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Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7) and review of policies and procedures related with patient's rights it was determined that facility failed to promote the right of each patient to a dignified existence, self-determination and communication with and access to services while receiving services in the facility which make this condition Not Met (Cross reference TAGS A117, A130, A131, A132, A154, A159, A164, and A168).

Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021 from, 8:00 AM through 4:00 PM, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7) interview and review of policies, it was determined that facility failed to comply with the Centers for Medicare and Medicaid Services (CMS) regulatory requirement that hospitals notify Medicare beneficiaries who are hospital inpatients about their hospital discharge rights. This deficient practice was identified on 7 out of 19 records reviewed (RR # 2, RR# 5, RR#6, RR #7, RR#14, RR # 15 and RR# 16).

Findings include:

A mechanism to ensure that facility issue the Important Message for Medicare (IM) within two (2) days of admission and obtain the signature of the beneficiary or his/her representative and deliver a copy of the signed notice to each beneficiary not more than two (2) days before the day of discharge were not promoted, not performed accordingly with the following findings:

1. RR # 5 is an 85 years old male patient admitted 11/14/2020 with a diagnosis of COVID-19 to the COVID-19 unit. It was found the Important Message for Medicare (IM) filed in the medical record without the signature of patient or patient relative when admitted on 11/14/2020 to an inpatient unit.

2. RR#7 is a 79 years old female patient admitted on 12/23/2020 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit.

It was found the Important Message for Medicare (IM) filed in the medical record without the signature of patient or patient relative when admitted on 12/23/2020 to an inpatient unit.

This patient receives care treatment and services and was discharged home on 01/15/2021.

It was found the Important Message for Medicare (IM) filed in the medical record without the signature of patient or patient relative facility did not issue or deliver the information 2 days before the day of discharge from the inpatient unit.

3. RR #15 is a 68 years old male patient admitted 03/18/2021 with a diagnosis of COVID-19 and Septic Shock to the COVID-19 unit. It was found the Important Message for Medicare (IM) filed in the medical record without the signature of patient or patient relative when admitted on 03/18/2021 to an inpatient unit.

4. RR #16 is an 82 years old male patient admitted 02/18/2021 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit. It was found the Important Message for Medicare (IM) filed in the medical record without the signature of patient or patient relative when admitted on 02/18/2021 to an inpatient unit.

This patient receives care treatment and services and was discharged home on 03/08/2021.

It was found the Important Message for Medicare (IM) filed in the medical record without the signature of patient or patient relative facility did not issue or deliver the information 2 days before the day of discharge from the inpatient unit.

Patient Rights notification to comply with the Centers for Medicare and Medicaid Services (CMS) regulatory requirement to inform Medicare beneficiaries who are hospital inpatients about their hospital discharge appeal rights policy were reviewed with the Coordinator of Emergency room admission department (employee # 10).

During this review on 04/22/2021 at 10:15 AM (employee #10) stated on interview that emergency room admission personnel are the responsible personnel to educate patients and relatives in relation with the Important Message for Medicare within two (2) days of admission and obtain the signature of the beneficiary or his/her representative.

He also stated that the education in relation of the Important Message for Medicare it is a process that is not being carried out because COVID-19 patients are on isolation and personnel are not permitted to have interaction with those patients. Employee # 10 stated that he believes that the responsibility to educate and obtain the signature of the beneficiary or his/her representative was reassigned to the nursing personnel since last year.

Director of Nursing (employee # 2) stated on interview on 04/21/2021 at 11:55 AM that she did not receive any special or official instructions related with the process of the Important Message for Medicare within two (2) days of admission and obtain the signature of the beneficiary or his/her representative. She also stated that nursing department personnel is not carrying out this task.

Facility Institutional Care Program Director (employee # 2) stated on interview on 04/21/2021 at 1:25 PM that the process to obtain the signature of the beneficiary or his/her representative and deliver a copy of the signed notice of the Important Message for Medicare to each beneficiary not more than two (2) days before the day of discharge is a process assigned to the hospital utilization department personnel. She also stated that she did not know the reason why the delivery of the Important Message for Medicare to each beneficiary not more than two (2) days before the day of discharge from the inpatient unit are not performed or promoted.


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5. RR#2 is a 73 years old female patient admitted on 08/25/2020 with a diagnosis of Colitis, Paralytic Ileus, Acute Gastroenteritis, Dehydration and Dementia at third floor area designated for patients with R/O COVID-19 awaiting result of COVID-19. On 08/27/2020 the result was reported ''Not Detected ''and the patient was transfer to the fifth floor.

It was found the Important Message for Medicare (IM) filed in the medical record without the signature of patient or patient relative on 08/26/2020 and lack of the hour.

This patient receives care treatment and services and was discharged home on 08/28/2020.

It was found the Important Message for Medicare (IM) filed in the medical record without the signature of patient or patient relative, the facility did not issue or deliver the information 2 days before the day of discharge from the inpatient unit.

6. RR#6 is an 80 years old female patient admitted on 11/23/2020 with a diagnosis of Viral Pneumonia to the COVID-19 unit with positive result of COVID-19.

It was found that the Important Message for Medicare (IM) filed in the medical record without the signature of patient or patient relative on 11/23/2020 and lack of the hour.

This patient receives care treatment and services until 02/01/2021 because the patient passed away.

7. R#14 is a 40 years old male patient admitted on 04/06/2021 with a diagnosis of Hypoxemia, COVID-19 positive on 04/05/2021. Admitted at the third-floor area designated for patients with COVID-19.

It was found the Important Message for Medicare (IM) filed in the medical record without the signature of patient or patient relative on 02/14/2021 and lack of the hour.

This patient receive care treatment and services and passed away on 04/11/2021.

Based on complaint survey PR00000636 performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7) interview and review of policies, it was determined that facility failed to promote the right of patient's representative to participate in the development and implementation of the patient plan of care. This deficient practice was identified on 3 out of 19 records reviewed ( RR # 2, RR#15 and RR # 17 ).

Findings include:

A mechanism to ensure that facility maintain communication on aspects related to plan of care implementation on patients who experienced disorientation or are receiving support with mechanical ventilation while being admitted and treated on the COVID-19 unit were not promoted, not followed accordingly with the following findings:

1. Accordingly with information provided by facility Institutional Care Program Director (employee # 2) and Director of Nursing (employee #3) on interview on 04/20/2021 at 3:35 PM since the beginning of the COVID-19 pandemic emergency in PR on March 2020 hospital discontinue visits to patients. As soon as facility suspends the visits, develop and implement procedures to guide virtual or telephonic communications to be performed by physicians and other authorized healthcare professionals. These procedures aimed maintain patient's relatives and representatives informed in relation with patient health status and the implementation of the plan of care.

2. During interview performed on 04/20/2021 at 3:30 PM the Facility Institutional Care Program Director (employee # 2) stated that it is very important to identify during admission process the person who is going to act as spokesperson of the patient. This is the person that is going to receive information related with care, treatment and services provided during patient stay at the inpatient unit. Coordination of this procedure must be performed during the admission process because once the patient is admitted, visits to the inpatient units are no longer permitted.

3. Review of facility patient education certification were facility documents education provided to patient's relatives and representatives when admitted receiving services to the COVID-19 unit did not evidence any topic related with the virtual or telephonic communications in place at the facility.

While it is true that facility appears to have a mechanism in place to maintain the communication with patient's relatives or patient's representative there is no evidence that the mechanism is operational and was performed in all cases were patients are vulnerable or experience health status issues (disorientation, sedation).

4. The contents of medical record documentation of plan of care treatment implementation of cases RR# 15 and RR #17 which experienced disorientation who requires to be put in physical restriction due to risk to injury to self and with high potential of removing lines tubes, equipment or dressings were reviewed and discussed with Intensive Care Unit Supervisor ( employee # 7) and the Director of Nursing ( employee #3 ) on 04/20/2021 at 3:38 PM.

During the review it was identified that there is no evidence documented on the progress notes or any other documentation in relation with notification to patient's representatives of patient health status the implementation of a physical restriction protocol and the responses exhibit by the patient while being on physical restriction.

Information related with patient relevant changes in health status or condition worsened were not found notified to relatives.

a. RR#15 is a 68 years old male patient admitted 03/18/2021 with a diagnosis of COVID-19 and Septic Shock to the COVID-19 unit.

On 03/23/2021 patient was connected to a mechanical ventilator and was apparently combative (or fighting) against the ventilator making it harder for the ventilator to help. Patient was assessed and a physical restriction order was prescribed on 03/23/2021 at 8:45 AM.

Physician's restraint orders were completed, as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

This patient died on 3/30/2021at 6:40 AM while was on mechanical ventilation, accordingly with information found documented on the medical record.

The physician who provide Cardiopulmonary Resuscitation wrote on the progress notes that he notifies patient's attending physician about patient death.

No information was found documented of the notification to patient relatives of patient death.

b. RR #17 is a 90 years old female patient admitted on 03/15/2021 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit.

On 03/15/2021 and accordingly with information found documented on the medical record on 03/15/2021 at 10:11 PM register nurse in charge of the patient apply physical restriction to the patient.

Physical restraint orders were completed, as well the assessment algorithm on 03/15/2021 at 11:00 PM.

However, order of 03/15/2021 was not authenticated (signed) by the physician.

No evidence was found documented on the medical record of information provided to patient's relatives in relation with changes in health status and the necessity of physical restriction due to cognitive status changes.

No evidence was found documented of the period of time were patient remained on physical restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.


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5. During review of the patient record #2 it was found that the contents of medical record documentation of plan of care treatment implementation of this case which experienced disorientation, to be put in physical restriction due to risk to injury to self and with high potential of removing lines tubes, equipment or dressings were reviewed during the record review and it was identified that there is no evidence documented on the progress notes or any other documentation in relation with notification to patient's representatives of patient health status, the implementation of a physical restriction protocol and the responses exhibit by the patient while being on physical restriction.

Information related with patient relevant changes in health status or condition worsened were not found notified to relatives.

a.RR#2 is a 73 years old female patient admitted on 08/25/2020 with a diagnosis of Colitis, Paralytic Ileus, Acute Gastroenteritis, Dehydration and Dementia at third floor area designated for patients with R/O COVID-19 awaiting result of COVID-19.

On 11/25/2020 at 8:51 PM and accordingly with information found documented on the medical record the register nurse in charge (employee #15) observed that the patient removes the nasogastric tube, another nasogastric tube is inserted and the patient is suctioned obtaining a gastric residue of 600 milliliters.

The register nurse (employee #15) proceed to notify the physician (employee #14) and refers to restrict by two '' both hands '' and the nurse educates the family member of the patient who refers to understand. However, the nurse note did not indicate which family member was educated, date, time and reason for restriction.

On 11/25/2020 at 9:45 PM according to the progress nurse reveled that the patient is received from the emergency room with the nurse (employee #15) restricted by both wrists for patient safety.

No evidence of Physical restraint orders in the Emergency Room.

The official '' Physicians restraint telephone order's according of the medical record reviewed on 04/20/2021 at 11:30 AM provide evidence that the telephone initial restraint orders was written by the nurse (employee #17) on 08/26/2020 at 12:30 AM ordered by physician (employee #11) not on 08/25/2020 when the nurse initiated the restraint.

According to the '' Physicians Restraint Order's the reason to restraint was ''High Risk of Injury to self and High Potential for removing lines tubes, equipment or dressing and patient to be restraint for 24 hours.

The physician signed the restraint orders on 08/26/2020 however, lacks of the hour when the physician signed the telephone order.

No evidence when the Physicians initiated and completed the assessment algorithm initiated on 08/25/2020.

No evidence was found documented of the period of time were patient remained on physical restriction (when began and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

However, according of the '' Physician's Orders Discharge Order Form '' the patient is discharge home on 08/28/2020 at 1:10 PM on wheelchair.

No evidence was found documented on the medical record of information provided to patient's relatives in relation with changes in health status and the necessity of physical restriction due to cognitive status changes.

Based on complaint survey PR00000636 performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7) and review of policies, it was determined that facility failed to ensure that the clinical records contain complete informed decisions (consents) documentation regarding treatment and care signed by patient or his or her representative. This deficient practice was identified on 14 of 19 records reviewed (RR) ( RR # 1 through RR # 14 ).

Findings include:

A mechanism to ensure that emergency room admission department used the approved forms and system to document informed decisions (consents) regarding treatment and care were not promoted, not followed accordingly with the following findings:

1.This facility had a hybrid (paper based and electronic) medical record system. During the review of fourteen out of nineteen medical records of cases admitted through emergency room department it was identified that paper based consent and authorization for treatment, and consent to disclose confidential information related with treatment and services provided was documented with the initials of the admission officer in charge of the admission process and the date of the admission in the spaces provided for this purpose on the consent form. However, the consent form was not signed by the patient or relative.

While reviewing the electronic medical record of those fourteen medical records it was identified that facility had electronic formularies to be used to consent and authorize for treatment, and consent to disclose confidential information related with treatment and services provided.

On those fourteen medical records the consent to authorize for treatment, and the consent to disclose confidential information related with treatment and services provided were completed and signed with a system of electronic signature.

The lack of complete documentation of the paper-based consents gives the appearance that patient or relative did not consent or authorize for treatment, and consent to disclose confidential information related with treatment and services provided.

2. The facility failed to update admission package paper-based documents provided to patients and relatives to be used during admission process.

Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor (employee # 7) interview and review of policies, it was determined that facility failed to promote the right of each patient to formulate advance directives. This deficient practice was identified on 7 out of 19 records reviewed (RR) (RR#5, RR#7, RR#9, RR#11, RR#14, RR#15 and RR#17).

Findings include:

A mechanism to ensure that facility maintain a complete documentation of the advance directive formulary were not promoted, not performed accordingly with the following findings:

1. RR # 5 is a 85 years old male patient admitted 11/14/2020 with a diagnosis of COVID-19 to the COVID-19 unit. This patient relative imparted wishes and preferences in order to guide health care team in making clear decisions about his care, on the advance directives document on 11/14/2020. However, the physician did not sign the advance directives document.

2. RR#7 is a 79 years old female patient admitted on 12/23/2020 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit. This patient imparted wishes and preferences in order to guide health care team in making clear decisions about his care, on the advance directives document on 12/23/2020. However, the physician did not sign the advance directives document.

3. RR#9 is a 72 years old female patient admitted on 2/12/2021 with a diagnosis of COVID-19 to the COVID-19 unit. This patient imparted wishes and preferences in order to guide health care team in making clear decisions about his care, on the advance directives document on 2/12/2021. However, the physician did not sign the advance directives document.

4. RR #15 is a 68 years old male patient admitted 03/18/2021 with a diagnosis of COVID-19 and Septic Shock to the COVID-19 unit. This patient relative imparted wishes and preferences in order to guide health care team in making clear decisions about his care, on the advance directives document on 03/18/2021. However, the physician did not sign the advance directives document.

5. RR #17 is a 90 years old female patient admitted on 03/15/2021 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit. This patient imparted wishes and preferences in order to guide health care team in making clear decisions about his care, on the advance directives document on 03/15/2021. However, the physician did not sign the advance directives document.

Advance Directives facility protocols and policies were reviewed with the Facility Institutional Care Program Director (employee # 2) on 04/20/2021 at 2:50 PM. During the review employee # 2 stated on interview on 04/20/2021 at 3:00 PM that is the responsibility of the register nurse and physician to educate patients and relatives in relation with the advance directives. She explains that once the patient or relative impart the advance directives the physician must validate with the patient or relatives and proceed to signed de advanced directives document.


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6. RR#11 is a 52 years old male patient admitted on 02/22/2021 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit. This patient imparted wishes and preferences in order to guide health care team in making clear decisions about his care, on the advance directives document on 02/22/2021 at 10:00 PM.

However, the physician did not sign the advance directives document.

7. RR #14 is a 40 years old male patient admitted 04/06/2021 with a diagnosis of BKP and COVID-19 positive. This patient relative imparted wishes and preferences in order to guide health care team in making clear decisions about his care, on the advance directives document on 04/05/2021 at 3:45 PM.

However, the physician did not sign the advance directives document.

Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7) interview and review of physical restriction protocol and policies, it was determined that the facility failed to protect patient ' s rights, dignity, and well-being physical restriction episode. (This deficient practice was identified on 3 out of 19 cases reviewed (RR # 2, RR# 15 and RR# 16).

Findings include:

A mechanism to ensure that facility only imposed physical restriction to maintain the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time were not promoted, not performed accordingly with the following findings:

1.RR #15 is a 68 years old male patient admitted 03/18/2021 with a diagnosis of COVID-19 and Septic Shock to the COVID-19 unit. On 03/23/2021 patient was connected to a mechanical ventilator and was apparently combative (or fighting) against the ventilator making it harder for the ventilator to help.

Patient was assessed and a physical restriction order was prescribed on 03/23/2021 at 8:45 AM. There is no evidence that patient relative was contacted to inform the necessity of the physical restriction.

Physician's restraint orders were completed, as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

2. RR #16 is an 82 years old male patient admitted 02/18/2021 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit.

On 02/23/2021 patient was connected to a mechanical ventilator and was apparently combative (or fighting) against the ventilator making it harder for the ventilator to help and disoriented.

Patient was assessed and a physical restriction order was prescribed on 02/23/2021 at 10:40 AM. Relatives was informed of the necessity of physical restriction.

Physician's restraint orders were completed, as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physician restriction episode) and the status of the patient when the physical restriction was discontinued.

On 03/02/2021 a verbal telephone order to put the patient on restriction was ordered by the physician at 7:00 AM.

Physician's restraint orders was completed as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/02/2021 was not authenticated (signed) by the physician. On 03/03/2021 verbal telephone order to put the patient on restriction was ordered by the physician at 7:00 AM.

Physician's restraint orders were completed, as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/03/2021 was not authenticated (signed) by the physician. The register nurse document on the progress notes of 03/03/2021 at 11:12 AM that patient was disoriented and combative, however did not include information of the physical restriction status of the patient.

The Licensed practical nurse document of the progress notes care and services provided to the patient, however, did not include information of the physical restriction status of the patient.

On 03/08/2021 verbal telephone order to put the patient on restriction was ordered by the physician at 12:00 AM. Physician's restraint orders was completed as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/08/2021 was not authenticated (signed) by the physician.

3. Physical restriction facility protocols and policies were reviewed with the Director of Nursing (employee # 2) and the facility Institutional Care Program Director ( employee # 2) on 04/21/2021 at 11:35AM provisions included in the protocol who indicate the management and documentation of a patient on restriction and responsibilities of the physician and nurse in charge were discussed.

Director of Nursing (employee # 2) and facility Institutional Care Program Director ( employee # 2) stated on interview on 04/21/2021 at 1:30 PM that understand and agree that the process of physical restriction of patients receiving services at the COVID-19 unit must improve in order to comply with facility protocols.


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4. RR#2 is a 73 years old female patient admitted at Emergency Room on 08/24/2020 with
diagnoses of Syncope. Patient chief complaint: Fade and Low Pressure 92/66. Laboratory samples was taken and was admitted at observation area cubicle 16 B. Physician's orders of Chloride Intravenous Solution 0.9% 1000 ml. continuous infusion, connected to cardiac monitor and oxygen by nasal cannula and CT Head OR Brain W/O Contrast. According to the physician (employee #12) patient at present more alert, laboratories stable, Brain CT without acute pathology.

On 8/24/2020 at 8:33 PM the nurse note written by (employee #13) the patient discharge home, alert and oriented, B/P 149/84 without respiratory distress and continue follow up with primary physician.

On 08/25/2020 at 7:36 AM patient admitted at Emergency Room with diagnosis of Acute Colitis, Gastroenteritis, Dehydration and Dementia.

Nasogastric tube placed according with the physician order at 4:44 PM.

On 08/25/2020 at 8:51 PM the patient removed the nasogastric tube.

The nurse (employee #15) reinsert a new nasogastric tube and notify the physician (employee #14) related to the nasogastric tube removal.

According to the nurse note written by the (employee #15) the physician ordered restriction per two, both hands but no evidence of this order.

Nursing note reads as follows: '' The relative of the patient is educated, who verbalizes understand.'' The nursing note indicates that the family is educated but it does not appear what relationship, the reason for restriction has with the patient and what type of education was offered. The nurse note it does not say what time the patient was restricted.

Patient was assessed and a physical restriction order was prescribed on 08/26/2020 at 12:30 AM. There is no evidence that patient relative was contacted to inform the necessity of the physical restriction.
Physician's telephone restraint orders were signed by the physician however lack of the hour when signed.

No evidence of the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

According of the physician discharge note written on 08/28/2020 at 1:25 PM the patient responding well to the treatment and discharge to home to continue outpatient treatment however the patient record lacks orders for restriction during the patient stay in the hospital included when the patient discharge to home.

Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7) and review of physical restriction protocol, policies and interview, it was determined that the facility failed to maintain a complete medical record documentation of patient's on physical restriction. (This deficient practice was identified on 3 out of 19 cases reviewed (RR # 2, RR# 15 and RR# 16).

Findings include:

A mechanism to ensure that facility maintain a complete and pertinent documentation on the medical records on cases were physical restrictions is in use were not promoted, not performed accordingly with the following findings:

1.RR #15 is a 68 years old male patient admitted 03/18/2021 with a diagnosis of COVID-19 and Septic Shock to the COVID-19 unit. On 03/23/2021 patient was connected to a mechanical ventilator and was apparently combative (or fighting) against the ventilator making it harder for the ventilator to help.

Patient was assessed and a physical restriction order was prescribed on 03/23/2021 at 8:45 AM.

There is no evidence that patient relative was contacted to inform the necessity of the physical restriction.

Physician's restraint orders were completed, as well the assessment algorithm, however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

2. RR #16 is an 82 years old male patient admitted 02/18/2021 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit. On 02/23/2021 patient was connected to a mechanical ventilator and was apparently combative (or fighting) against the ventilator making it harder for the ventilator to help and disoriented.

Patient was assessed and a physical restriction order was prescribed on 02/23/2021 at 10:40 AM.

Relatives were informed of the necessity of physical restriction.

Physician's restraint orders were completed as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physician restriction episode) and the status of the patient when the physical restriction was discontinued.

On 03/02/2021 a verbal telephone order to put the patient on restriction was ordered by the physician at 7:00 AM. Physician's restraint orders was completed as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/02/2021 was not authenticated (signed) by the physician.

On 03/03/2021 verbal telephone order to put the patient on restriction was ordered by the physician at 7:00 AM. Physician's restraint orders was completed as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/03/2021 was not authenticated (signed) by the physician. The register nurse document on the progress notes of 03/03/2021 at 11:12 AM that patient was disoriented and combative, however did not include information of the physical restriction status of the patient.

The Licensed practical nurse document on the progress notes care and services provided to the patient, however, did not include information of the physical restriction status of the patient.

On 03/08/2021 verbal telephone order to put the patient on restriction was ordered by the physician at 12:00 AM. Physician's restraint orders was completed as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/08/2021 was not authenticated (signed) by the physician.

3. Physical restriction facility protocols and policies were reviewed with the Director of Nursing (employee # 2) and the facility Institutional Care Program Director ( employee # 2) on 04/21/2021 at 11:35 AM provisions included in the protocol who indicate the management and documentation of a patient on restriction and responsibilities of the physician and nurse in charge were discussed.

Director of Nursing (employee # 2) and facility Institutional Care Program Director (employee # 2) stated on interview on 04/21/2021 at 1:30 PM that understand and agree that the
documentation of the process of physical restriction of patients receiving services at the COVID-19 unit did not include all elements required to comply with facility protocols and promote the appropriateness of the processes.


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4. RR#2 is a 73 years old female patient admitted at Emergency Room on 08/24/2020 with
diagnoses of Syncope. Patient chief complaint: Fade and Low Pressure 92/66. Laboratory samples was taken and was admitted at observation area cubicle 16 B. Physician's orders of Chloride Intravenous Solution 0.9% 1000 ml. continuous infusion, connected to cardiac monitor and oxygen by nasal cannula and CT Head OR Brain W/O Contrast.

According to the physician (employee #12) patient at present more alert, laboratories stable, Brain CT without acute pathology.

On 8/24/2020 at 8:33 PM the nurse note written by (employee #13) the patient discharge home alert and oriented, B/P 149/84 without respiratory distress and continue follow up with primary physician.

On 08/25/2020 at 7:36 AM patient admitted at Emergency Room with diagnosis of Acute Colitis, Gastroenteritis, Dehydration and Dementia. Nasogastric tube placed according with the physician order at 4:44 PM.

On 08/25/2020 at 8:51 PM the patient removed the nasogastric tube. The nurse (employee #15) reinsert a new nasogastric tube and notify the physician (employee #14) related to the nasogastric tube removal.

According to the nurse note written by the (employee #15) the physician ordered restriction per two, both hands but no evidence of this order.

Nursing note reads as follows: '' The relative of the patient is educated, who verbalizes understand.''

The nursing note indicates that the family is educated but it does not mention what relationship with the patient, the reason for restriction and what type of education was offered. The nurse note does not say what time the patient was restricted.

Patient was assessed and a physical restriction order was prescribed on 08/26/2020 at 12:30 AM. There is no evidence that patient relative was contacted to inform the necessity of the physical restriction.

Physician's telephone restraint orders were signed by the physician however no hour when signed.

No evidence of the assessment algorithm, there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

According of the physician discharge note written on 08/28/2020 at 1:25 PM the patient responding well to the treatment and discharge to home to continue outpatient treatment however the patient record lacks orders for restriction during the patient stay in the hospital included when the patient discharge to home.

Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7), review of physical restriction protocol, policies and interview, it was determined that the facility failed to ensure physician's orders specify the reason for restraint or seclusion, the type of restraint, and the duration of restraint or seclusion. This deficient practice was identified on 4 out of 19 records reviewed (RR) (RR # 2, RR# 15, RR# 16 and RR# 17).

Findings include:

A mechanism to ensure that facility document the severity of the behavior who justify the restraint use, physician individual patient assessment and a revision of the plan of care, changes in behavior and staff concerns regarding safety risks to the patient and staff, for the prompting use of restraint were not promoted, not performed accordingly with the following findings:

1.RR #15 is a 68 years old male patient admitted 03/18/2021 with a diagnosis of COVID-19 and Septic Shock to the Covid-19 unit. On 03/23/2021 patient was connected to a mechanical ventilator and was apparently combative (or fighting) against the ventilator making it harder for the ventilator to help.

Patient was assessed and a physical restriction order was prescribed on 03/23/2021 at 8:45 AM.

There is no evidence that patient relative was contacted to inform the necessity of the physical restriction.

Physician's restraint orders were completed, as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

2. RR #16 is a 82 years old male patient admitted 02/18/2021 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit. On 02/23/2021 patient was connected to a mechanical ventilator and was apparently combative (or fighting) against the ventilator making it harder for the ventilator to help and disoriented.

Patient was assessed and a physical restriction order was prescribed on 02/23/2021 at 10:40 AM.

Relatives was informed of the necessity of physical restriction. Physician's restraint orders were completed, as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physician restriction episode) and the status of the patient when the physical restriction was discontinued.

On 03/02/2021 a verbal telephone order to put the patient on restriction was ordered by the physician at 7:00 AM.

Physician's restraint orders were completed, as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/02/2021 was not authenticated (signed) by the physician.

On 03/03/2021 verbal telephone order to put the patient on restriction was ordered by the physician at 7:00 AM.

Physician's restraint orders were completed, as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/03/2021 was not authenticated (signed) by the physician. The register nurse document on the progress notes of 03/03/2021 at 11:12 AM that patient was disoriented and combative, however did not include information of the physical restriction status of the patient.

The Licensed practical nurse document on the progress notes care and services provided to the patient, however, did not include information of the physical restriction status of the patient.

On 03/08/2021 verbal telephone order to put the patient on restriction was ordered by the physician at 12:00 AM. Physician's restraint orders was completed as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/08/2021 was not authenticated (signed) by the physician.

RR #17 is a 90 years old female patient admitted 03/15/2021 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit.

On 03/15/2021 patient was disoriented and was apparently combative (or fighting) against any treatment.

Patient was assessed and a physical restriction order was prescribed on 03/15/2021 at 11:00 PM.

There is no evidence that patient relative was contacted to inform the necessity of the physical restriction. Nursing restraint orders was completed, as well the assessment algorithm however there are no evidence of physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/15/2021 was not authenticated (signed) by the physician.

3. Physical restriction facility protocols and policies were reviewed with the Director of Nursing (employee # 2) and the facility Institutional Care Program Director ( employee # 2) on 04/21/2021 at 11:35 AM provisions included in the protocol who indicate the management and documentation of a patient on restriction and responsibilities of the physician and nurse in charge were discussed.

Director of Nursing (employee # 2) and facility Institutional Care Program Director ( employee # 2) stated on interview on 04/21/2021 at 1:30 PM that understand and agree that a complete documentation of the comprehensive assessment of the patient and determination that the risks associated with the use of the restraint is outweighed by the risk of not using the restraint was not performed.


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4. RR #2 is 73 on 08/25/2020 at 7:36 AM patient admitted at Emergency Room with diagnosis of Acute Colitis, Gastroenteritis, Dehydration and Dementia. Nasogastric tube placed according with the physician order at 4:44 PM.

On 08/25/2020 at 8:51 PM the patient removed the nasogastric tube. The nurse (employee #15) reinsert a new nasogastric tube and notify the physician (employee #14) related to the nasogastric tube removal.

According to the nurse note written by the (employee #15) the physician ordered restriction per two both hands but no evidence of this order. Nursing note reads as follows: '' The relative of the patient is educated, who verbalizes understand.'' The nursing note indicates that the family is educated but it does not show what relationship has with the patient, the reason for restriction and what type of education was offered. The nurse note does not say what time the patient was restricted.

There is no evidence that patient relative was contacted to inform the necessity of the physical restriction.

Physician's telephone order was signed by the physician but lacks the hour when initiated the restriction.

There are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7), review of physical restriction protocol, policies and interview, it was determined that the facility failed to ensure that the use of restraint are in accordance with the order of a physician who is responsible for the care of the patient and authorized to order restraint. (This deficient practice was identified on 3 out of 19 records reviewed (RR) (R # 2, RR# 16 and RR #17).

Findings include:

A mechanism to ensure that facility obtain an authenticated order to restraint patients when it has been necessary to restraint so quickly that an order cannot be obtained prior to the application of restraint were not promoted, not performed accordingly with the following findings:


1.RR #16 is an 82 years old male patient admitted 02/18/2021 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit. On 02/23/2021 patient was connected to a mechanical ventilator and was apparently combative (or fighting) against the ventilator making it harder for the ventilator to help and disoriented.

Patient was assessed and a physical restriction order was prescribed on 02/23/2021 at 10:40 am.

Relatives was informed of the necessity of physical restriction. Physician's restraint orders were completed, as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physician restriction episode) and the status of the patient when the physical restriction was discontinued.

On 03/02/2021 a verbal telephone order to put the patient on restriction was ordered by the physician at 7:00 AM. Physician's restraint orders was completed as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/02/2021 was not authenticated (signed) by the physician.

On 03/03/2021 verbal telephone order to put the patient on restriction was ordered by the physician at 7:00 AM. Physician's restraint orders was completed as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/03/2021 was not authenticated (signed) by the physician.

The register nurse document on the progress notes of 03/03/2021 at 11:12 AM that patient was disoriented and combative, however did not include information of the physical restriction status of the patient.

The Licensed practical nurse document of the progress notes care and services provided to the patient, however, did not include information of the physical restriction status of the patient.

On 03/08/2021 verbal telephone order to put the patient on restriction was ordered by the physician at 12:00 AM.

Physician's restraint orders were completed, as well the assessment algorithm however there are no evidence of nurses or physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/08/2021 was not authenticated (signed) by the physician.

2.RR #17 is a 90 years old female patient admitted 03/15/2021 with a diagnosis of COVID-19 and Bronchopneumonia to the COVID-19 unit.

On 03/15/2021 patient was disoriented and was apparently combative (or fighting) against any treatment. Patient was assessed and a physical restriction order was prescribed on 03/15/2021 at 11:00 PM.

There is no evidence that patient relative was contacted to inform the necessity of the physical restriction. Nursing restraint orders was completed, as well the assessment algorithm however there are no evidence of physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Order of 03/15/2021 was not authenticated (signed) by the physician.

3. Physical restriction facility protocols and policies were reviewed with the Director of Nursing (employee # 2) and the facility Institutional Care Program Director ( employee # 2) on 04/21/2021 at 11:35 AM provisions included in the protocol who indicate the management and documentation of a patient on restriction and responsibilities of the physician and nurse in charge were discussed.

Director of Nursing (employee # 2) and facility Institutional Care Program Director ( employee # 2) stated on interview on 04/21/2021 at 1:30 pm that accordingly with facility policy if the nurse call the physician and notify the need of use physical restriction the physician could order a restriction order and had 2 hours to authenticate the order.


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4. RR #2 is 73 on 08/25/2020 at 7:36 AM patient admitted at Emergency Room with diagnosis of Acute Colitis, Gastroenteritis, Dehydration, Dementia and Suspected COVID- 19. Nasogastric tube placed according with the physician order at 4:44 PM.

On 08/25/2020 at 8:51 PM the patient removed the nasogastric tube. The nurse (employee #15) reinsert a new nasogastric tube and notify the physician (employee #14) related to the nasogastric tube removal.

According to the nurse note written by the (employee #15) the physician ordered restriction per two, both hands but no evidence of this order.

Nursing note reads as follows: '' The relative of the patient is educated, who verbalizes understand.'' The nursing note indicates that the family is educated but it does not say what has relationship with the patient, the reason for restriction and what type of education was offered.

The nurse note it does not say what time the patient was restricted.

There is no evidence that patient relative was contacted to inform the necessity of the physical restriction.

According of nurse (employee #16) the note written on 08/25/2020 at 9:45 PM the patient was maintained with restriction however no evidence of physician order for restriction on 08/25/2020.

The Physician's telephone order for restraint was written by the nurse (employee #17) on 08/26/2020 at 12:30 AM and was signed by the physician but lacks the hour when initiated the restriction.

There is no evidence of physician progress notes that include additional information related with patient status while being on physical restriction.

No evidence was found of documentation who include the time that patient was on restriction (when begin and ended the physical restriction episode) and the status of the patient when the physical restriction was discontinued.

Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021, on the review of six medical staff credential files, it was determined that the facility failed to examine credential files (C.F) to ensure that medical staff have updated Health Certificates, Cardio-pulmonary Resuscitation Certificates (CPR), Mal Practice Policy, Medical Colege, Law 300 and Good Standing for 6 out of 6 C.Fs (C.F #1, #2, #3, #4, #5 and #6).

Findings include:

1. During the review of nineteen medical staff credential files on 04/21/2021 from 10:05 AM till 12:05 PM the following was found:

a. One out of six medical staff's credential files provided evidence of expired Health Certificates (C.F #5 (from 09/13/2020).

b. One out of six medical staff's credential files the CPR expired on 12/2018.

c. One out of six medical staff's credential files the Mal Practice Policy expired on 01/10/2021 ( C.F. #2).

d. One out of six medical staff's credential files the Medical Colege expired on 12/31/2020 ( C.F. #5).

e. Six out of six medical credential files did not have evidence of Law 300 ( C.F.#1, #2, #3, #4, #5 and #6).

f. One out of six medical staff's credential files the Good Standing expired on 08/17/2018 ( C.F. #5).

Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7), it was determined that the facility failed to ensure that when verbal orders or telephone orders are used are signed as soon as possible according of the facility policies and procedures for 2 out of 19 records reviewed (R.R #10 and #11).

Findings include:

1.Evidence was found on 04/20/2021 from 10:00 AM till 3:30 PM and 04/21/2021 from 10:00 AM till 3:00 PM as reviewed on the Policies and Procedures that established in page number two (2) item number (7) '' Telephone medical orders '' letter a '' number (4) established the following: '' Any verbal or telephone order meets the following criteria: a. Date and time the order was issued, b. Name of the doctor who prescribes, c. Name, dose, route and frequency of the drugs and documents without leaving spaces between orders, e. Name and license number of the recipient and documents the order with signature. On number five (5) of policies and procedures established related to the timeliness of countersignatures when verbal or telephone orders are used, and it states that the physician has 24 hours to countersign the telephone order.

However, the following telephone orders lacks the physician's signature, license number, date and hour when the physician ordered:

a. RR #10 was reviewed on 04/20/2021 at 2:35 PM patient with 64 years old male who was admitted on 02/14/2021 at 5:37 PM. with diagnosis of BKP related to COVID-19. History of Hight Blood Pressure, Epilepsy and Seizures. Admitted to COVID -19 Area.

The following telephone orders lacks the physician's signature, license number, date and hour when the physician ordered:

- 02/16/2021 11:00 AM
- 02/16/2021 10:00 PM
- 02/19/2021 7:30 AM
- 02/21/2021 9:58 AM
- 02/21/2021 10:01 AM
- 02/22/2021 1:00 PM
- 02/22/2021 12:00 PM
- 02/22/2021 11:00 AM

b. RR #11 was reviewed on 04/20/2021 at 1:20 PM patient with 52 years old male who was admitted on 02/22/2021 at 6:39 PM with diagnosis of COVID-19, Pneumonia due to Coronavirus Disease, Hypoxemia, Dependence on Supplemental Oxygen, contact with and suspected Exposure to COVID -19.

The record was reviewed and was found the following telephone orders lacks the physician's signature, license number, date and hour when the physician ordered:

- 04/06/2021 1:05 AM physician (employee #18)
- 04/06/2021 4:20 AM physician (employee #18)
- 04/06/2021 9:00 AM physician (employee #26)
- 04/07/2021 12:30 PM physician (employee #18)
- 04/06/2021 9:30 AM physician (employee #26)
- 04/08/2021 10:00 AM physician (employee #26)
- 04/09/2021 8:20 AM physician (employee #18)
- 04/11/2021 5:45 AM physician (employee #27)
- 04/06/2021 the order for enteral nutrition lacks the hour and the physician signature.

Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7), it was determined that the facility failed to ensure that the patient medical records contain complete information and documentation regarding to consults, nurses notes, physician progress notes, physician's orders included telephone order's, vital signs and physician discharge summary evaluation and other information and documents in the patient medical record that are not accessible for 4 out of 17 records reviewed (R.R #2, #10, #11 and #14 ).

Findings include:

During nineteen medical records reviewed during the complaint survey performed from 04/20/2021 from 04/21/2021 from 8:00 am till 4:00 PM, it did not contain complete information and documentation related to consults, nurses order's, physician's orders included restraint telephone order's, vital signs and patient history, and other information and documents in the patient medical record that are not accessible or not complete.

1. RR #2 was reviewed on 04/20/2021 at 11:30 AM patient with 73 years old female who was admitted on 08/24/2020 at Emergency Room with Diarrheas, Vomits, Hypotension then discharge home on 08/24/2020 at 8:33 PM. Readmitted on 08/25/2020 to Emergency Room with diarrhea, vomits, cough and fever. Admitted to the COVID - 19 ward with rule out (R/O) COVID-19. The record was reviewed and was found the following:

a. The patient history performed on 08/25/2020 at 11:00 PM. it is incomplete by the physician (employee #11).

b. The Discharge Summary performed by the physician (employee #11) lacks the date when the patient was discharge to home.

c. An important message from Medicare about your rights dated on 08/26/2020 not signed by the patient or representative.

d. Physician's telephone order to insert urethral catheter on 08/25/2020 at 10:50 PM ordered by physician (employee #11) lacks the date and the hour when the physician signed the order.

e. The physician's orders performed by the physician (employee #11) on 08/28/2020 at 1:10 PM for final disposition ''discharge home" not signed by the nurse and lacks date and hour.

f. Admission and transfer check form missing patient or relative signature.

g. The physician order to admit to COVID-19 ward performed by the physician (employee #11) on 08/25/2020 at 3:39 PM lacks the hour when the nurse (employee #25) signed the order.

h. Authorization of cases admitted to the Emergency Room, Receipt of admissions signatures, Release of responsibility and Important notification upon discharge lacks the patient or relative signature.

2. RR #10 was reviewed on 04/20/2021 at 2:35 PM patient with 64 years old male who was admitted on 02/14/2021 at 5:37 PM. with diagnosis of BKP related to COVID-19. History of Hight Blood Pressure, Epilepsy and Seizures. Admitted to COVID -19 area.

The following telephone orders lacks the physician's signature, license number, date and hour when the physician ordered:

- 02/16/2021 11:00 AM
- 02/16/2021 10:00 PM
- 02/19/2021 7:30 AM
- 02/21/2021 9:58 AM
- 02/21/2021 10:01 AM
- 02/22/2021 1:00 PM
- 02/22/2021 12:00 PM
- 02/22/2021 11:00 AM

3. RR #11 was reviewed on 04/20/2021 at 1:20 PM patient with 52 years old male who was admitted on 02/22/2021 at 6:39 PM with diagnosis of COVID-19, Pneumonia due to Coronavirus Disease, Hypoxemia, Dependence on Supplemental Oxygen, contact with and suspected Exposure to COVID -19.

The record was reviewed, and the following was found:

a. The Transfusion Consent signed by the patient on 02/22/2021 at 9:30 PM is not signed by the physician and lacks the date, the hour and license number.

b. The informed consent on COVID -19 treatment with Baricitinib in combination with Remdesivir signed by the patient on 02/22/2021 at 6:57 PM not signed by the physician and lacks the date, the hour, license number and printed name.

c. The Advance Directives taken and signed by the patient on 02/22/2021 at 10:00 PM lacks physician signature and license number

4. RR #14 was reviewed on 04/20/2021 at 1:45 PM patient with 40 years old male who was admitted on 04/06/2021 at 9:30 AM. room 353-02 with diagnosis of COVID-19 positive 0n 04/05/2021 at 9:55 PM. History of short breaths, general malaise, fever, hypoxemia.

The record was reviewed, and the following was found:

a. The Transfusion Consent signed by the patient on 04/21/2021 not signed by the physician and lacks the date, the hour and license number.

b. The physician order for suspected COVID -19 lacks the nurse signature and license number.

c. The Advance Directives taken and signed by the patient on 04/05/2021 at 3:45 PM lacks of physician signature and license number.

d. The following telephone orders lacks the physician's signature, license number, date and hour when the physician ordered:

- 04/06/2021 1:05 AM physician (employee #18)
- 04/06/2021 4:20 AM physician (employee #18)
- 04/06/2021 9:00 AM physician (employee #26)
- 04/07/2021 12:30 PM physician (employee #18)
- 04/06/2021 9:30 AM physician (employee #26)
- 04/08/2021 10:00 AM physician (employee #26)
- 04/09/2021 8:20 AM physician (employee #18)
- 04/11/2021 5:45 AM physician (employee #27)
- 04/06/2021 the order for enteral nutrition lacks the hour and the physician signature

e. The telephone order on 04/06/2021 at 7:35 AM for CPR lacks the nurse signature and license number.

Based on complaint survey PR00000636, performed on 04/20/2021 through 04/21/2021, review of nineteen medical records with Intensive Care Unit Supervisor ( employee # 7) and review of policies, it was determined that facility failed to identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning. This deficient practice was identified on 7 out of 19 records reviewed ( RR #1, RR#2, RR#6, RR#9, RR#10, RR#11 and RR#13).

Findings include:

A mechanism to ensure that facility promote coordination of services following discharge from hospital to engage patients and relatives in the transition from hospital to home with the goal to reduce adverse events and prevent readmissions were not promoted, not performed accordingly with the following findings:

1. RR # 1 is a 45 years old female patient admitted 08/02/2020 with a diagnosis of COVID-19 to the Covid-19 unit. Patient receive care and treatment until 08/09/2020 when was discharge home. There is no evidence on the medical record of discharge planning process considering the availability of resources and social support for ongoing care at place of residence.

2. RR#9 is a 72 years old female patient admitted on 2/12/2021 with a diagnosis of COVID-19 to the COVID-19 unit. Patient was evaluated by discharge planning personnel on 02/19/2021.

Policy and procedure for discharge planning process was reviewed with the facility Institutional Care Program Director (employee # 2) on 04/21/2021 at 11:55 AM. The policy establish that all COVID-19 patients must be assessed, and that this assessment must be performed in a period of 24 hours through 72 hours.
However, this case exceeds the period of time were the initial assessment for discharge planning must be performed.


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3. RR # 2 is a 73 years old female patient admitted 08/25/2020 with a diagnosis of Acute Colitis, Gastroenteritis, Dehydration, BKP, Dementia and Suspected COVID-19. Patient receive care and treatment until 08/25/2020 was discharged to home on 08/28/2020 at 1:10 PM. There is no evidence on the medical record of discharge planning process considering the availability of resources and social support for ongoing care at place of residence.

4. RR#6 is an 80 years old female patient admitted on 11/23/2020 at 6:32 PM with a diagnosis of Viral Pneumonia Unspecified and Positive for COVID-19 admitted to the Intermediate Care COVID-19 unit.

No evidence of the initial discharge planning evaluation. The patient record provides evidence of a progress note performed by the Social Worker (employee #19) request of the physician (employee #18) to evaluate the patient by discharge planning personnel on 11/30/2020 at 3:30 PM six days after the admission.

According to the social worker progress note this case was discussed with the social worker supervisor (employee #20) because the patient lives in a condominium where the patient is not accepted for being positive for COVID and cannot return until she is negative.

According to the social worker of the condominium the patient has a brother and she provides the name and the telephone number. The case was discussed with the social worker supervisor (employee #20) and refers to follow - up case if necessary.

The next social worker (SW) intervention performed by (SW. employee # 21) was on 12/30/2020 at 4:27 PM thirty days (30) later and she wrote '' case in follow up.''

No evidence of social worker intervention until 12/30/2020 at 4:47 PM the social worker note wrote '' A call is generated to the patient's brother to complete care alternatives to able to discharge, the patient family member expressed being unwell.'' She documented '' Follow - up case.''

However, the final disposition by the social worker (employee #21) was performed on 02/01/2021 at 5:39 PM thirty-two (32) days later and the social worker wrote '' Patient died '' family member notified about the matter.

5. RR#10 is 64 years old male patient evaluated in Emergency Room on 02/14/2021 at 8:19 PM by the physician (employee #22) with a diagnosis of BKP related to COVID-19. Admitted to the Intermediate Care COVID-19 unit.

The initial discharge planning evaluation was performed on 02/26/2021 at 10:56 AM twelve days later (12) after the admission.

The patient record provide evidence that on the initial discharge planning performed by the Social Worker (employee #23) she documented that this patient did not required intervention at this moment and follow-up will be given as needed. However, the patient died on 03/17/2021.

6. RR#11 is a 52 years old male patient admitted on 02/22/2021 at 6:39 PM with a diagnosis of Covid-19. Admitted to the Intermediate Care COVID-19 unit. The initial discharge planning evaluation was performed on 03/02/2021 at 1:51 PM eight (8) days later from the admission.

The patient record provide evidence that on the initial discharge planning performed by the Social Worker (employee #23) she documented that this patient did not required intervention at this moment and follow-up will be given as needed.

7. RR#13 is a 30 years old female patient admitted on 04/13/2021 at 10:30 AM with a diagnosis of COVID -19 Positive Antigen and BKP. Admitted to the Intermediate Care COVID-19 unit.

The initial discharge planning evaluation was performed on 04/19/2021 at 1:53 PM six days after the admission.

8. Policy and procedure for discharge planning process was reviewed with the facility Institutional Care Program (employee #2) and Nursing Executive (employee #3) on 04/20/2021 at 2:30 PM.

The policy reads as follows: '' All patients with specified needs for their discharge needs plan will be re-estimated by the planner within 72 hours from the initial estimate.''

The policy for the discharge planning standard does not establish a specific time for the discharge planner to perform the initial evaluation after the patient is admitted.