitors for the amount of patients seen in the ER and two out of nine records reviewed failed to have appropriate transfer documentation and discharge information (R.R #47 and #50) and the facility failed to comply with EMTALA regulations related to on-call surgeons roster to cover the emergency room in the event that this specialty is needed. All of the above findings makes this condition "Not Met".

Based on the review of the policies/procedures manual with the emergency room medical director (employee #24) and Nursing Supervisor (employee #2), it was determined that the facility failed to comply with procedures related to the integration or coordination between the emergency room and other departments.

Findings include:

1. The following was determined related to the emergency department's policies/procedures reviewed on 8/21/12 from 2:30 pm:

a. Policies/procedures were found that the integration and coordination between the Emergency Department with the other departments of the hospital such as: the surgical services, laboratory, intensive care unit, admission department, pharmacy services, diet services and the radiology department, however the policies/procedures did not include the time frame. The hospital must be able to demonstrate how the hospital's other departments provide emergency patients the care and services needed within a safe environment, within a timely manner and with appropriate/available personnel.

Based on the review of nine closed and active records reviewed (R.R), policies/procedures manual, interview and the observational tour with the emergency room Nursing Supervisor (employee #2), it was determined that the facility failed to comply with revision dates for E.R manuals, policies and procedures related to the compliance with EMTALA requirements, no sign posting at the ambulance entrance and the entrance/waiting area notifying of the rights of the individuals who enter the emergency room (E.R), emergency personnel do not have a plan or assignments for all specific tasks in the event of an emergency, failure to ensure infection control standards of practice, a sharp container was attached to the venopuncture cart with tape, no evidence was found of the policies/procedures for the daily registration of the cleaning and disinfecting of the digital thermometer in the triage room, the minor surgery room is not appropriately maintained related to Cidex OPA use and temperature and humidity, the monitors at the critical care area used to stabilize patients at the ER were not appropriately set for sound, the ER does not count with the help of Licensed Practical Nurses, five crash carts and medications carts were found unlocked and their content accessible to non-authorized persons, medications were found on the top of a medication cart and preserved medications were found in a drawer, patients were disconnected from cardiac monitors without an order from the physician and there are not enough cardiac monitors for the amount of patients seen in the ER and two out of nine records reviewed failed to have appropriate transfer documentation and discharge information (R.R #47 and #50).

Findings include:

1. The following was observed related to the review of the policies/procedures manual and observations of the emergency department with the E.R Nursing Supervisor (employee #2) on 8/21/12 from 10:00 am till 3:00 pm and 8/29/12 from 1:30 pm till 3:30 pm:

a. No evidence was found that the Emergency Department manual adopted and revised all of their policies/procedures according with the recent changes related to accepted standards of practice and procedures to provide emergency services. The Emergency Room Administrative Manual of policies and procedures did not have the last revision date and date that the manual was approved.

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

2. No signs were posted at the entrance (ambulatory/ambulance) and treatment area for the notification of the rights of the individuals who enter the E.R as observed on 8/21/12 at 10:10 am.

3. No evidence was found on 8/21/12 at 10:45 am that emergency personnel have a plan or assignments for all specific tasks in the event of an emergency. All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

4. The following was observed in the ER on 8/21/12 from 10:00 am till 3:00 pm related to infection control procedures:

a. All venopuncture access tray were observed in the ER (triage, observation area, minor surgery and venopuncture area) with non-sterile gauze without protective covers, exposing them to the environment. Also, venopuncture access trays were observed unorganized and with all of the used material (one open bottle of sterile water (single dose), alcohol pads envelops, Angiocath caps, etc.) left behind from various venopuncture procedures.

b. IVPB lines were observed in cubicles #A-1, #A-2, #A-3, #A-4 and #A-5 (connecting to the main line) in the observation area without a label indicating the date when the IVPB was started. The facility's policies and procedures was reviewed on 8/21/12 at 1:30 pm and provided evidence that the IVPB were to be changed every 24 hours.

c. Respiratory therapy equipment (oxygen cannula and ventury mask) were observed in cubicles #A-1b, #A-4, #A-6 and #14 in the observation area without a label indicating the date when the respiratory therapy equipment was started. The facility's policies and procedures was reviewed on 8/21/12 at 1:30 pm and provided evidence that respiratory therapy equipment are to be changed every 72 hours.

d. Used suction tubes with suction catheters were observed in cubicles #A-4 and #A-5 in the observation area after used with other patients.

e. Two bedpans were observed directly on the floor in cubicles #A-5 and #A-9 in the observation area after used with the patients.

f. Three I.V bags of .9 normal saline were found in the medication room with labels already placed and did not have their plastic protective covers.

g. A foley catheter collector bag was observed directly on the floor in cubicle #12.

h. Two urinals were observed (one on the floor and the other was hanging from the bed rails) at cubicle #4 with urine from the same patient.

5. Near cubicle A-2 a venopuncture cart was found on 8/21/12 at 11:00 am with a sharp container on the side of it attached by various pieces of tape used to keep it in place.

6. No evidence was found of the policies/procedures for the daily registration of cleaning and disinfecting of the digital thermometer in the triage room as reviewed on 8/21/12 at 1:45 pm.

7. The minor surgery room of the ER was visited on 8/21/12 at 10:45 am with the nursing supervisor (employee #2) and provided evidence that this room has one tray with Cidex OPA with a preparation date of 4/1/12 and no test strips were found or provided in this area. Within this container were found a laryngoscope blade and a disposable suture kit. According with the Manufacturers' recommendations, this solution is to be tested and discarded within 28 days of the date of preparation or if its effectivity is lost when tested with the strips, whichever comes first. Also, no evidence was found that the facility has a spill kit to use if Cidex OPA accidentally falls on the floor and no procedures were found how the facility disposes of the Cidex OPA.
a. The facility failed to record temperature and humidity for this room to ensure that it complies with appropriate perimeters.

8. The critical area used to stabilize and manage patients who arrive at the ER was visited on 8/21/12 from 11:45 am till 12:00 noon with the facility's ER Nursing Supervisor (employee #2) and provided evidence that this is an area with three cubicles are used to place critical/intensive patients and it is located in front of the nursing station. On 8/21/12 at 11:45 am there were two patients located in this area with cardiac monitors but no nursing supervision was found. The emergency room nursing supervisor (employee #2) was interviewed on 8/21/12 at 11:50 am and stated that personnel at the nursing counter can hear the monitors and nursing personnel are entering constantly to verify the patients. However when the sound of the cardiac monitors were tested by going behind the nursing counter, they could not be heard over the environment noise of the emergency room. The biomedical technician (employee #3) was interviewed on 8/21/12 at 11:55 am and she stated that the volume was too low and she adjusted it so that staff could hear them and she also stated that the alarm will now also ring louder to ensure that personnel at the nursing counter can hear it.
a. Interview with the ER nursing supervisor (employee #2) on 8/21/12 at 11:45 am provided evidence that her entire roster of nursing personnel is composed of Registered Nurses (RN). She stated that they do not have Licensed Practical Nurses (LPN), so the RN's are responsible related to patient observations, patient care, answering nursing calls, patient hygiene, feeding patients, changing disposable briefs, emptying bed pans and supplying the different areas with materials.

9. The crash carts and medications carts (5 carts in total) located throughout the ER were observed on 8/21/12 from 10:00 am till 12:00 noon with the Nursing Supervisor (employee #2), unlocked and their content accessible to non-authorized persons and these carts were placed in areas that were not readily visible by nursing personnel.

10. The medication cart located near cubicle #6 was found with 6 bottles of preserved medications for patients (Carafate, Guiferin and Kayexalate) and 2 vials of multivitamins. Also, on top of this medication cart was a bottle of cold sterile water to be used to administer patient medications. In this medication cart in the drawer marked A-2, a cup with 3 preserved medications were found for a patient but the patient was taken for a study and was not present.

11. Two active clinical records were reviewed on 8/21/12 from 1:30 pm till 3:00 pm to verify documentation of patients who received treatment in the Emergency Room (ER) and provided evidence of the following:

a. R.R #46 is a 48 years old male who visited the emergency room on 8/20/12 with a diagnosis of Abdominal Pain with vomits and nauseas. The record review was performed on 8/21/12 at 1:45 pm. The patient was triaged at 4:48 am and was classified "urgent" with the following vital signs (V/S): temperature-37.1ºC, pulse-107, respiration-21 and blood pressure-103/54. The patient was evaluated by the physician at 6:30 pm and ordered NPO, bed rest, phenergan, Pepcid and laboratories. At 8:00 pm the physician ordered a cardiac monitor, portable chest X-Ray, EKG, ABG and antibiotics in the observation area. On 8/20/12 at 11:00 pm the patient was ordered to be admitted to the medicine telemetry area or the intensive care unit with a diagnosis of UCHF (congestive heart failure), CAD (coronary artery disease), Digoxin Intoxication and Abdominal Pain. On 8/21/12 at 11:00 am a patient (R.R #48) was observed in cubicle #1 while he was receiving a bed bath. Next to the patient's bed was observed a cardiac monitor and the patient's wife stated on 8/21/12 at 11:15 am that it was being used on her husband but they removed it when they took him for a study. She also stated that the study (echocardiogram) was about an hour ago and when he returned they did not connect him back to the monitor. The E.R nursing supervisor (employee #2) stated during an interview on 8/21/12 at 11:20 am that all patients connected to cardiac monitors are to remain connected at all time even when they are sent for studies. Policies and procedures reviewed on 8/21/12 at 3:10 pm provided evidence that patients who are ordered cardiac monitors shall remain with the monitors until the physician discontinues the order regardless of studies or other circumstances. Also, no evidence was found in nursing progress notes related to how the patient was transferred for the study, at what time and hour and what equipment was sent with him (oxygen, cardiac monitor, personnel, etc.) or when the patient returned to the E.R.

b. R.R #26 is a 94 years old male who visited the emergency room on 8/19/12 with a diagnosis of Bronchopneumonia, Sepsis, Congestive Heart Failure with vomits and nauseas. The record review was performed on 8/21/12 at 2:15 pm. The patient was triaged at 2:52 am and was classified "emergency" with the following vital signs (V/S): temperature-36ºC, pulse-62, respiration-19 and blood pressure-100/59. The patient was evaluated by the physician at 3:30 am and ordered Ventury mask 50%, EKG, Brain CT, chest X Ray, Tridil to run 1 ml per hour, antibiotics therapy and blood sample laboratories in the observation area. At 9:00 am the physician was consulted by internal medicine. On 8/19/12 at 9:00 am the patient was ordered to be admitted to the medicine telemetry ward or intensive care unit with a diagnosis of Congestive Heart Failure and Bronchopneumonia. On 8/20/12 the physician ordered Ativan 1 mg HS and every 8 hours and Haldol 1 mg IV every 12 hours. On 8/21/12 at 10:45 am a patient (R.R #26) was observed in cubicle #6 with a ventury mask and Tridil without a cardiac monitor. The E.R nursing supervisor (employee #2) stated during an interview on 8/21/12 at 10:50 am that the patient was removed from this area and disconnected from the monitor because another patient arrived in the morning with cardiac arrest and they needed this critical area to manage this patient. The nursing supervisor also stated that the E.R only has five cardiac monitors, and today there are thirty-three patients waiting to be admitted to the hospital from the E.R, with some who are going to be admitted to the telemetry area and others to the Intensive Care Unit. E.R protocols reviewed on 8/21/12 at 3:10 pm provided evidence that patients who are ordered Tridil shall remain with the cardiac monitors until the physician discontinues the order or until the patient is re-evaluated.

12. One out of three closed clinical records were reviewed for transfer procedures on 8/30/12 from 10:30 am till 12:30 pm for emergency room services and provided evidence that the physician's risks for transfer was unexpected events, instead of a risk related to the patients health condition.

a. R.R #47 is a 95 years old female who visited the emergency room on 7/1/12 with a diagnosis of Head Trauma. The record review was performed on 8/30/12 at 10:45 am. The patient was triaged at 1:41 am and was classified "urgent" and was evaluated by the physician at 2:33 am and ordered local care, X ray and CT. No evidence was found of the physician's documentation of the condition at the moment of the transfer to another facility and no evidence was found of the risk related to the transfer diagnosis of intracranial bleeding.

13. One out of four closed clinical records (evaluated on 8/29/12) were reviewed on 8/30/12 from 10:30 am till 12:30 pm to verify documentation of patients who receiving treatment in the Emergency Room and provided evidence of the following:

a. R.R #50 is a 53 years old male who visited the emergency room on 8/29/12 with Bronchial Asthma and a history of Diabetes Mellitus. The record was reviewed on 8/30/12 at 11:45 am and provided evidence that the patient was triaged at 2:24 pm and was classified "non-urgent" with the following vital signs (V/S): temperature-37.5ºC, pulse-103, respiration-20 and blood pressure-135/95. The patient was evaluated by the emergency room physician on 8/29/12 at 3:12 pm with the principal diagnosis of bronchial asthma, was ordered respiratory therapy, X ray, laboratories and Levaquin 750 mg IV for one dose and was consulted for by an internal medicine physician on 8/29/12 at 9:00 pm. The laboratory results taken on 8/29/12 at 5:23 pm from the emergency room services provided evidence that the patient's white blood cells was 24,000 u/l. However, when the patient was discharged from the ER, no evidence was found of the X ray results ordered by the physician and no documented evidence was found that the patient received instructions related to his condition and what to do if he did not get better (considering that his WBC was 24,000 u/l).

Based on the review of the policies/procedures manual, physician's on-call list, interview and the observational tour with the emergency room nursing supervisor, it was determined that the facility failed to comply with EMTALA regulations related to on-call surgeons roster to cover the emergency room in the event that this specialty is needed.

Findings include:

No evidence was found on 8/21/12 at 2:00 pm of an on-call surgeon roster to cover the Emergency Room in the event that this specialty is needed on Tuesdays from 4:00 pm till 7:00 am. The Medical Director (employee #22) stated during an interview on 8/29/12 at 2:30 pm that there is a problem with this specialty for on-call services and it is being discussed with the Medical Staff to reach an agreement with these physicians so that they can comply with an on-call program for surgeons. The program from June to September of 2012, provided evidence that only one Tuesday from each month is covered by a group of surgeon (composed of three surgeons), but it does not state specifically which one. Also, the program was not signed by the Medical Director and did not have the first call and second call options.

Based on the review of two medical records and policies/procedures and interview with the respiratory therapy supervisor employee # #15), 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 orders in accordance with standards of practice related to the type and amount of diluents and the unit of concentration of the medication provided for 2 out of 6 clinical records reviewed (R.R #6 and #9).

Findings include:

1.Six medical records were reviewed on 8/30/12 from 10:00 am till 2:30 pm and provided evidence the physician's lack of written respiratory therapy orders in accordance with standards of practice related to the type and amount of diluents and the unit of concentration of the medication provided and provide evidence that respiratory therapists do not administer respiratory therapy treatment in accordance with the physician's order and documented the amount of diluents and the unit of concentration of the medication provided in the Respiratory care treatment sheet for 2 out 6 records reviewed with respiratory therapy.

a.R.R #6 is an 80 years old male admitted on 8/24/12 with a diagnosis of Sepsis. The record review was performed on 8/30/12 at 1:00 pm with the Respiratory Therapist Supervisor (employee #15) the following was found:

1.T he physician ordered on 8/24/12 at 7:30 pm Atrovent every 6 hours.

2.. The physician order lack of the dose of Atrovent to be administered.

3. The Respiratory care treatment sheet from 8/24/12 provide evidence that the treatment was administered at 8:00 pm, Atrovent 2.5/ NSS every 6 hour,

4. The respiratory therapist failed to documented the dose unit and the amount of diluent.

5. No evidence was found related to the communication between the respiratory therapist and the physician to evaluate the respiratory therapy order.

6. The respiratory therapist failed to administer the treatment accordance to physician order related to the next dose was provided at 11:00 pm 3 hour after last dose, not every 6 hour. The next dose was administered on 8/25/12 at 8:06 am (nine hour later), then at 5:30 pm (nine hour later). Then on 8/26/12 at 1:00 am (seven and half hour later) then at 8:50 am (7 hour 50 minute later), then at 1 :00 pm (two hour before the next dose), then at 5:30 pm (one and half hour before the next dose) Then on 8/27/12 at 12:00, at 7:00 and at 12:30 the respiratory therapist did not document the am or pm at the hour of administration. The next dose be administrated on 8/28/12 at 12:00 (twelve hour later), at 7:55 am (one hour 55 minute later) at 12:30 pm (one and half hour before the next dose). Then on 8/29/12 at 12:00, at 7:00 am, at 1:00 pm and at 6:00.
g. The respiratory therapist failed to documented the dose unit, the amount of diluent, the am or pm of the hour of administration.