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Based on a complaint investigation survey PR00000648 conducted on 10/12/21 through 10/13/21, the review of nursing credential file (C.F.), and the review of physician C.F it was determined that the facility failed to updated personnel credential files related to annual evaluations, cardio pulmonary Resuscitation certificates (CPR), health certificates, Hepatitis B vaccine, Influenza vaccine, Association with Puerto Rico Physician College, federal narcotic license, state narcotic license, license registration, Competency and job description for 19 out of 19 credential files reviews, ( Nursing NCF #1, #2, #3, #4, #5, #6 and #7) (Physicians PCF #1, #2, #3, #4, #5, #6 #7, #8, #9, #10, #11 and #12).

Findings include:

During credential files review on 10/13/2021 at 11:00 AM the following was found:

1. Four out of nineteen CF reviews, does not provide evidence of and updated Annual Evaluation (NCF #1, #2, #3 and #7).

2. Seven out of nineteen CF reviews, does not provide evidence of and updated CPR (PCF #1, #4, #6, #7, #8, #9 and #10).

3. Twelve out of nineteen CF reviews, do not show an updated health certificate, (NCF #1, #7) (PCF #3, #4, #5, #6 #7, #8, #9, #10, #11 and #12).

4. Six out of nineteen CF reviews, does not provide evidence of Hepatitis B vaccination. (PCF #3, #6, #7, #8, #10 and #11).

5.Seventeen out of nineteen CF reviews, does not provide evidence of an Influenza vaccination, (PCF #1, #2, #3 #4, #5, #6, #7, #8, #9, #10, #11 and #12) (NCF #1, #5, #6 and #7). The facility does not comply with Department of Health Administrative Order Number 244 of October 10, 2008.

6. Four out of nineteen CF reviews, does not provide evidence of Association with Puerto Rico Physician College. (PCF #6, #8, #9 and #10).

7. Five out of nineteen five CF reviews, does not provide evidence of the job description (NCF #1, #2, #4, #5 and #6).

8. Seven out of nineteen five CF reviews, does not provide evidence of the competency (NCF #1, #2, #3, #4, #5, #6 and #7).

9. Four out of nineteen five CF reviews, does not provide evidence of the license registry (PCF #3, #5, #6 and #9).

10. Four out of nineteen five CF reviews, does not provide evidence of the Federal narcotic license (PCF #3, #6, #8 and #10).

11. Five out of nineteen five CF reviews, does not provide evidence of the State narcotic license (PCF #1, #6, #8, #9 and #10).

The facility failed to updated personnel credential files related to annual evaluations, cardiopulmonary Resuscitation certificates (CPR), health certificates, Hepatitis B vaccine, and Influenza vaccine, Association with Puerto Rico Physicians College, job description, competency, license registry, Federal narcotic license and State narcotic license.

Based on a complaint investigation (PR00000648), evaluation of the Quality Assessment and performance Program with the Quality coordinator (employee #5), it was determined that the facility failed to provide evidence of an ongoing and comprehensive quality assessment performance improvement program who include all services offered at the facility. Facility failed to evidence implementation of the QAPI program who address all emergency room system of care and management practices that reflect the complexity of the Emergency Room and focuses on indicators related to improved health outcomes and the prevention and reduction of the adverse event. errors which made this condition Not Met ( Cross reference to Tag A273 and Tag A297).

Based on a complaint investigation (PR00000648), evaluation of the Quality Assessment and Performance Program with the Quality Coordinator (employee #5) and interview with Emergency room manager ( employee # 3 ) and emergency room Utilization supervisor (employee #4) on 10/14/2021 at 9:15 AM, it was determined that the facility failed to provide evidence of the Quality Program include an ongoing program that shows measurable improvement indicators for the emergency room for the last trimester (September, October, November) of 2018, 2019, 2020 was not provided.

Findings include:

During interview with the Quality Coordinator (employee #5) on 10/14/2021 at 9:15 AM she states that she started in the position as Quality Coordinator one week ago.

1.The surveyor request to review during survey procedures on 10/13/2021 and 10/14/2021 the indicator from Emergency Room (ER) for the last trimester (September, October, November) 2018, 2019, 2020, however information was not provided.

2.The facility provides the Annual plan surveillance indicator from emergency room that measure the triage, Dextrose, Transfer sheet, and Lettering.

3.No evidence was provided that the facility emergency room measure aspect related to the emergency room, or priority establishment indicator related to patient outcome.

4.No evidence was provided that the facility integrated measure for the ER adequality for Elopement, Leaving Against Medical Advice (LAMA), Left Without Being Seen (LWBS), Admission, Exoneration, Transfer, and Patient Satisfaction.

5.No evidence was provided that the hospital measure, analyze, and track adverse patient events.


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During interview on 10/14/21 at 9:00 AM the emergency room manager (employee #3) show evidence documented of surveillance of appropriateness of patient transfer, patient screen and triage and documentation of cases who leave against medical advice from emergency room as well as patient satisfaction with services received in the emergency room since her beginning as manager approximately a year ago.

6. However, this information is not included as part of the emergency room department QAPI program.

During interview on 10/14/21 at 9:15 AM the Utilization supervisor (employee #4) shows evidence documented (in electronic format) of surveillance of appropriateness of patient triage and tracking of the care to each individual who comes to the hospital seeking care for an emergency medical condition as well as other aspects related with compliance with basic EMTALA provisions.

7. However, this information is not included as part of the emergency room department QAPI program.

Based on a complaint investigation (PR00000648), evaluation of the Quality Assessment and Performance Program with the Quality Coordinator employee #5 on 10/14/2021 at 9:15 AM, it was determined that the facility failed to performance a quality improvement project to improve patient safety and quality of care.

Findings include:

During the evaluation of the Quality Assessment and Performance Program on 10/14/2021 at 9:15 AM surveyor requested to review the quality improvement project to the Quality coordinator employee #5 and she stated that she do not know if the facility have one.

The Utilization Manager, employee #4 stated that they do not have an improvement project.