HospitalInspections.org

Based on the review of documents, observations, tests and interviews from 7/7/10 through 7/9/10 from 9:00 am till 4:00 pm, it was determined that the Governing Body failed to carry out its responsibility for the operation and management of the hospital. It did not provide the necessary oversight and leadership as evidenced by the lack of compliance with: (42 CFR 482.21) QAPI Condition, (42 CFR 482.41) Physical Environment, (42 CFR 482.55) Emergency Services and (42 CFR 482.57) Respiratory Care Services.

Based on records reviewed (R.R), Do Not Resuscitate (DNR) Policies and Procedures, it was determined that the facility failed to ensure that patients or their representatives formulate advance directive and comply with these directives related to written DNR or "Do Not Intubate" (DNI) orders in accordance to the patient's signed consent for DNR or DNI for one out of two records reviewed (R.R #25 ).

Findings include:

1. The facility failed to inform patients or their representatives that they have the right to formulate advance directives and comply with these directives related to DNR and DNI order requests as reviewed on 7/7/10 from 9:15 am till 4:00 pm and on 7/8/10 from 9:45 am till 12:00 noon:

a. R.R #25 is a 90 year old female who was admitted on 6/17/10 with a diagnosis of Congestive Heart Failure (CHF) and Diabetes Mellitus (DM). On 7/8/10 at 11:30 am the record was reviewed with the Director of Nursing (DON) (employee #7). It was found that the patient's representative signed a DNI consent on 6/24/10 at 2:00 pm and this consent was re-evaluated and signed by the patient's representative on 6/27/10 at 7:26 pm and re-evaluate on 7/1/10 at 1:20 pm because they wanted to intubate the patient, but wanted chemical treatment. Evidence was found of the physician's written DNI order and the justification, orientation and re-evaluation of the patient related to the DNI on the physician's progress note on 6/24/10 at 2:00 pm and 7/1/10 at 1:20 pm. However on 6/27/10 at 7:26 pm the physician's written order was for DNR which is not according to the patient's representative signed DNI consent. The DNI consent and the written DNI order was performed by the resident physician or the internal physician, however no evidence was found that the attending physician countersigned the DNI consent and DNI order. According to the facility's policies and procedure related to the DNR or DNI order reviewed on 7/8/10 at 1:00 pm it states "If the patient has not taken the decision but takes the decision of not receiving heroic measures during their hospitalization; nursing personnel will provide the format of the decision to not resuscitation. The resident doctor is notified, who communicates with the primary physician about this decision in order to discuss this with the patient and relatives and write the order. Orders written by the resident physician needs to be countersigned by the primary physician, in a period not greater than 24 hours, from the order given".

Based on records reviewed (R.R) with the director of nursing (employee #7), it was determined that the facility failed to promote the patient's right to be free of restraints and failed to continually assess and monitor three out of three records reviewed (R.R #22, #23 and #24).

Findings include:

1. R.R #22 is a 67 years old male who was admitted on 7/2/10 with a diagnosis of Abdominal Pain, Dehydration, Diabetes Mellitus (DM) and Peripheral Vascular Disease (PVD). The record review was performed on 7/7/10 at 3:30 pm with the nursing Director (employee #7) and provide evidence that the physician placed an order on 7/3/10 at 3:00 pm for restrictions. The physical restraints order sheet did not provide evidence of the type of restraint to use and the nurse did not write the date that the order was signed on. No evidence was found related to the nursing restraint assessment for the 3-11 shift, the nursing progress notes documented that the patient was restrained on the upper extremities due to disorientation, for treatment and patient safety. On 7/4/10 at 3:00 pm and 7/5/10 at 1:00 pm the physician placed a restraint order, however it lacked the nurse's signature, date and hour. No evidence was found of the patient's plan of care related to the restraints to be activated by the registered nurse on 7/3/10.

2. R.R #23 is a 77 years old male who was admitted on 6/25/10 with a diagnosis of Respiratory Failure and Right foot gangrene, D.M and Heart Disease. The record review was performed on 7/8/10 at 9:45 am with the nursing director (employee #7) and provided evidence that the physician placed an order on 7/5/10 at 1:15 am for restrictions. The physical restraint order sheet did not provide evidence of the date and hour when the nurse signed the order. On 7/6/10 at 10:10 am the physician places an order for restraints and the physical restraints order sheet provided evidence that the nurse did not take the order, however the patient was restrained and the nurse's assessment was performed for the 11-7, 7-3 and 3-11 shifts, date and hour when the nurse signed the order. No evidence was found that the patient's plan of care related to the restraints was activated by the registered nurse on 7/5/10.

3. R.R #24 is a 95 years old male who was admitted on 7/1/10 with a diagnosis of Neurologic Deficit. The record review was performed on 7/8/10 at 10:30 am with the nursing director (employee #7) and provide evidence that the physician places an order on 7/1/10 at 9:30 pm for restrictions. The physical restraint order sheet provided evidence that the nurse took the order on 7/2/10 at 9:30 am, 7/3/10 at 9:30 am and 7/5/10 at 1:30 pm. On 7/2/10 no evidence was found related to the restraint nursing assessment. The nurse's progress notes performed on 7/2/10 for the 11-7 shift provided evidence that the patient was restrained at the beginning of the shift, the 7-3 shift documented that the patient had soft restraints of the upper extremities with good blood venous return and the 3-11 shift did not provide evidence of the restraints. On 7/6/10 at 1:30 pm the physician's notes were re-evaluated for the order and placed an order for restraints on 7/7/10 at 5:30 am. Evidence was found that the patient's plan of care related to the restraints was activated by the registered nurse on 7/5/10 after 5 days that the patient was restraint.

Based on records reviewed (R.R) with the director of nursing (employee #7), it was determine that the facility failed to ensure that the attending physician is consulted as soon as possible if the attending physician did not order the restraints for three out of three records reviewed (R.R #22, #23 and #24).

Findings include:

During records reviewed on 7/7/10 from 10:00 am till 4:00 pm and on 7/8/10 from 9:45 am till 4:00 pm, it was found that R.Rs #22, #23 and #24 provided evidence that the restraint order was signed by a resident physician or physician intern, but no evidence was found that the attending physician countersigned the restraint order or that the attending physician was consulted as soon as possible.

Based on the review of the Quality assessment and performance improvement program, interviews accompanied by the facility's Quality Improvement Officer (employee #3) on 7/9/10 from 1:15 am till 2:30 pm, it was determined that the facility failed to ensure an effective on going hospital wide data driven Quality assessment and performance improvement activities that is implemented, maintained and reflects the complexity of hospital's organization and services, involves all hospitals departments and services (including those services furnished under contract or arrangement) and focuses on indicators related to improve health outcomes.

Based on review of quality assurance activities with the quality assurance officer (employee
#3), 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 committee meetings as established by the hospital's governing body and promotes quality assurance activities focused on patient health outcomes.

Findings include:

1. During the review of the facility's hospital-wide quality assurance activities master plan with the quality assurance officer (employee #3) on 7/9/10 at 1:00 pm it was identified that contracted services were not included as part of services to be submitted as quality indicators data in order to evaluate the performance of the services.

2. According with hospital Governing Body regulations, with the quality assurance officer (employee #3) on 7/9/10 at 1:23 pm the following was determined:

a. Hospital wide quality and assurance committee must meet monthly to identify issues with respect to which quality assessment and assurance activities are necessary and to develop and implement appropriate plans of action to correctly identify quality deficiencies. However this committee has not meet since November of 2009.

b. No evidence was found that quality assurance committee members meet on an ongoing basis to identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies, including monitoring the effects of implemented changes and making needed revisions to the action plans.

c. No evidence was found of the discussion of the review or identification of potential quality deficiencies or actual deviations from appropriate care processes or facility procedures that require action since November of 2009.

d. No evidence was found that quality assurance committee members who have knowledge of facility systems and the authority to change these systems due to their responsibility to manage the facility, and make change to facility systems participate with quality assurance committee meeting since November of 2009.

e. No evidence was found of the development and implementation of patient care policies
and coordination of medical care issues identified by quality assurance program and that it is discussed with the person in charge of the hospital's medical direction since November of 2009.

f. No evidence was found that quality assurance identified issues that require potential intervention with staff that are responsible for direct patient care and services such as nursing, therapists, staff nurses, social workers and staff with responsibility for the physical plant, such as maintenance and housekeeping that are discussed and informed since November of 2009.

3. Discharge planning services are collecting and reporting information to the Quality Assurance Program Statistical Reports instead of reports that include surveillance of issues that need to be assessed to ensure that quality of care offered to patients. Reports submitted by services from the year of 2010 were reviewed with the quality assurance officer (employee #3) on 7/9/10 at 1:43 pm. The data was not presented as indicators or information obtained in order to present facility approaches of quality improvement and patient health outcomes as the result of the care provided by the service.

4. Dietary services quality assurance activities were reviewed with the administrative dietitian
(employee #24) on 7/7/10 at 11:39 am. The quality assurance activities did not include in their plan surveillance for patients' outcome indicators. This was discussed with the Quality Improvement Officer (employee #3) during the review of quality assurance hospital-wide activities and services on 7/9/10 at 11:57 am and she was in agreement with the findings.

Based on the review of quality assurance activities with the quality assurance officer
(employee #3), it was determined that the facility failed to ensure that one or more specific quality improvement projects are undertaken each year.

Findings include:

The facility failed to provide evidence on 7/9/10 at 11:25 am with the quality assurance officer (employee #3) of performance improvements projects currently underway, as well as those completed in the prior year.

Based on the review of twenty-one medical staff credential files, it was determined that the facility failed to examine credential files (C.F) to ensure that medical staff have updated Health Certificates and Cardio-pulmonary Resuscitation Certificates (CPR) for six out of twenty-one credential files reviewed (C.F #1, #11, #14, #15, #16 and #18).

Finding include:

1. During the review of twenty-one medical staff credential files on 7/9/10 from 10:30 am till 11:20 am the following was found:

a. Two out of twenty-one medical staff credential files provided evidence of expired Health Certificates for C.F #1 (from 1/28/10) and C.F #16 (from 2/26/09).

b. Five out of twenty-one medical staff credential files provided evidence of expired cardio- respiratory certificates for C.F #1 (from 3/14/10), C.F #5 (from 9/27/09), C.F #14 (from 4/30/10), C.F #16 (from 3/25/10) and C.F #18 (from 2/8/08).

Based on the review of Medical Staff Rules and Regulations, it was determined that the facility failed to ensure that services provided by the medical staff have protocols which address Organ, Tissue and EMTALA administrative protocols.

Findings include:

During the review of Medical Staff Rules and Regulations on 7/9/10 at 2:30 pm with the Secretary of the medical director (employee #27), no evidence was found of written bylaws for Organ, Tissue and Eye Procurement protocols and EMTALA administrative protocols.

Based on the review of clinical records and policies/procedures with the director of nursing (employee #7) and Social Workers (employees #12 and #13), it was found that the facility failed to ensure that thirteen out of sixty records reviewed (R.R #19, #20, #21, #22, #23,
#24, #25, #26, #27, #28, #29, #30 and #60) have developed, updated and implemented nursing care plans.

Findings include:

1. Thirteen out of sixty records reviewed for care plans on 7/7/10 from 10:00 am till 4:00 pm and on 7/8/10 from 9:45 am till 4:00 pm with the nursing director (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 #19 is a 68 years old female who was admitted on 7/6/10 with a diagnosis of Left Knee Degenerative Joint Disease, no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

b. R.R #20 is a 78 years old male who was admitted on 6/6/10 with a diagnosis of Bronchopneumonia, Alzheimer and Parkinson, no evidence was found of the revision of the patients' needs according to the patient's changes during the in-patient stay.

c. R.R #21 is an 89 years old female who was admitted on 6/30/10 with a diagnosis of Congestive Obstructive Pulmonary Disease (COPD), R/O Bronchopneumonia (BKP), Diabetes Mellitus, and Cervical Cancer and Pulmonary Failure, no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

d. R.R #22 is a 67 years old male who was admitted on 7/2/10 with a diagnosis of Abdominal Pain, Moderate dehydration, Diabetes Mellitus type II Peripheral Vascular Disease (PVD), no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

e. R.R #23 is a 77 years old male who was admitted on 6/25/10 with a diagnosis of Respiratory Failure, Right foot gangrene, Diabetes Mellitus and Heart Disease, no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

f. R.R #24 is a 95 years old male who was admitted on 7/1/10 with a diagnosis of Neurologic Deficit and Seizure, no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

g. R.R #25 is a 90 years old female who was admitted on 6/17/10 with a diagnosis of Congestive Heart Failure (CHF), Diabetes Mellitus and Congestive Obstructive Pulmonary Disease (COPD), no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

h. R.R #26 is an 80 years old female who was admitted on 7/2/10 with a diagnosis of Acute Gastroenteritis (AGE), Severe Dehydration, Acute Renal Failure and Diabetes Mellitus, no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

i. R.R #27 is a 79 years old male who was admitted on 7/6/10 with a diagnosis of Abdominal Pain, no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

j. R.R #28 is an 82 years old male who was admitted on 7/3/10 with a diagnosis of Symptomatic Bradycardia, Hypotension Left Pleural Effusion and End Stage Renal Disease (ESRD), no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

k. R.R #29 is a 53 years old male who was admitted on 6/12/10 with a diagnosis of Human Immunodeficiency Virus (HIV positive), Hepatitis C, Thrombocytopenia, Septic Shock and Respiratory Failure, no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

l. R.R #30 is a 79 years old male who was admitted on 6/22/10 with a diagnosis of Congestive Heart Failure, Diabetes Mellitus type II, Respiratory Failure, no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

m. R.R #60 is a 91 years old female who was admitted on 7/5/10 with a diagnosis of Acute Bronchitis, Pneumonia, no evidence was found of the revision of the patients' needs according to the patient's changes during the hospitalization.

Based on thirteen active patient's records reviewed (R.R) and review of policies/procedures with the nursing director (employee #7), it was determined that the facility failed to ensure that all drugs and biological must be administered by or under supervision of nursing in accordance with Federal and State laws and regulations for one out of thirteen active records reviewed (R.R #21).

Findings include:

1. One out of thirteen active records reviewed on 7/7/10 from 10:00 am till 4:00 pm and on 7/8/10 from 9:45 am till 4:00 pm provided evidence that the registered nurse (RN) did not sign the order prescribed by the physician:

a. R.R #21 provided evidence that a physician placed an order on 6/30/10 at 10:00 pm for Advair 250 mg/50 mg 1 inhalation two times a day transcribed by a registered nurse to the Medication Administration Record (MAR). However, the MAR provided evidence that the Advair was given to the patient and no evidence was found related to the Advair administration on 7/1/10, 7/3/10, 7/4/10, 7/5/10, 7/6/10 and 7/7/10 at 9:00 am. The physician placed an order on 6/30/10 at 10:00 pm for Metformin 1000 mg by mouth in the morning, transcribed by a registered nurse to the MAR. However, no evidence was found in the MAR related to the Metformin administration on 7/1/10 at 9:00 am and the blood sugar was 268 mg/dl at 1:00 pm.

Based on thirteen active patient's records reviewed (R.R) and review of policies/procedures with the nursing director (employee #7), it was determined that the facility failed to ensure that orders for drugs and biological are documented and signed by a practitioner who is authorized to write orders by hospital policies and in accordance with nursing standards of practice for three out of thirteen active records reviewed (R.R #22, #23 and #24).

Findings include:

1. Three out of thirteen active records reviewed on 7/7/10 from 10:00 am till 4:00 pm and on 7/8/10 from 9:45 am till 4:00 pm provided evidence that the registered nurse (RN) did not sign the order prescribed by the physician:

a. R.R #22 provided evidence that a physician placed an order on 7/20/10 at 9:20 pm for Intravenous fluids (IVF's) 0.9% Saline Solution at rate 75 ml/hr, Arterial Blood Gas (ABG's), Electrocardiogram (EKG), Dextrose, Complete Blood Count (CBC), Basic Metabolic Panel (BMP), Urine Analysis (U/A), Amylase, Lipase, Creatine Kinase MP fraction (CKMB), Chest and Abdominal X-Ray, however no evidence was found that the registered nurse (RN) signed the order prescribed by the physician. On 7/4/10 at 3:00 pm, on 7/5/10 at 1:00 pm the physician placed an order to restrain the patient's left arm and right arm with soft restraints for 24 hours, however no evidence was found that the registered nurse (RN) signed the order prescribed by the physician.

b. R.R #23 provided evidence that a physician placed an order on 7/6/10 at 10:10 am, to restrain the patient's left arm and right arm with soft restraints for 24 hours, however no evidence was found that the registered nurse (RN) signed the order prescribed by the physician.

c. R.R #24 provided evidence that a physician placed an order on 7/4/10 at 10:00 am to decrease IVF's to keep vein open, CBC and differential, BMP, however no evidence was found that the registered nurse (RN) signed the order prescribed by the physician. No evidence was found that the order was executed. On 7/2/10 at 9:30 am, on 7/3/10 at 9:30 am and 7/5/10 at 1:30 pm the physician placed an order to restrain the patient's left arm and right arm with soft restraints for 24 hours, however no evidence was found that the registered nurse (RN) signed the order prescribed by the physician.

Based on records reviewed (R.R) with the director of nursing (employee #7), it was determined that the facility failed to ensure that telephone orders are signed as soon as possible for one out of thirteen records reviewed (R.R #24).

Findings include:

1. Evidence was found on 7/8/10 at 11:45 am of policies and procedures related to the timeliness of countersignatures when telephone orders are used and it states that the physician has 24 hours to countersign the telephone order.

a. R.R #24 provided evidence of a telephone order placed on 7/2/10 at 12:20 pm for Intubation protocol, placed on ventury mask at 50% of oxygen and ABG's in one hour, however no evidence was found that the physician countersigned the order.

Based on the observational tour of the medical records department with the medical record administrator (employee #4), it was determined that the facility failed to ensure the proper storage and placement of medical records in the medical record department, properly secure an alternate storage room related to boxes with records directly on the floor, dust covered records, records exposed to possible water damage and complete clinical records within 30 days following discharge.

Findings include

1. During the observational tour of the medical record storage area with the medical record administrator (employee #4) on 7/8/10 at 2:00 pm, it was found that this area has approximately 500 clinical records directly on the floor and approximately 100 clinical records directly on the floor (they were loose not in boxes) near the exit door exposing them to possible water damage. This exit door which gives access to the outside was observed with a two inch gap between the door and the floor. The rest of this central file area has active records and is completely full to capacity and the physical structure does not have extra space available for new records to be filed.

2. The exit door which has direct access to the outside (to the parking area) was observed unlocked on 7/8/10 at 2:30 pm which will not prevent unauthorized access.

3. A room located at the incomplete medical record area on the first floor was observed on 7/8/10 at 2:45 pm with the medical record administrator (employee #4) and was found with approximately 5,000 active records. This room was found under construction, the medical record cabinets were found with sheets over then to keep dust and dirty off of them. However, due to the nature of the construction the records can not be left in this room due to the chance that they can be damaged and because of unauthorized access when construction workers are in this room.

4. The incomplete medical record report reviewed on 7/9/10 at 2:30 pm revealed that there are 3,048 incomplete records, 340 from 0-30 days and those over 30 days there are 2,708 by the physician, nursing staff and other disciplines. There is an average of 754 monthly discharges.

5. No evidence was found on 7/9/09 at 3:30 pm of an abbreviation manual that includes the pharmacy supervisor's signature of participation.

Based on the observational tour of the medical records department with the Medical Record Administrator (employee #4), it was determined that the facility failed to ensure that unauthorized individuals cannot gain access to or alter patient records.

Findings include

During the observational tour of the medical record department located on the first floor with the medical record administrator (employee #4) on 7/8/10 at 2:45 pm, it was found that the area used by the facility to allow record revision by facility personnel and health plan auditors does not ensure medical record unauthorized access. The entrance door of the medical records department was not locked and did not prevent unauthorized access. This area contains desks that medical record personnel have placed approximately 2,000 to 3,000 medical records. When facility staff or health plan auditors are allowed access to this area to review selected records, they are in the same area where other non selected records are placed which does not allow confidentiality for these other records.

Based on the review of sixty closed and active clinical records, it was determined that the facility failed to ensure that medical staff, nursing personnel and other disciplines maintain legible and complete entries for sixty out of sixty records reviewed (R.R #1 through #60).

Findings include:

1. Sixty clinical records reviewed from 7/7/10 through 7/9/10 from 9:30 am till 4:00 pm contained portions that are not legible. Most notable were the diagnosis, operative reports, informed consent forms, anesthesia reports, physician's orders, signatures (physicians and nurses), progress notes, consults and nurse's notes.


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2. Eleven clinical records reviewed performed on 7/7/10 from 9:40 am till 4:00 pm and on 7/8/10 from 9:30 am till 12:00 noon with the nursing director (employee #7) and on 7/8/10 from 1:30 pm till 4:00 pm with the social worker director (employee #12 and #13) contained evidence that five out of eleven medical records reviewed for nursing services and discharge planning services, the following were left in blank, the initial nursing assessment was incomplete related to the nurse that performed the assessment, the Braden pressure ulcer risk assessment scale in blank, the nutritional evaluation patient orientation, educational needs, discharge planning evaluation ID Band identification, multidisciplinary group refers, nursing diagnosis, initial intravenous (for five out of eleven medical records reviewed (R.R #19, #21, #22, #29 and #60).

Based on the review of Medical Staff Bylaws Rules and Regulations, Medical Record policies/procedures, Emergency Room policies/procedures and twelve closed clinical records, it was determined that the facility failed to ensure that all records have complete
histories and physical examinations before admission or within 24 hours after admission for a procedure for one out of twelve records reviewed (R.R #17).

Findings include:

R.R #17 is a female patient who was admitted to the hospital on 2/2/10 with a diagnosis of Cerebrovascular Accident and Bronchopneumonia and died on 2/9/10. The record review was performed on 7/9/10 at 9:30 am and no evidence was found that a medical history and physical examination was performed before admission or within 24 hours after admission for this patient.

Based on the review of Medical Staff Bylaws Rules and Regulations, Medical Record policies/procedures, Emergency Room policies/procedures and twelve closed clinical records, it was determined that the facility failed to ensure that all records with consultation requests contain evidence of the results and time of the consultations for two out of twelve records reviewed (R.R #15 and #16).

Findings include:

1. R.R #15 is a female patient who was admitted to the hospital on 5/2/10 with a diagnosis of Symptomatic Anemia, Acute Renal Failure and Bronchopneumonia and died on 6/10/10. The record review was performed on 7/9/10 at 9:45 am and provided evidence that a surgeon was consulted related to place a PEG (percutaneous enteral gastrointestinal) for the patient on 5/24/10 at 7:40 pm, however it was not until 5/31/10 that the consult was answered from the surgery services.

2. R.R #16 is a female patient who was admitted to the hospital on 3/14/10 with a diagnosis of Cerebrovascular Accident with Subarachnoid Hemorrhage and died on 3/15/10. The record review was performed on 7/9/10 at 10:00 am and provided evidence that two consults were requested from different disciplines on 3/14/10. However, no evidence was found of the documentation on the consult request order of the consulted physician's response to the consult.

3. Medical Staff Bylaws Rules and Regulations, Medical Record policies/procedures and Emergency Room policies/procedures related to consults were reviewed on 7/9/10 at 2:00 pm. It was found that medical staff Bylaws Rules and Regulation states that medical consults should be performed with 24 hours. A complete consultation report should be placed in the medical report within 48 hours and all consultations must be written and signed by the consultant.

Based on twelve closed records reviewed (R.R), it was determined that the facility failed to ensure that discharge or death summaries are performed with all pertinent information for one out of twelve records reviewed (R.R #16).

Findings include:

R.R #16 is a female patient who was admitted to the hospital on 3/14/10 with a diagnosis of Cerebrovascular Accident with Subarachnoid Hemorrhage and died on 3/15/10. The record review was performed on 7/9/10 at 10:00 am and provided evidence that the death summary was not completed.

Based on the review of documents, observational tour with the Pharmacist (employee #25), 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 and lack of documentation of information related with patient's history of allergies in the Medication Administration Record (MAR).

Findings include:

1. During the initial observational tour with the pharmacist (employee #25) on 7/8/10 from 9:18 am though 11:56 am the following was found:

a. The pharmacy formulary found at Medicine wards, Surgery and Intensive Care were last dated on 2008. The Pharmacy Formulary reviewed with the Pharmacist (employee #25) on 7/8/10 at 10:23 am did not include the date when last reviewed. The facility failed to keep an update Pharmacy Formulary at the patient's Medicine, Surgery and Intensive Care Units.

b. At the Intensive Care unit nine medication drawers used to store patient's medications were found opened. These drawers did not provide a lock to be used to protect these medications from non authorized persons.

c. At the Surgery ward, twelve out of twelve Medication Administration Records (MARs)
reviewed lacked information related to the patient's history of allergies.

d. At the Medicine Ward on the second floor the refrigerator used to store antibiotics prepared by the pharmacy was found unlocked and available to non authorized persons.

Based on observations and review of documents with the pharmacist (employee #25), it was determined that the facility failed to ensure that responsibilities of personnel who deliver pharmacy services are clearly defined and include the development, supervision and coordination of all activities for two out of two pharmacy technician students credential files (C.F #1 and #2).

Findings include:

Two out of two pharmacy technician student credential files (C.F #1 and #2) were reviewed on 7/9/10 at 2:58 pm. These credential files did not include responsibilities or objectives for the area of practice and personnel who are going to supervise the students.

Based on the observational tour and review of policies/procedures, it was determined that the facility failed to ensure that the X-ray department is free from hazards for patients and personnel as evidenced by sharp containers directly on the floor without security bases and unattended and unlocked contrast media.

Findings include:

1. A sharp containers (five gallon sizes) was observed on 7/9/10 at 11:00 am without security base during the observational tour of the X-Ray department in the CT room with biohazardous materials. Security bases are needed to protect the sharp containers from unauthorized removal and prevent the containers from tipping over.

2. During the X-Rays department tour with the X-Ray supervisor (employee #10) on 7/9/10 from 10:00 am till 11:05 am it was observed that different types of contrast media were available for non authorized personel that was stored in different areas of the department unlocked.
a. In Fluoroscope room #1 it was found that 4 bottles of Barium Sulfate for suspension tonopaque 180 gm in a cabinet without a lock was available to unauthorized persons.
b. In room #2 it was found that 13 bottles of Barium Sulfate for suspension tonopaque 180 gm in the catheter cart without a lock and available to unauthorized persons.
c. In Computerized Tomography (CT) room it was found that an open shelf with a box with vials of 100 ml of Omnipaque Liohexol Inj. 300 mg/ml, a box of Banana Smoothie Readicat 2 and four boxed of 24 Barium Sulfate for suspension 2.1% of 450 ml. In a cabinet without a lock it was found that eleven vials of Gasto View Diatrizoate Meglumine and Diatrizoate Sodium Solution was available to unauthorized persons.

Based on observations and the review of policies and procedure and interview with the X-Ray supervisor (employee #10), it was determined that the facility failed to maintain copies of reports and printouts, films, scans and other image records as appropriate for at least five years.

Findings include:

During the observational tour of the X-Ray Department with the supervisor (employee #10)on 7/9/10 at 10:45 am it was observed that approximately one thousand X-Ray films from 2009 were on an open shelf in the mammography room unattended and unlocked available for unauthorized personnel. The X-Ray supervisor (employee #10) stated during interview on 7/9/10 at 10:50 am that they put that X- Ray record in the mammography room due to the remodeling and do not have sufficient space in the unit, and those are the records from the last year, if a patient wants the record they do not have to go the offsite storage of the hospital.

Based on the kitchen observational tour with the administrative dietitian (employee #24), review of policies/procedures and food code guidelines, it was determined that the facility failed to operationalize procedures to ensure that relative humidity of dry food storage area are recorded and registered, that garbage containers are located outside the kitchen tray cleaning area, that dish soap containers are label according with its contents, that served food is label with the date that they were prepared on, that eggs are not located directly on the floor and that the ice machine is cleaned in accordance with the manufacturer's instructions.

Findings include:

1. The kitchen was visited with the administrative dietitian (employee #24) on 7/7/10 from 9:25 am through 12:18 pm the following was determined:

a. In the dry food storage area the relative humidity was not measured, nor registered by kitchen personnel.

b. Garbage cart containers were located in the area where trays are washed and cleaned.

c. A container with a blue liquid was found in the area where fruits and vegetables are washed and prepared. The administrative dietitian (employee #24) stated on 7/7/10 at 9:55 am that this liquid is a common household dish detergent and not a commercial industrial dish detergent. No label was found that indicated the name of the blue liquid as the product that the dietitian referred was in the bottle.

d. Three trays of milk, juice and gelatin were found in a refrigerator near to the tray line area without labels that include information of the date when these items were prepared. The Administrative dietitian (employee #24) stated on 7/7/10 at 10:20 am that the milk, gelatin and juice are going to be used during the lunch tray line assembly.

e. Five boxes with thirty dozen eggs per box were found placed directly on the floor of the walk-in refrigerator.

f. An ice maker machine (manitowoc ice machine model) used for meals and products of the kitchen and cafeteria were found in the area where fruits and vegetables are prepared. The policy for the cleaning and maintenance of the machine were requested of the administrative dietitian (employee #24) on 7/7/10 at 11:00 am. The policy was provided on 7/8/10 at 1:00 pm and it establishes that the machine is cleaned with diluted bleach. This procedure does not include information related to the frequency of the cleaning. However, the manufacturer's specification for the cleaning of this ice machine provided by the engineering department on 7/7/10 at 2:14 pm, provided evidence that the machine must be cleaned every six months according with the manufacturer's specifications and no cleansers containing bleaching agents can be used to clean the machine. Equipment used and care guides established that mild soap and water and a soft clean cloth must be used to clean the machines' exterior and the interior must be clean only with ice machine cleaner (part number 94-0546-3) and sanitizer (part number 94-05650-3) every six months.

g. The refrigerator located in the kitchen was visited on 7/8/10 at 11:10 am with the administrative dietian (employee #24) and provided evidence that a large metal container was filled with cut vegetables, however it was not covered with plastic wrap to protect it from refrigerator odors and other environment elements in the refrigerator.

h. The refrigerator located in the kitchen was visited on 7/8/10 at 11:10 am with the administrative dietian (employee #24) and provided evidence that a large plastic container had ten heads of white cabbage in it, however it was not covered with plastic wrap to protect it from refrigerator odors and other environment elements in the refrigerator.

i. Observations of the kitchen on 7/7/10 and 7/8/10 from 9:00 am till 11:45 am with the administrative dietitian (employee #24) provided evidence that large dumpster style trash containers filled with trash are being transported through the main hallway of the hospital on the first floor. The administrative dietian (employee #24) stated on 7/7/10 at 9:40 am that due to the construction of the new building, they do not have access from the back door of the kitchen and are using the main hallway. The facility failed to develop policies/procedures related to the proper removal of trash through the hospital or to find an alternate route that is less transited.

Based on nine medical records reviewed (R.R), policies/procedures, it was determined that the facility failed to ensure that patient's nutritional needs are addressed according with professional standards of practice for eight out of nine records reviewed
(R.R #2, #23, #28, #46, #48, #49, #50 and #53).

Findings include:

1. A mechanism to ensure that patients identified at nutritional risk receive dietitian evaluations as early as possible so interventions can be initiated to prevent complications and adverse outcomes was not performed, nor followed for three out of nine records reviewed (R.R #28,
#50 and #53).

a. R.R #53 is a 79 years old female admitted to the facility on 7/5/10 from the emergency room with a diagnosis of Sepsis and Abdominal Pain as reviewed on 7/9/10 at 9:23 am. The patient was ordered Jevity enteral nutrition at 35 cc/hour every 16 hours by nasogastric tube. According with the facility's nutritional risk needs evaluation this patient must be assessed
between 24-48 hours based the patient's diagnosis and level of nutritional risk. The medical record of the patient was reviewed on 7/9/10 at 9:23 am and no dietitian evaluation was found documented. The facility failed to intervene and implement specialized nutritional therapies and counseling accordingly with policies established and based on patient diagnosis in order to evaluate the patient's nutritional status and identify if the patient has nutritional related problems.

b. R.R #28 is a 82 years old male admitted to the facility on 7/3/10 with a diagnosis of
End Stage Renal Disease, Diabetes Mellitus and High Blood Pressure as reviewed on 7/7/10 at 9:57 am. According with the facility's nutritional risk needs evaluation this patient must be assessed between 48-72 hours based on the patients' diagnosis and level of nutritional risk. The medical record of patient was reviewed on 7/7/10 at 9:50 am and no dietitian evaluation was found documented until 7/7/10. The patient was evaluated on 7/7/10 because the case was consulted by the physician. From 7/3/10 through 7/7/10 the patient was not evaluated based on the nutritional risk scale established by the facility and failed to intervene and implement specialized nutritional therapies and counseling according with policies established and based on the patients' diagnosis in order to evaluate the patient's nutritional status and identify if the patient has nutritional related problems.

c. R.R #50 is an 81 years old female admitted to the facility on 7/2/10 with a diagnosis of Cerebro Vascular Accident, Bronchopneumonia by Aspiration, Dysphagia and R/O Sepsis as reviewed on 7/7/10 at 10:57 am. This patient was admitted with a Peg tube for feeding but ordered to remain NPO after admission. On 7/3/10 at 12:10 pm she was ordered a soft mechanical diet. The soft mechanical diet order was omitted on 7/3/10 at 12:20 pm and the physician ordered a liquid diet by Peg tube. The patient was receiving a liquid diet by Peg tube until 7/3/10 at 11:00 pm when Pulmocare enteral nutrition at 30 ml hour by Peg tube was ordered. Patient was not evaluated until 7/6/10 when according with low levels of hemoglobin and serum albumin the dietitian recommends Nutren enteral nutrition at 63 ml/hour every 16 hours. According with the facility's nutritional risk needs evaluation this patient must be assessed between 24-48 hours based on the patients' diagnosis and level of nutritional risk. The facility failed to intervene and implement specialized nutritional therapies and counseling according with policies established and based on patients' diagnosis in order to evaluate the patient's nutritional status and identify if the patient has nutritional related problems.

2. A mechanism to ensure that recommendations established by the dietitian after evaluation of patients by nutritional services were ordered by the physician in charge of the patient in a timely manner was not promoted, nor performed according with professional standards of practice and patients' individualized needs for two out of nine records reviewed (R.R #23 and #48).

a. R.R #48 is a 66 years old male admitted to the facility on 6/21/10 with a diagnosis of End Stage Renal Disease, Diabetes Mellitus and R/O of Myocardial Infarction as reviewed on 7/7/10 at 1:29 pm. This patient was evaluated by the dietitian on several occasions since admission in the telemetry ward to evaluate the patient's nutritional status and identify if the patient has nutritional related problems. At the ward the patient was receiving 2 gms Renal
Soft Mechanical Blenderized Diet by nasogastric tube. On one of the dietitian's evaluations (from 6/24/10) she recommends Nepro enteral nutrition by nasogastric tube at 25 ml/hour. However, this recommendation was never considered or ordered by the physician in charge of the patient. On 7/2/10 the patient was transferred to the Intensive Care Unit due to his worsening health condition and was ordered to remain NPO by the physician. On 7/3/10 the previous diet of 2 Gms Renal Soft Mechanical Blenderized Diet by nasogastric tube was reordered. At the Intensive Care Unit the patient was receiving Dialysis and was on Mechanical Ventilation due to his health condition. Dietitian recommendations of Nepro enteral nutrition by nasogastric tube at 25 ml/hour was never considered or ordered by the physician in charge of the patient. The facility failed to implement specialized nutritional therapies for this patient based on his acute health status needs for specialized nutritional support.

b. R.R #23 is a 77 years old male admitted to the facility on 6/25/10 with a diagnosis of Hypoglycemia, Hypocalcemia, Hypoalbuminemia, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus and Acute Renal Failure as reviewed on 7/7/10 at 2:28 pm. This patient was evaluated by the dietitian on several occasions since admission to the medicine
telemetry ward to evaluate the patient's nutritional status and identify if the patient has nutritional related problems. On 7/5/10 the patient was transferred to the Intensive Care Unit due to his worsening health condition and was ordered to remain NPO by the physician. The dietitian evaluates the patient on 7/6/10 and recommends Pulmonary enteral nutrition at 35 ml/hour. This recommendation was not considered or ordered by the physician in charge of the patient until 7/7/10. The facility failed to implement specialized nutritional therapies for the patient based on his acute health status needs for specialized nutritional support.

3. Patients who receive initial evaluations for nutritional services to implement specialized nutritional therapies and counseling do not receive further assessments and nutritional interventions on an ongoing basis and according with the patients' needs. Policies and procedures for the nutritional re-assessment were reviewed with the administrative dietitian (employee #24) on 7/7/10 at 10:08 am. These policies establishes that the nutritional re-assessment is performed based on the physician's order. However, the nutritional risk assessment screening mechanism establishes that according with the patient's level of nutritional risk, re-assessment varies and where performed according with the follow-up established parameters. For four out of nine records reviewed (R.R #2, #23, #46 and #49) the follow-up reassessment were performed based only on physician's order and not according with nutritional risk assessments and re-assessment screening mechanisms established by the facility. The facility failed to ensure that nutritional re-assessments are performed based on the patient's needs and according with professional standards of practice.

Based on tests performed on equipment, interviews, review of documents and observations made during the survey for the physical environment and Life Safety with the facility's Engineer (employee #17) and Safety Officer (employee #18) from 7/7/10 through 7/9/10 from 9:00 am till 4:00 pm, it was determined that the physical structure and care areas failed to ensure that the metal frames of the stretchers throughout the emergency room are rust free, failed to provide food tray tables for patients in the emergency room, the dirty utility closet of the emergency room was found with dirty linen bags on the floor and on top of the linen container and they were touching the paper dispenser, no evidence was provided of the annual internal cleaning and sanitizing of the ice maker in the kitchen and two elevators that provides service to patients, visitors, maintenance employees, transport materials and remove regular and biohazardous trash were found with large dumpster style trash containers with regular trash and biohazardous trash and at the same time with visitors, it was also 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 intravenous bag storage area near patient's cubicles of the emergency room did not ensure appropriate temperatures for this room, the medical record department located on the ground floor was found with an estimated 10,000 medical records that were found on the floor, stacked up to the ceiling on shelves and on the floor near an exit door, under a window mounted air conditioner, outside windows of the medical record department have been boarded up with wood panels which will not protect and safe guarded the records from unauthorized persons or thief, a drying rack in the kitchen used to place pots and pans, is located within twelve inches from the floor and the bottom shelves of the rack in the refrigerators and freezer of the kitchen are located within twelve inches from the floor, it was determined that this facility's physical structure is not designed to provide protection of patients and staff related to the emergency room observation cubicles containing two patients each and only one emergency nursing call system and one oxygen outlet and suction outlet per cubicle and no ceiling mounted curtains, the emergency rooms' designated decontamination room is not properly designed, the emergency room does not have a designated temporary parking space located conveniently to the entrance, the area designated for pediatric patients in the emergency room is located down a hallway away from the nursing station, Cidex-OPA is used to disinfect equipment at the Ambulatory Procedure Department-Gastrostomy services area but no evidence was found of a spill kit or that they are neutralizing Cidex-OPA before disposal, the operating room department is not maintained or constructed appropriately, the morgue does not have a housekeeping closet, a large electric floor mixer in the kitchen is located near a frequently used passageway and does not have a protective cover over the large mixing bowl, the housekeeping closet in the kitchen does not meet minimum requirements, the bathroom located near the physical therapy department does not comply with Americans with Disabilities Act (ADA) requirements, the acute dialysis room is not appropriate related to size and storage space, a privacy curtain is needed in the physical therapy department, no evidence was found of routine and preventive maintenance and testing activities incorporated into the hospital's Quality Assessment Performance Improvement program and no evidence was found that representatives of the physical environment and life safety are attending committee meetings, 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, K0021, K0026, K0046, K0048, K0050, K0051, K0052, K0056, K0062, K0069, K0072, K0130 and K0211. 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 #17), it was determined that the physical structure and care areas failed to ensure that the metal frames of the stretchers throughout the emergency room are rust free, failed to provide food tray tables for patients in the emergency room, the dirty utility closet of the emergency room was found with dirty linen bags on the floor and on top of the linen container and they were touching the paper dispenser, no evidence was provided of the annual internal cleaning and sanitizing of the ice maker in the kitchen and two elevators that provides service to patients, visitors, maintenance employees, transport materials and remove regular and biohazardous trash were found with large dumpster style trash containers with regular trash and biohazardous trash and at the same time with visitors.

Findings include:

1. The emergency room was visited on 7/7/10 from 9:30 am till 11:30 am with the facility's Engineer (employee #17) and provided evidence that the patient in cubicle #2 was eating from her food tray that was placed on her lap. The facility failed to use food tray tables so that patients can eat in a comfortable manner.

2. The emergency room was visited on 7/7/10 from 9:30 am till 11:30 am with the facility's Engineer (employee #17) and provided evidence that the stretchers throughout the emergency room were found with rust along their metal frames.

3. The dirty utility closet of the emergency room was visited on 7/7/10 from 9:30 am till 11:30 am with the facility's Engineer (employee #17) and provided evidence that dirty linen bags were found on the floor and on top of the linen container and they were touching the paper dispenser.

4. During the kitchen observational tour on 7/8/10 at 11:05 am, an ice maker was found with ice cubes inside of it. The dietitian (employee #24) stated during an interview on 7/8/10 at 11:10 am that the ice is used for the kitchen area. No evidence was found on 7/8/10 at 11:15 am that the facility is following manufacturer's recommendations related to the annual internal cleaning and sanitizing of the ice maker.

5. During the observational tour of the facility from 7/7/10 through 7/9/10 from 9:00 am till 4:00 pm with the facility's Engineer (employee #17), it was found that the facility has two elevators that provides service to patients, visitors, maintenance employees, to transport materials and remove regular and biohazardous trash. The elevators were observed during the three day inspection with large dumpster style trash containers with regular trash and biohazardous trash and at the same time with visitors. The elevators were also observed with patients in their beds being moved through the elevators for different procedures or studies while other patients or visitors were also using the same elevator at the same time. The elevators were also seen with patients in a wheel chair and housekeeping carts with the mop pail filled with water. The facility failed to design a plan or develop policies/procedures to reduce the risk of cross contamination and ensure patients' privacy and dignity when using these elevators.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Engineer (employee #17) and the Life Safety Officer (employee #18), 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 from 7/7/10 through 7/9/10 from 9:00 am till 4:00 pm with the facility's Engineer (employee #17) and the Life Safety Officer (employee #18); for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0018, K0021, K0026, K0046, K0048, K0050, K0051, K0052, K0056, K0062, K0069, K0072, K0130 and K0211).

Based on tests and observations made during the survey for the physical environment with the facility's Engineer (employee #17), 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 intravenous bag storage area near patient's cubicles of the emergency room did not ensure appropriate temperatures for this room, the medical record department located on the ground floor was found with an estimated 10,000 medical records that were found on the floor, stacked up to the ceiling on shelves and on the floor near an exit door, under a window mounted air conditioner, outside windows of the medical record department have been boarded up with wood panels which will not protect and safe guarded the records from unauthorized persons or thief, a drying rack in the kitchen used to place pots and pans, is located within twelve inches from the floor and the bottom shelves of the racks in the refrigerators and freezer of the kitchen are located within twelve inches from the floor.

Findings include:

1. The intravenous (I.V) bag storage room located near patient's cubicles in the emergency room was visited on 7/7/10 at 10:15 am with the facility's Engineer (employee #17) and provided evidence that the area was warm and does not have a thermometer to ensure that the appropriate temperature is maintained for these I.V bags (this room should be maintained between 68?F and 71?F according with the I.Vs manufacturer's recommendations).

2. The medical record department located on the ground floor was visited on 7/8/10 at 10:00 am with the facility's Engineer (employee #17) and provided evidence that an estimated 10,000 medical records were found on the floor, stacked up to the ceiling on shelves and on the floor near an exit door. This procedure does not ensure that the records are protected and safe guarded.

3. The medical record department located on the ground floor was visited on 7/8/10 at 10:00 am with the facility's Engineer (employee #17) and provided evidence that approximately 500 medical records were placed directly under a window mounted air conditioner. This procedure does not ensure that the records are protected and safe guarded against water damage if the air conditioner malfunctions.

4. The medical record department located on the ground floor was visited on 7/8/10 at 10:00 am with the facility's Engineer (employee #17) and provided evidence that outside windows have been boarded up with wood panels. This procedure does not ensure that medical records are protected and safe guarded from unauthorized persons or thief.

5. The kitchen was visited on 7/8/10 at 11:00 am with the facility's Engineer (employee #17) and provided evidence that the bottom shelf of the drying rack used to place pots and pans, is located within twelve inches from the floor. Also, the pots and trays are placed in a manner that does not allow for proper drying, when they were tipped over accumulated water poured out.

6. The kitchen was visited on 7/8/10 at 11:05 am with the facility's Engineer (employee #17) and provided evidence that the bottom shelves of the racks in the refrigerators and freezer are located within twelve inches from the floor. These shelves are used to store food and the proximity to the floor does not ensure that infection control standards are met.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Engineer (employee #17) and interview, it was determined that this facility's physical structure is not designed to provide protection of patients and staff related to the emergency room observation cubicles containing two patients each and only one emergency nursing call system and one oxygen outlet and suction outlet per cubicle and no ceiling mounted curtains, the emergency rooms' designated decontamination room is not properly designed, the emergency room does not have a designated temporary parking space located conveniently to the entrance, the area designated for pediatric patients in the emergency room is located down a hallway away from the nursing station, Cidex-OPA is used to disinfect equipment at the Ambulatory Procedure Department-Gastrostomy services area but no evidence was found of a spill kit or that they are neutralizing Cidex-OPA before disposal, the operating room department is not maintained or constructed appropriately, the morgue does not have a housekeeping closet, a large electric floor mixer in the kitchen is located near a frequently used passageway and does not have a protective cover over the large mixing bowl, the housekeeping closet in the kitchen does not meet minimum requirements, the bathroom located near the physical therapy department does not comply with Americans with Disabilities Act (ADA) requirements, the acute dialysis room is not appropriate related to size and storage space, a privacy curtain is needed in the physical therapy department, no evidence was found of routine and preventive maintenance and testing activities incorporated into the hospital's Quality Assessment Performance Improvement program and no evidence was found that representatives of the physical environment and life safety are attending committee meetings.

Findings include:

1. The emergency room was visited on 7/7/10 from 9:30 am till 11:30 am with the facility's Engineer (employee #17) and provided evidence that observation cubicles contained two patients each except for those cubicles with cardiac monitors. Within these cubicles there was only one emergency nursing call system and an oxygen outlet and suction outlet and no ceiling mounted curtains to separate the patients in these cubicles. The facility placed removable curtains between the patients located in the cubicles, however these curtains are an obstacle for patients (can fall on them) and for staff in the event of an emergency and staff need to surround the patient with life saving equipment.

2. The emergency room was visited on 7/7/10 at 10:00 am with the facility's Engineer (employee #17) and provided evidence that the facility has a decontamination room that does not comply completely with the Guidelines for Design and Construction of Health Care facilities (GDCHCF) for the 2006 edition in chapter 2.1, section 5.1.3.7, number 5 and appendix A5.1.3.7 (4) on page 72 "Decontamination room within the facility"). This decontamination room does not have a curtain for privacy, does not have two hand held shower heads with temperature controls, does not have portable or hard-piped oxygen or portable suction for this room and no evidence was provided that the water drainage system is a contained system to safely dispose of the used water to ensure that it does not enter into the hospital or community drainage systems.

3. The entrance of the emergency room was observed on 7/7/10 at 9:30 am and provided evidence that a designated temporary parking space located conveniently to the entrance is not provided to allow patients to be dropped off patients and take them into the emergency room according with the GDCHCF from the 2006 edition in chapter 2.1, section 5.1.3.2.

4. The emergency room was visited on 7/7/10 at 11:00 am with the facility's Engineer (employee #17) and provided evidence that the area designated for pediatric patients is located down a hallway away from the nursing station. Pediatric observation areas in the emergency room shall be located where there is visual control by the nursing station and where traffic from visitors and other patients can be controlled.

5. During observations of the Ambulatory Procedure Department-Gastrostomy services area on 7/8/10 at 2:45 pm with the facility's Engineer (employee #17), it was found that Cidex-OPA is used to disinfect equipment. No evidence was found that this department has a spill kit in the event that Cidex-OPA spills on the floor and no evidence was found that they are following manufacturer's recommendations as stated in "Disinfectant /Container Disposal Information" related to neutralizing Cidex-OPA before disposal. "A minimum of 25 grams of glycine (free base) should be used to neutralize one gallon of Cidex OPA solution. The minimum recommended neutralization time is one hour. Discard residual solution into drain. Flush drain thoroughly with water".

6. The operating room department was visited on 7/7/10 from 1:50 pm till 3:50 pm with the facility's Engineer (employee #17) 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. Seven out of seven operating suites (#1 through #7) were found with large and small sharp containers directly on the floor.
c. Seven out of seven operating suites (#1 through #7) were found with trash basket for regular waste without lids.
d. Cidex OPA trays were found on a portable stand in the orthopedic storage room. Manufacturers' recommendations suggests 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.
e. Cidex OPA trays were found in operating suite #4 and in the orthopedic storage room on the top of carts with wheels. An operating room nurse (employee #14) was asked what he would do if the solution tipped over and fell on the floor and he stated on 7/7/10 at 2:10 pm that he would call to have maintenance personnel take care of it. A maintenance personnel (employee #15) was interviewed on 7/7/10 at 2:15 pm and she stated that she did not know what was in the blue container (it contained Cidex OPA) and she was not trained nor instructed in the procedures to follow if it fell to the floor. No evidence was found that the operating room department has a spill kit to deal with spills and no evidence was found that they are following manufacturer's recommendations related "Disinfectant /Container Disposal Information" related to neutralizing Cidex-OPA before disposal.
f. Five operating suites (suites #1 through #5) were found with mops and pails located outside of the suite doors. The pails were found with water and the mops placed in them and after cleaning suite #5 the dirty mop water was not observed changed.
g. The housekeeping closet was found without a door closer and the door did not latch.
h. The biohazardous waste storage closet was found without a door closer, air extractor and the door did not latch. Also, a large trash container was full and two bags of biohazardous waste was found on the floor and one bag was found on the top of the trash container.
i. Operating suites #6 and #7 were visited and were observed equipped with central air conditioner vents and each suite had a return. According with "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) (2006 edition) chapter 2.1, Appendix A10.2.2.4: The system should have a single directional flow regime, with both high and low exhaust locations, 20 to 25 air changes per hour and turbulence and air movement shall be considered to minimize the fall of particulates on sterile surfaces. Also, consideration should be made to meet minimum requirements from the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) (2001 edition) 9.31.D4 which states "Return air shall be near the floor level and each operating and delivery room shall have at least two return-air inlets located as remotely from each other as practical".
j. Operating suites #6 and #7 provided evidence that wall finishes are not monolithic. The walls are painted with a common household "flat" paint. The porous nature of flat paint will not allow for proper cleaning and disinfection during the terminal cleaning of the operating suites. No evidence was provided that the walls were treated with specifically approved operating suite products to ensure that they are appropriately sealed and can be cleaned with chemicals as required for operating suites.
k. The housekeeping closet located near operating suites #6 and #7 was visited and provided evidence that it does not have a floor receptors (floor sink). A service sink was found at approximately three feet from the floor, which increases the risk of staff hurting themselves when lifting pails filled with dirty water and splashing. Please refer to minimum requirements from "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) (2001 edition) Section 9.5.F5 (The following services shall be provided in surgical service area) paragraph (m).
a. A mop hanger is also needed at this closet to ensure proper drying (usually placed over the floor receptor).

7. The morgue was visited on 7/8/10 at 11:00 am with the facility's Engineer (employee #17) and provided evidence that it does not have housekeeping facilities to ensure that spills can be cleaned appropriately and that the area is cleaned after used.

8. The kitchen was visited on 7/8/10 at 11:10 am with the facility's Engineer (employee #17) and provided evidence that a large electric floor mixer is located near a frequently used passageway. The mixer was on at full speed and provided evidence that it does not have a protective cover over the large mixing bowl to prevent accidentally latching on to aprons or clothes as personnel pass the mixer.

9. The kitchen was visited on 7/8/10 at 11:10 am with the facility's Engineer (employee #17) and provided evidence that there is a housekeeping closet located near the back exit door. However, this closet does not comply with minimum requirements related to separation by a physically solid door (separation is by a metal door with holes in it), a floor sink, door closer, extractor and smoke detector. This closet was observed with cleaning chemicals and also containers of paint. Also, the area used to wash patient's trays was found on 7/8/10 at 11:20 am with a housekeeping closet, but it needs a door closer.

10. The bathroom located near the physical therapy department was visited on 7/9/10 at 9:00 am and provided evidence that grab bars are needed behind and at one side of the toilet, the toilet seat needs to be between 17 and 19 inches in height and the door does not have a universal handicapped sign, all of which does not comply with Americans with Disabilities Act (ADA).

11. The acute dialysis room was visited on 7/8/10 at 10:00 am and provided evidence that two patients were lying in their beds receiving dialysis treatment. The patient's beds were separated by less than four feet and the beds were pushed up against the wall and little space was left to provide emergency medical care in the event of an emergency (a minimum of 80 square feet is required for each patient). The room was also observed with boxes of materials used for treatment directly on the floor (a storage closet is needed to ensure that materials are not on the floor to reduce environmental dust and dirt.

12. No evidence was found on 7/9/10 at 11:30 am of routine and preventive maintenance and testing activities incorporated into the hospital's Quality Assessment Performance Improvement program. Also, no evidence was found that representatives of the physical environment and life safety are attending committee meetings.

13. The physical therapy department was visited on 7/9/10 at 9:00 am and provided evidence that a privacy curtain is needed for the bed mat in the event that the front door is opened when a patient is exercising on the mat.

Based on the observations tour with the infection control officer and interviews, it was determined that the facility failed to promote a sanitary and safe care through its infection control program in the emergency room, medicine intensive care unit, delivery room department, physical therapy room and nursery 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 emergency room on 7/7/10 from 9:30 am till 4:00 pm related to infection control procedures:

a. All regular trash containers in the emergency room (patient's cubicles and treatment area)were observed on 7/7/10 from 10:45 am till 4:30 pm and provided evidence that they do not have lids. Self closing (foot pedal) garbage containers are needed to ensure that personnel do not have to touch the lids when opening and trash located in the container is separated for the environment.

b. Two large plastic bags of biohazardous trash and dirty linen were found over the hamper and a bag was observed near the paper dispenser in the dirty utility room on 7/7/10 at 10:30 am.

c. A food tray was found over the biohazardous trash container in isolation room (cubicle #14) on 7/7/10 at 11:35 am.

d. One bottle of normal saline and one bottle of sterile water for irrigation were observed on the top of a table in cubicle #16 without the date and hour when opened. The licensed practical nurse (LPN) (employee #28) stated on 7/7/10 at 11:10 am that the solutions are used to suction and irrigate nasogastric tubes, however the bottles do not specify the use of each bottle. The manufacturer's specification states to "discard unused portion" of normal saline and sterile water after opened.

e. Two plastic bags with respiratory equipment were observed in cubicle #4 and #16
without a label with the date and time when started. The ER supervisor (employee #5) stated on 7/7/10 at 11:20 that respiratory therapy equipment are changed every 24 hours according with respiratory therapy policies and procedures.

f. During the observational tour of the emergency room on 7/7/10 at 11:30 am, a respiratory staff member (employee #29) was observed removing respiratory therapy equipment after administering respiratory therapy to the patients in cubicles #4 and #16. Employee #29 cleaned the respiratory therapy equipment from the patient in cubicle #16 and put it into a plastic bag with the resident's name, removed her gloves and deposited them in the regular trash container. She then changed her gloves (she took them from her lab coat pocket) and without washing her hands she repeated the same procedure for the patient in cubicle #4.

2. The following was observed in the medicine intensive care unit (MICU) on 7/8/10 from 10:30 am till 11:00 am related to infection control procedures:

a. During the observational tour of the dirty utility room on 7/8/10 at 10:30 am, it was observed that this room is used to store clean and dirty equipment (Warm Touch machine) and maintenance equipment (mops, broom and dust pan). Also the biohazardous trash was observed with regular trash and did not have a lid.

b. One gallon of 70% alcohol was observed over the counter near the nursing station. The nursing supervisor (employee #30) stated on 7/8/10 at 10:40 am that alcohol is used to clean the thermometer and counters.

3. The following was observed in the delivery room department (DLP) on 7/8/10 from 11:10 am till 11:30 am related to infection control procedures:

a. During observations of the DRL on 7/8/10 at 11:15 am the Registered Nurse (employee #1) was observed walking in a common non-restricted hallway with her scrubs on. According to Policies and Procedures (P/P) reviewed on 7/8/10 at 11:20 am personnel can not walk in these hallway with using a protective gown over the scrubs.

b. The doors of the delivery room were observed in the open position on 7/8/10 at 11:30 am. P/P reviewed on 7/7/10 at 11:35 am states that these doors are to remain in the closed position at all times.

4. The following was observed in the nursery department on 7/8/10 from 11:45 am till 12:10 pm related to infection control procedures:

a. One gallon of 70% alcohol was observed over the counter near the nursing station. The nursing supervisor (employee #2) stated on 7/8/10 at 11:50 am that alcohol is used to clean equipment and counters.

b. A small sharp container was observed open over the nursing counter without a security base on 7/8/10 at 11:55 am.


15884


5. A mechanism to ensure that procedures to prepare equipment to give whirlpool therapy to patients follows accepted standards of practice in order to prevent cross contamination was not promoted as determined on 7/8/10 at 1:15 pm:

a. Two whirlpool tanks used to give treatment to patients were observed store on the first floor due to the lack of space in the physical therapy area as observed on 7/8/10 at 1:47 pm. Accordingly with information given by the physical therapy director (employee #26) on 7/8/10 at 2:00 pm, the tanks are prepared in this area with two thirds full of water, the water temperature is set at 96 ?F to 105?F. Then personnel add disinfectant when treating an open or infected lesion. Once the tank is prepared it is moved through the hospital to the patient's room to give the treatment. When the treatment is finished the tank is moved through the hospital to the area where the tanks are stored. Personnel empty, clean and disinfect the tanks. This procedure does no limit the possibility of cross contamination due to the movement and management of the tank through the hospital to patient's rooms. Temperature and disinfection of the tank procedure were not documented or registered by personnel who manage the equipment in order to ensure that facility policies of management and disinfection of the tanks are performed according with accepted standards of practice.

Based on review of clinical records and policies/procedures and interview with the director of Social Worker (employee #11), 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.

Findings included:

1. During interview with the social worker director (employee #11) on 7/8/10 from 1:30 pm related to discharge planning process she state that she performed discharge planning to all patient over 60 years old in a period of 24 and 48 hour of admission or when a discharge need is identified. Their priority was this patient. The rest of the patient from private medical insurance she evaluates them as per consult. The re assessment is to be performed every 24 to 48 hour or as needed. Related to the quality program she state that she is collecting and reporting to the Quality Assurance Program Statistical report of admitted patient, how many are Medicare and other insurance plan. How many patients were interview and separated for interventions.

2. The facility policy and procedure related to Discharge planning needs reviewed on 7/8/10 at 1:45 pm state that the Social Worker Department checks the admitted patient's census every day and the cases are distributed to the social workers in order for them to conduct the initial interview.

3. The facility policy and procedure related to the initial evaluation and reassessment for discharge planning was reviewed on 7/8/10 at 1:50 pm and state that the social worker performed an evaluation on the first 48 hours of the admission and the patient will be re-evaluated during the hospitalization and when necessary. Every patient referred to social work, received the services of evaluation in the first 24 hours of the admission. However 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.

4. The facility failed to establish a mechanism of screening according to the risk criteria. The Discharge planning services failed to surveillance the issues which need to be assess 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.

Based on six medical record review (R.R) for discharge planning, policies and procedure and interviews with the social worker director (employee #11), it was found that the facility failed to ensure that discharge planning evaluations are performed during the first 48 hours for four out of six record review (R.R #26, #28, #29 and #60 )

Findings include:

1. On 7/8/10 at 2:30 pm the facility failed to establish a list of criteria and place a mechanism to screen all cases admitted at the facility to identify them during the admission process and which cases have psycho-social problems and require discharge planning interventions according to patients needs.

2. The facility policy and procedure related initial evaluation and reassessment to discharge planning reviewed on 7/8/10 at 1:50 pm state that the social worker performed an evaluation on the first 48 hours of the admission and the patient is to be re-evaluated during the hospitalization and when necessary. Every patient referred to social work, received the services of evaluation in the first 24 hours of the admission.

3. Four out six records reviewed (R.R #26, #28, #29 and #60) provide evidence that the discharge planning personnel- social worker performed the initial evaluations and discharge planning evaluations after 48 hour of admission as reviewed on 7/8/10 from 2:30 pm till 4:00 pm with the social worker director (employee #11) and the patient social workers (employee #12 and #13):

a. R.R #26 is a 80 years old female who was admitted on 7/2/10 with Acute Gastroenteritis, severe dehydratation, Renal Failure and Diabetes Mellitus as reviewed on 7/8/10 at 2:35 pm with the social workers (employee #12 and #13). As evidence provided, the patient was admitted to the emergency room admission area then was brought to ward on 7/5/10 at 5:00 am. The nursing discharge planning evaluation on 7/5/10 state that the patient was suitable to auto care. However the social worker performed the discharge planning initial assessment to identify the patients' social needs on 7/8/10.

b. R.R #28 is an 82 years old male who was admitted on 7/3/10 with Symptomathic Bradicardia Hypotension, Left pleural effusion and End Stage Renal Decease as reviewed on 7/8/10 at 2:50 pm with the social worker (employee #12 and #13). Evidence was found that he nurse performed a discharge planning evaluation on 7/3/10 and state that the patient was suitable to auto care. However the social worker performed the discharge planning initial assessment to identify the patients' social needs on 7/7/10 and the patient was referred to homemaker services on the community and need ambulance when discharge home.

c. R.R #29 is a 53 years old male who was admitted on 6/12/10 with Human Immunodeficiency Virus (HIV positive), Hepatitis C, Thrombocytopenia, Septic Shock, Respiratory Failure, as reviewed on 7/8/10 at 3:10 pm with the social workers (employee #12 and #13). No evidence was found that the nurse performed a discharge planning evaluation on the admission; the discharge planning assessment was left in blank in the nursing initial patient assessment. However the social worker performed the discharge planning initial assessment to identify the patients' social needs on 7/1/10 after the physician refer the patient for discharge planning evaluation and identified home care services needs. On 7/2/10 the home care services was coordinated by the social worker. On 7/8/10 the patient was hospitalized and due to clinical complication and the discharge was postpone. This according to the patient social worker (employee #13) interviewed on 7/8/10 3:15 pm.

d. R.R #60 is a 91 years old female who was admitted on 7/5/10 with Acute Bronchitis and Pneumonia as reviewed on 7/8/10 at 2:15 pm with the social worker (employee #12 and #13). No evidence was found that the nurse performed a discharge planning evaluation on the admission; the discharge planning assessment was left in blank in the nursing initial patient assessment performed on 7/5/10. However the social worker performed the discharge planning initial assessment to identify the patients' social needs on 7/8/10 and refer that the patient do not have discharge planning needs at the moment.

Based on the review of policies and procedures and six medical records with the social worker director (employee #11), 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.

Findings include:

Policies and procedures were reviewed on 7/8/08 at 1:30 p.m. and provided evidence that they do not address the time frame that reassessments are to be performed. The policies and procedure reviewed state that "the needs were re-evaluated up to the moment of the discharge".

Based on the review of documents and policies/procedures, it was determined that the facility failed to ensure that its discharge planning process is reassessed on an on-going basis.

Findings include:

1. Discharge planning services is collecting and reporting to the Quality Assurance Program Statistical Reports instead of reports that include the surveillance of issues which need to be assess to ensure the quality of care offered to patients. Reports submitted by services on year 2010 were reviewed with the quality assurance officer (employee #3) on 7/91/0 at 1:43 pm. 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.

2. No evidence was found on 7/9/10 at 1:450 pm of an ongoing mechanism to reassess its discharge planning process.

Based on observations made of the surgical department, interview and review of policies/procedures with the Operating Room Manager (employee #19), it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice and patients' care.

Findings include:

1. Observations made of the surgical department on 7/7/10 from 9:30 am till 4:00 pm provided the following evidence:

a. No delineation was observed on 7/7/10 at 9:30 am for employees to access sterile and non-sterile areas. The surgical facility is not divided into three designated areas: unrestricted, semirestricted and restricted. No signs were provided at all entrances to the restricted areas that clearly indicates the surgical attire required.
b. It is required by local law to comply with the guidelines for Design and Construction of Hospital and Health Care Facilities. These guidelines on table 7.2 (ventilation requirements for areas affecting patient care in hospitals and outpatient facilities) requires that the relative humidity must be kept between 30-60 % and temperature of 68-73?F in the operating suites, the following relative humidity were measured on 7/7/10: in suite #5 the temperature registered 64?F at 9:40 am, in suite #4 the temperature registered 64.6?F at 9:55 am, in suite #3 the temperature registered 59.8?F at 10:40 am, in suite #2 the temperature registered 62.1?F at 11:10 am, suite #5 the temperature registered 59.9?F at 11:50 am and suite #1 the relative humidity registered 62.2?F at 11:50 am.
c. No evidence was found on 7/7/10 at 2:40 pm of the daily and weekly terminal cleaning for the operating suites.
d. The housekeeping maintenance room was observed on 7/7/10 at 10:00 am with five mops and five pails without identification labels.
e. Cidex OPA trays were found on a portable stand in operating suite #1 and #7. Manufacturers' recommendations suggests 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.

2. Mechanisms were not developed to ensure that infection control practices are followed as reviewed on 7/7/10 from 9:30 am till 4:00 pm to properly maintain a sanitary environment as evidenced by the following:

a. In operating suite #5 the following was observed on 7/7/10 at 9:55 am:
i. One sharp container directly on the floor without a security rack.
ii. Nine Spinal Anesthesia Trays, twenty tracheal tubes, four packages of blue pads, four blankets, two piggy bags of .9% Sodium Chloride 1000 ml and one gallon imitation vinegar on a table exposed to the environment.

b. In operating suite #5 the following was observed on 7/7/10 at 10:15 am:
i. Ten Spinal Anesthesia Trays, twenty-five tracheal tubes, ten midlength secondary I.V sets and eight piggy bags of Lactated Ringer 1000 ml on a table exposed to the environment.
ii. I.V Stand with rust.

c. In the corridor between operating suite #5 and #4, the following was observed on 7/7/10 at 10:20 am:
i. sixteen blankets, rolls of red, blue and black plastic garbage bags, hand paper, two boxes of vinyl gloves and two containers with fullsan II on a table exposed to the environment.

d. In operating suite #3 the following was observed on 7/7/10 at 10:30 am:
i. Eight Spinal Anesthesia Trays, three boxes of tracheal tubes, four piggy bags of .9% Sodium Chloride 1000 ml and seven piggy bags of Lactated Ringer 1000 ml on a table exposed to the environment.

e. In the central supply area the following was observed on 7/7/10 at 10:50 am:
i. The door was found opened.
ii. No evidence was found of the relative humidity and temperature log.

f. In operating suite #2 the following was observed on 7/7/10 at 11:20 am:
i. Eight Spinal Anesthesia Trays, two boxes of tracheal tubes, piggy bags of .9% Sodium Chloride 1000 ml and six piggy bags of Lactated Ringer 1000 ml on a table exposed to the environment.

g. In operating suite #1 the following was observed on 7/7/10 at 11:20 am:
i. Eight Spinal Anesthesia Trays, gauze, seventeen boxes of sutures on a table exposed to the environment.
ii. One sharp container directly on the floor without a security rack.
iii. Two chairs were found with broken vinyl which does not allow for proper cleaning.

h. The house keeping room was observed on 7/7/10 from 11:50 am:
i. Three rolls of toilet paper without protective covers.
ii. Nine 2.5 gallons of Fullsan II.
iii. The floor was very dirty.

i. The biohazardous trash storage room was visited on 7/7/10 at 1:10 pm and was found with one open trash containers and eight plastic bags directly on the floor.

j. In operating suite #6 the following was observed on 7/7/10 at 1:20 pm:
i. One chair was found with broken vinyl which does not allow for proper cleaning.

k. In operating suite #7 the following was observed on 7/7/10 at 1:20 pm:
i. Two sharp containers directly on the floor without a security rack.
ii. One arm board was found with broken vinyl which does not allow for proper cleaning.

Based on the review of seven medical records and policies/procedures of the operating room with the Operating Room Manager (employee #19), it was determined that the facility failed to execute complete surgery informed consents that includes the name of the surgeon who obtained the patient's informed consent for seven out of seven records reviewed (R.R #31,
#32, #33, #34, #35, #36 and #37).

Findings include:

During the review of seven medical records on 7/8/10 from 9:40 am till 10:30 am the surgery consent form did not provide space to write the name of the surgeon who obtain the patient's informed consent (R.R #31, #32, #33, #34, #35, #36 and #37).

Based on documents reviewed with the Operating Room Manager (employee #19), it was determined that the facility failed to ensure that the operating room log registry is complete.

Findings include:

A surgery registration log book and recovery room registration log book were observed on 7/7/10 at 11:00 am with incomplete spaces and left in blank, number of record, name of surgeon, surgical nurse, diagnostics post-operative and number of record.

Based on the review of seven medical records to evaluate anesthesia services with the Operating Room Manager (employee #19), it was determined that the facility failed to ensure that informed consent forms are properly executed for one out of seven records reviewed (R.R #34).

Findings include:

1. During the review of seven medical records on 7/8/10 from 9:40 am till 10:30 am the anesthesia consent form did not provide space to write the hour that the consent was taken.

a. One out of seven medical record were incomplete due to the lack of the signature taken (R.R #34).

Based on twelve medical records reviewed (R.R), policies/procedures manual and the observational tour with the emergency room (E.R) nursing supervisor (employee #5) on 7/7/10 from 9:30 am till 4:00 pm and on 7/9/10 from 2:00 pm till 3:30 pm, it was determined that the facility failed to have signs posted at the entrance (ambulatory/ambulance) and treatment area for the notification of the rights of the individuals who enter the E.R, emergency room personnel do not have a plan or assignments for all specific tasks in the event of an emergency, the emergency room failed to follow infection control standards to prevent cross contamination, the facility failed to ensure that triage screening and categorization are performed according to the patient's needs as they arrive at the ER and failed to ensure that treatment orders are carried out within a reasonable time frame, emergency room personnel are not reassessing patient's pain levels after the initial assessment and physician's risks for transfer was unexpected events, instead of a risk related to the health conditions. All of the above findings makes this condition "Not Met".

Based on twelve medical records reviewed (R.R), policies/procedures manual and the observational tour with the emergency room (E.R) nursing supervisor (employee #5) and interview, it was determined that the facility failed to have signs posted at the entrance (ambulatory/ambulance) and treatment area for the notification of the rights of the individuals who enter the E.R, emergency room personnel do not have a plan or assignments for all specific tasks in the event of an emergency, the emergency room failed to follow infection control standards to prevent cross contamination, the facility failed to ensure that triage screening and categorization are performed according to the patient's needs as they arrive at the ER and failed to ensure that treatment orders are carried out within a reasonable time frame, emergency room personnel are not reassessing patient's pain levels after the initial assessment and physician's risks for transfer was unexpected events, instead of a risk related to the health conditions.

Findings include:

1. The following was observed related to the review of the policies/procedures manual and observations of the emergency department on 7/7/10 from 9:30 am till 4:00 pm:

a. 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 7/7/10 at 9:35 am.

b. No evidence was found on 7/7/10 at 11:00 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.

2. During the Emergency Room (ER) visit on 7/7/10 at 9:40 am the waiting room was found full of patients and a sign-in sheet was found near the triage entrance. This sign-in sheet is used by patients to register their visit related to the order in which they arrived and the hour as stated by the ER supervisor (employee #5). Some of these patients were called to ask when they arrived and why they came to the ER and the following was determined:

a. R.R #1 is a 25 years old female who visited the emergency room on 7/7/10 at 9:25 am with Gastroenteritis with Intrauterine Pregnancy (IUP) of 10 weeks. The patient was observed sitting in the waiting room leaning on her husband. Her husband stated on 7/7/10 at 9:50 am that she has been vomiting, had abdominal pain during the night and she is pregnant and she was not triaged. The patient was taken into the triage room after her condition was identified and triage was performed at 10:15 am and the patient was categorized as "semi-urgent". The record was reviewed on 7/7/10 at 3:30 pm and provided evidence that the ER physician evaluates the patient related to Gastroenteritis and IUP of 10 weeks and ordered treatment at 11:45 am. It is not until 2:46 pm that an ER registered nurse takes the order and administers treatment. The facility failed to ensure that triage screening and categorization are performed according to the patient's needs as they arrive at the ER and failed to ensure that treatment orders are carried out within a reasonable time frame.

b. R.R #2 is a 76 years old male who visited the emergency room on 7/7/10 with Left Foot Cellulitis, Left Leg Cellulitis/Ulcer and Bronchial Asthma. The patient was observed in the observation area with intravenous fluids and an empty piggy bag with Zosyn that was started on 7/7/10 at 3:00 am. The patient stated on 7/7/10 at 10:30 am that he has leg pain and was waiting for the physician to admit him. During interview with the Nursing Supervisor (employee #5) on 7/7/10 at 10:40 am, she stated that the morning dose of Zosyn (9:00 am) was not administered because the pharmacy department did not make it available at the ER. The record was reviewed on 7/7/10 at 3:30 pm and provided evidence that the patient was triaged at 12:35 am and was classified "semi-urgent". The laboratory results from the emergency room services provided evidence that the patient's hemoglobin was: 13.4 mg/ml, 16,600 white blood cell and Blood Sugar 148 mg/dl. The patient was evaluated by the emergency room physician on 7/7/10 at 2:24 am with the principal diagnosis of left leg cellulitis, was ordered Zozyn 3.375 every 6 hours and was consulted for an internal medicine physician on 7/7/10. The patient was admitted on 7/7/10 at 1:40 pm with diagnosis of Left Leg Cellulitis/Ulcer and ordered Zosyn 3.375 gm every six hours. The dose of Zosyn was administered by ER nursing staff on 7/7/10 at 3:00 pm (12 hours later). The facility failed to ensure the continuation of treatment and failed to ensure that treatment orders are carried out within a reasonable time frame.

c. R.R #3 is a 79 years old female who visited the emergency room on 7/7/10 at 9:15 am with abdominal pain. The patient was observed sitting in the waiting room and she stated on 7/7/10 at 10:15 am that she had pain during the night and the patient was not triaged. The patient was taken to the triage room after her condition was identified and triaged at 10:10 am and categorized as "semi-urgent". The record was reviewed on 7/7/10 at 2:45 pm and provided evidence that the ER physician evaluates the patient related to Diverticulosis and Abdominal Pain and orders treatment at 11:15 am. It is not until 2:00 pm that an ER registered nurse takes the order for Tigan 200 mg intramuscular, however at 2:45 pm the ER registered nurse took the order but did not administer the treatment for: Protonix 40mg IV, Flagyl 500 mg IV, N/S .456 to run at 110 ml per hour and Abdominal CT. The facility failed to ensure that triage screening and categorization are performed according to the patient's needs as they arrive at the ER and failed to ensure that treatment orders are carried out within a reasonable time frame.

d. R.R #6 is a 31 years old female who visited the emergency room on 7/7/10 at 9:10 am with Fever and Vomits. The patient was observed sitting in the waiting room accompanied by her mother. She stated on 7/7/10 at 10:20 am that she was vomiting and had fever and abdominal pain last night and the patient was not triaged. The patient was taken to the triage room after her condition was identified and triage at 10:07 am and categorized as "semi-urgent" with a temperature of 39.7 ?C. The record was reviewed on 7/7/10 at 2:50 pm and provided evidence that the ER physician evaluates the patient related to Viral Syndrome/Dengue and orders treatment at 11:15 am. It is not until 3:00 pm that an ER registered nurse takes the order and administers treatment. The facility failed to ensure that triage screening and categorization are performed according to the patient's needs as they arrive at the ER and failed to ensure that treatment orders are carried out within a reasonable time frame.

e. R.R #7 is an 83 years old male who visited the emergency room on 7/7/10 with dehydration. The patient was observed leaning back in his wheelchair with his eyes closed, mouth open and non-responsive. The caregiver stated on 7/7/10 at 9:55 am that she called his attending physician but the physician has not arrived yet and the patient was not triaged. The patient was taken to the triage room after his condition was identified and triaged at 10:05 am and categorized as "urgent". The record was reviewed on 7/7/10 at 2:30 pm and provided evidence that the ER physician evaluates the patient related to Severe Dehydration and Sepsis, consulted with an internal medicine physician and ordered treatment at 11:00 am. It is not until 1:00 pm that an ER registered nurse takes the order and administers treatment. The facility failed to ensure that triage screening and categorization are performed according to the patient's needs as they arrive at the ER and failed to ensure that treatment orders are carried out within a reasonable time frame.

3. No evidence was found on 7/7/10 from 1:30 pm till 4:00 pm that emergency room personnel are reassessing patient's pain levels after the initial assessment or duration of pain management for patients' seen at the triage area of the emergency room for eight out of twelve records reviewed (R.R #1, #2, #3, #5, #6, #7, #10 and #11).

4. Two out of five closed clinical records were reviewed for transfer procedures on 7/9/10 from 2:00 pm till 3:30 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 health condition (R.R #8 and #11). R.R #8 provided evidence that the physician documented the same vital signs, that the nurse took during the triage process, at the moment of the transfer to another facility. R.R #10 provided evidence that the physician did not document vital signs at the moment of the transfer and no evidence was found of the physician's documentation of the condition at the moment of the transfer for RR #9 and #11. The patients were evaluated and stabilized with diagnosis of Acute Testicular Pain, Right Supracondylar Fracture and Ureterallithiasis after the initial evaluation of the emergency room visit.

5. The following was observed in the emergency room on 7/7/10 from 9:30 am till 4:00 pm related to infection control procedures:

a. All regular trash containers in the emergency room (patient's cubicles and treatment area)were observed on 7/7/10 from 10:45 am till 4:30 pm and provided evidence that they do not have lids. Self closing (foot pedal) garbage containers are needed to ensure that personnel do not have to touch the lids when opening and trash located in the container is separated for the environment.

b. Two large plastic bags of biohazardous trash and dirty linen were found over the hamper and a bag was observed near the paper dispenser in the dirty utility room on 7/7/10 at 10:30 am.

c. A food tray was found over the biohazardous trash container in isolation room (cubicle
#14) on 7/7/10 at 11:35 am.

d. One bottle of normal saline and one bottle of sterile water for irrigation were observed on the top of a table in cubicle #16 without the date and hour when opened. The licensed practical nurse (LPN) (employee #28) stated on 7/7/10 at 11:10 am that the solutions are used to suction and irrigate nasogastric tubes, however the bottles do not specify the use of each bottle. The manufacturer's specification states to "discard unused portion" of normal saline and sterile water after opened.

e. Two plastic bags with respiratory equipment were observed in cubicle #4 and #16
without a label with the date and time when started. The ER supervisor (employee #5) stated on 7/7/10 at 11:20 that respiratory therapy equipment are changed every 24 hours according with respiratory therapy policies and procedures.

f. During the observational tour of the emergency room on 7/7/10 at 11:30 am, a respiratory therapy staff member (employee #29) was observed removing respiratory therapy equipment after administering respiratory therapy to the patients in cubicles #4 and #16. Employee #29 cleaned the respiratory therapy equipment from the patient in cubicle #16 and put it into a plastic bag with the resident's name, removed her gloves and deposited them in the regular trash container. She then changed her gloves (she took them from her lab coat pocket) and without washing her hands she repeated the same procedure for the patient in cubicle #4.

6. A cabinet used to store respiratory therapy equipment and blood gas kits located near isolation room #14 was found open and could be accessed by non authorized persons on
7/7/10 at 11:20 am.

Based on the observational tour, review of policies/procedures, six records reviewed (R.R) with the Physical Therapy Director (employee #26), it was determined that the facility failed to ensure that services are provided according to the scope of services offered to implement policies/procedures related to services, temperature and disinfection procedures, privacy of patient care area, no information of the percent of dilution and material safety data sheets not available for disinfectants used at this area

Findings include:

1. No evidence was found on 7/8/10 at 2:00 pm of the temperature registry for whirlpools when the equipment is used on patients.

2. The area where the exercise mattress is located lacks a curtain to provide privacy to a patient receiving therapy at the area on 7/8/10 at 2:15 pm.

3. Two containers with a label of "fullsan" disinfectant to be used to sanitize physical therapy equipment used in this area did not include information on the label of the percent of dilution of this chemical on 7/8/10 at 2:10 pm.

4. No Material Safety Data Sheets for "fullsan" disinfectant to be used to sanitize physical therapy equipment were found at this area on 7/8/10 at 2:12 pm.

5. Two whirlpool tanks used to give treatment to patients were observed store on the first floor due to the lack of space in the physical therapy area as observed on 7/8/10 at 1:47 pm. Accordingly with information given by the physical therapy director (employee #26) on 7/8/10 at 2:00 pm, the tanks are prepared in this area with two thirds full of water, the water temperature is set at 96 ?F to 105?F. Then personnel add disinfectant when treating an open or infected lesion. Once the tank is prepared it is moved through the hospital to the patient's room to give the treatment. When the treatment is finished the tank is moved through the hospital to the area where the tanks are stored. Personnel empty, clean and disinfect the tanks. This procedure does no limit the possibility of cross contamination due to the movement and management of the tank through the hospital to patient's rooms. Temperature and disinfection of the tank procedure were not documented or registered by personnel who manage the equipment in order to ensure that facility policies of management and disinfection of the tanks are performed according with accepted standards of practice.

Based on observations, the review of medical records, documents and the lack of policies and procedures on 7/8/10 from 9:00 am till 4:00 pm, it was determined that the facility failed to meet the needs of its patients in accordance with acceptable standards of practice, perform post-assessment, patient's assessment after respiratory therapy treatment, patient's estimated initial respiratory therapy treatments, in-services training for the department, sufficient personnel available, sign posting for those patients using oxygen, labeled with the date and hour when started on the equipment, acoustic wet in space used to disinfect, credential files and the respiratory therapy staff pattern.

Based on seven medical records reviewed (R.R), the lack of documents provided, the lack of policies/procedures, with the director of the Respiratory Therapy Department (employee #21), it was determined that the facility failed to ensure that the organization of the respiratory care services is appropriate to the scope and complexity of the services for seven out of seven clinical records reviewed (RR # 38, #39, #40, #41, #42, #43 and #44).

Findings include:

1. Evidence was found on 7/8/10 at 3:50 pm of in-service training for the year of 2010.The only one in-serves training offered in 2010 was in April, education on values panic.

2. Seven medical records were reviewed on 7/8/10 from 9:30 am till 3:40 pm of patients who received respiratory therapy and provided evidence of incomplete patient's assessment after respiratory therapy treatments for seven out seven (RR # 38, #39, #40, #41, #42, #43 and #44).
3. Evidence was provided by the Director of the Respiratory Therapy Department (Employee #21) on 7/08/10 at 1:40 pm of written policies for the respiratory assessment. However, evidence was found from review of the policies and procedure for the respiratory initial assessment that the policies do not indicate the time for the in initial assessment to be complete .
4. Seven medical records were reviewed on 7/8/10 from 9:30 am till 3:40 pm of patients who received respiratory therapy and provided evidence of incomplete initial assessment for one out seven records reviewed (RR # 40).

5. Seven medical records were reviewed on 7/8/10 from 9:30 am till 3:40 pm of patients who received respiratory therapy and provided evidence that respiratory therapists did not administer respiratory therapy treatment in accordance with physician orders for five records reviewed, R.R #39, #40, #41, 42 and #44. Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis:

a. R.R #39 is a 78 years old female admitted on 6/28/10 with a diagnosis of Chronic Obstructed Pulmonary Disease (COPD). The record review was performed on 7/8/10 at 10:30 am and provided evidence that the physician ordered at 1:20 pm Xopenex 1.25mg and Atrovent 02% every 4 hours. On 6/29/10 respiratory therapy was given at 12:13 am (eleven hour and 40 minutes late), the next therapy was given at 3:40 am, the next therapy was given at 7:30 am, the next therapy was given at 11:05 am, the next therapy was given at 5:30 pm (two hour and 30 minutes late), the next therapy was given at 9:30 pm. On 6/30/10 respiratory therapy was given at 1:40 am, the next therapy was given at 5:00 am (50 minutes before), the next therapy was given at 9:55 am (30 minutes late), the next therapy was given at 1:50 pm, the next therapy was given at 5:10 pm, the next therapy was given at 9:15 pm. On 7/01/10 respiratory therapy was given at 1:06 am, the next therapy was given at 4:34 am, the next therapy was given at 10:20 am, the next therapy was given at 11:45 pm (twelve hour and 45 minute late). As evidence incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

b. R.R #40 is a 97 years old male admitted on 7/6/10 with a diagnosis of Coumadin Intoxication and Hematuria. The record review was performed on 7/8/10 at 3:05 pm and provided evidence that the physician ordered respiratory therapy with Albuterol 0.3 cc and Atrovent every 6 hours by power nebulizer on 7/6/10 at 9:25 am. The nurse takes the order on 7/6/10 at 9:47 am and notifies the respiratory therapy department to provide the treatment. The assessment that was done by the respiratory therapist was incomplete on 7/6/10. The record review on 7/07/10 at 9:30 am provided evidence that the new physician order was for respiratory therapy power nebulizer with Proventyl .2 cc and 3 cc NSS every 6 hours. The nurse takes the order on 7/07/10 at 10:50 am and notifies the respiratory therapy department to provide treatment. The patient received respiratory therapy treatments at 12:12 am, the next therapies were given at 7:15 am, 12:55 pm with Albuterol 0.3 cc and Atrovent . The therapy was given at 7:10 pm with Albuterol 0.3 cc and Atrovent. On 7/8/10 therapy was given at 12:15 am with Albuterol 0.3 cc and Atrovent . The next therapy was given at 7:15 am with Albuterol 0.3 cc and Atrovent . The next therapy was given at 1:15 pm with Albuterol 0.3 cc and Atrovent . Evidence was found that the respiratory therapists did not perform the post-assessment. The patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and of incomplete patient's assessment for initial respiratory therapy treatments.

c. R.R #41 is a 68 years old female admitted on 7/3/10 with a diagnosis of Diverticulitis. The record review was performed on 7/8/10 at 3:25 pm and provided evidence that the physician ordered respiratory therapy power nebulizer with Atrovent and NSS every 4 hours on 7/6/10 at 7:00 pm. The patient received respiratory therapy treatments at 10:27 pm, the next therapy was given on 7/7/10at 2:23 am, the next therapy was given at 6:20 am, the next therapy was given 11:15 am (25 minutes later), the next therapy was given at 3:05 pm, the next therapy was given at 7:05 pm, the next therapy was given at 10:57 pm. , On 7/8/10 respiratory therapies were given to the patient at 2:36 am, 6:43 am and 11:00 am. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

d. R.R #42 is a 97 years old female admitted on 7/2/10 with a diagnosis of Urosepsis. The record review was performed on 7/8/10 at 3:40 pm and provided evidence that the physician ordered respiratory therapy with Albuterol 0.83 % and Atrovent 0.02% every 4 hours by power nebulizer on 7/2/10 at 5:00 pm. The patient received respiratory therapy treatments at 6:30 pm and 10:00 pm with Proventyl and NSS, the record revealed that the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs. The record review on 7/03/10 at 6:00 pm provided evidence that the new physician order was for respiratory therapy by power nebulizer with Atrovent .02% and 3 cc NSS every 6 hours. The nurse takes the order on 7/03/10 at 7:35 pm and notifies the respiratory therapy department to provide treatment. On 7/3/10 at 1:38 am, 5:32 am, 9:40 am, 11:05 am, 2:43 pm, 7:07 pm and 10:20 pm the record revealed that the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

e. R.R #44 is a 78 years old female admitted on 7/3/10 with a diagnosis of Bronchitis. The record review was performed on 7/8/10 at 10:10 am and provided evidence that the physician ordered respiratory therapy with Proventyl .3cc and NSS every 6 hours by power nebulizer on 7/3/10 at 10:40 am. The patient received respiratory therapy treatments at 1:50 pm and 7:48 pm. On 7/4/10 the patient received respiratory therapy treatments at 1:00 am, the next therapy was given at 7:40 am, and the next therapy was given at 6:20 pm (10 hours and 40 minutes later). On 7/5/10 the patient received respiratory therapy treatments at 12:00 am, the next therapy was given at 6:03 am, the next therapy was given at 9:30 am (2 hours and 30 minutes before), the next therapy was given at 3:55 pm, and the next therapy was given at 9:35 pm. On 7/6/10 the patient received respiratory therapy treatments at 4:03 am, the next therapy was given at 10:05 am, and the next therapy was given at 4:06 pm. On 7/7/10 the patient received respiratory therapy treatments at 12:59 am (9 hours later), the next therapy was given at 6:37 am, the next therapy was given at 12:53 pm, the next therapy was given at 6:48 pm. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

Based on the review of medical records, documents, policies/procedures and interview with the Director of the Respiratory Therapy Department (employee #21), it was determined that the facility failed to ensure that there an adequate number of respiratory therapists and other personnel to meet qualifications specified by the medical staff and consistent with State law.

Findings include:

1. During the survey of the respiratory therapy services on 7/8/10, the supervisor of the Respiratory Therapy Department (employee #21) she stated during an interview on 7/8/10 at 3:00 pm that she provides perdiem shifts in order to have three employees on each shift.
2. The facility does not have sufficient personnel available to respond to respiratory care needs of its patient's population as reviewed on 7/8/10 at 3:20 pm. Review of the July monthly treatment of respiratory therapy services. The treatments offered by the respiratory therapy staff during July 1 to 8, 2010 are postural drainage, hand nebulizer, suction, oxygen patients, arterial blood gas (ABG), measurement of peak flow, pulmonary function test (PFT), incentive spirometry ( IS), cardio pulmonary resuscitation (CPR) and patient in ventilator.
3. Review of the July monthly program and treatment orders of respiratory therapy services with the director of the Respiratory Therapy Department (employee #21) on 7/8/10 at 3:25 pm provided evidence that on 7/1/10 for the 7-3, 3-11 and 11-7 shift three respiratory therapists for each shift was working for 311 treatment ordered by the physician per day. On 7/2/10 for the 7-3, 3-11 and 11-7 shift three respiratory therapists for each shift was working for 306 treatment ordered by the physician per day. On 7/3/10 for the 7-3 and 3-11 shift two respiratory therapists for each shift was working, 11-7 three respiratory therapists for each shift was working for 230 treatment ordered by the physician per day. On 7/4/10 for the 7-3 and 3-11 shift two respiratory therapists for each shift was working, 11-7 three respiratory therapists for each shift was working for 251 treatment ordered by the physician per day. On 7/5/10 for the 7-3, 3-11 and 11-7shift three respiratory therapists for each shift was working for 336 treatment ordered by the physician per day. On 7/6/10 for the 7-3, 3-11 and 11-7 shift three respiratory therapists for each shift was working for 330 treatment ordered by the physician per day. On 7/7/10 for the 7-3, 3-11 and 3-11 shift three respiratory therapists for each shift was working for 330 treatment ordered by the physician per day. On 7/8/10 for the 7-3, 3-11 and 11-7 shift three respiratory therapists for each shift was working for 336 treatment ordered by the physician per day.
4. The facility does not have sufficient personnel available to respond to the respiratory care needs of its patient population as determined on 7/8/10 at 4:00 pm. Seven medical records were reviewed on 7/8/10 from 9:30 am till 3:30 pm and provided evidence that patients are receiving respiratory therapy services but they did not receive respiratory therapies in accordance with the physicians' orders and their respiratory needs for five out of seven (#39, #40, #41, 42 and #44).

5. Seven medical records were reviewed on 7/8/10 from 9:30 am till 3:40 pm of patients who received respiratory therapy and provided evidence that respiratory therapist did not administer respiratory therapy treatment in accordance with physician orders for R.R #39, #40, #41, 42 and #44. Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis:

a. R.R #39 is a 78 years old female admitted on 6/28/10 with a diagnosis of Chronic Obstructed Pulmonary Disease (COPD). The record review was performed on 7/8/10 at 10:30 am and provided evidence that the physician ordered at 1:20 pm Xopenex 1.25mg and Atrovent 02% every 4 hours. On 6/29/10 respiratory therapy was given at 12:13 am (eleven hour and 40 minutes late), the next therapy was given at 3:40 am, the next therapy was given at 7:30 am, the next therapy was given at 11:05 am, the next therapy was given at 5:30 pm (two hour and 30 minutes late), the next therapy was given at 9:30 pm. On 6/30/10 respiratory therapy was given at 1:40 am, the next therapy was given at 5:00 am (50 minutes before), the next therapy was given at 9:55 am (30 minutes late), the next therapy was given at 1:50 pm, the next therapy was given at 5:10 pm, the next therapy was given at 9:15 pm. On 7/01/10 respiratory therapy was given at 1:06 am, the next therapy was given at 4:34 am, the next therapy was given at 10:20 am, and the next therapy was given at 11:45 pm (twelve hour and 45 minute late). As evidence incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

b. R.R #40 is a 97 years old male admitted on 7/6/10 with a diagnosis of Coumadin Intoxication and Hematuria. The record review was performed on 7/8/10 at 3:05 pm and provided evidence that the physician ordered respiratory therapy with Albuterol 0.3 cc and Atrovent every 6 hours by power nebulizer on 7/6/10 at 9:25 am. The nurse takes the order on 7/6/10 at 9:47 am and notifies the respiratory therapy department to provide the treatment. The assessment that was done by the respiratory therapist was incomplete on 7/6/10. The record review on 7/07/10 at 9:30 am provided evidence that the new physician order was for respiratory therapy power nebulizer with Proventyl .2 cc and 3 cc NSS every 6 hours. The nurse takes the order on 7/07/10 at 10:50 am and notifies the respiratory therapy department to provide treatment. The patient received respiratory therapy treatments at 12:12 am; the next therapies were given at 7:15 am, 12:55 pm with Albuterol 0.3 cc and Atrovent. The therapy was given at 7:10 pm with Albuterol 0.3 cc and Atrovent. On 7/8/10 therapy was given at 12:15 am with Albuterol 0.3 cc and Atrovent. The next therapy was given at 7:15 am with Albuterol 0.3 cc and Atrovent. The next therapy was given at 1:15 pm with Albuterol 0.3 cc and Atrovent. Evidence was found that the respiratory therapists did not perform the post-assessment. The patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and of incomplete patient's assessment for initial respiratory therapy treatments.

c. R.R #41 is a 68 years old female admitted on 7/3/10 with a diagnosis of Diverticulitis. The record review was performed on 7/8/10 at 3:25 pm and provided evidence that the physician ordered respiratory therapy power nebulizer with Atrovent and NSS every 4 hours on 7/6/10 at 7:00 pm. The patient received respiratory therapy treatments at 10:27 pm, the next therapy was given on 7/7/10at 2:23 am, the next therapy was given at 6:20 am, the next therapy was given 11:15 am (25 minutes later), the next therapy was given at 3:05 pm, the next therapy was given at 7:05 pm, the next therapy was given at 10:57 pm. , On 7/8/10 respiratory therapies were given to the patient at 2:36 am, 6:43 am and 11:00 am. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

d. R.R #42 is a 97 years old female admitted on 7/2/10 with a diagnosis of Urosepsis. The record review was performed on 7/8/10 at 3:40 pm and provided evidence that the physician ordered respiratory therapy with Albuterol 0.83 % and Atrovent 0.02% every 4 hours by power nebulizer on 7/2/10 at 5:00 pm. The patient received respiratory therapy treatments at 6:30 pm and 10:00 pm with Proventyl and NSS, the record revealed that the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs. The record review on 7/03/10 at 6:00 pm provided evidence that the new physician order was for respiratory therapy by power nebulizer with Atrovent .02% and 3 cc NSS every 6 hours. The nurse takes the order on 7/03/10 at 7:35 pm and notifies the respiratory therapy department to provide treatment. On 7/3/10 at 1:38 am, 5:32 am, 9:40 am, 11:05 am, 2:43 pm, 7:07 pm and 10:20 pm the record revealed that the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

e. R.R #44 is a 78 years old female admitted on 7/3/10 with a diagnosis of Bronchitis. The record review was performed on 7/8/10 at 10:10 am and provided evidence that the physician ordered respiratory therapy with Proventyl .3cc and NSS every 6 hours by power nebulizer on 7/3/10 at 10:40 am. The patient received respiratory therapy treatments at 1:50 pm and 7:48 pm. On 7/4/10 the patient received respiratory therapy treatments at 1:00 am, the next therapy was given at 7:40 am, and the next therapy was given at 6:20 pm (10 hours and 40 minutes later). On 7/5/10 the patient received respiratory therapy treatments at 12:00 am, the next therapy was given at 6:03 am, the next therapy was given at 9:30 am (2 hours and 30 minutes before), the next therapy was given at 3:55 pm, and the next therapy was given at 9:35 pm. On 7/6/10 the patient received respiratory therapy treatments at 4:03 am, the next therapy was given at 10:05 am, and the next therapy was given at 4:06 pm. On 7/7/10 the patient received respiratory therapy treatments at 12:59 am (9 hours later), the next therapy was given at 6:37 am, the next therapy was given at 12:53 pm, the next therapy was given at 6:48 pm. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

Based on the review of policies and procedures and observations with the supervisor of the Respiratory Therapy Department, it was determined that the facility failed to ensure that services are provided in accordance with acceptable standards of practice related to respiratory equipment not labeled with the date and hour when started on the equipment, evidence of sign posting for those patients using oxygen for twelve of twelve patients rooms visited (patient's rooms #265a, #265B, #267A, #269B, #253A, #459B, #460A, #461B, #464A, #464B, #472A and #472B).
and wet acoustic.

Findings include:

1. Evidence was provided from the Director of the Respiratory Therapy Department
(Employee #21) on 7/08/10 at 1:40 pm of written policies for the delivery of respiratory care services, developed and approved by the medical staff for the posting of signs and gas line identification.

2. During the observational tour with the Director of the Respiratory Therapy Department (employee #21) on 7/08/10 at 11:15 am in twelve out of twelve patient's rooms did not have evidence of sign posting for those patients using oxygen (patient's rooms #265a, #265B, #267A, #269B, #253A, #459B, #460A, #461B, #464A, #464B, #472A and #472B).

3. During the observational tour on 7/08/10 from 11:15 am till 12:00 pm with a Director of the Respiratory Therapy Department (Employee #21) of patient's sleeping rooms #120A, #127A, #128A and #128B visited and provided evidence that the patient's respiratory equipment were found in plastic bags on the patient's night tables. However, evidence was found of the respiratory equipment in plastic bags do not have the labeled with the date and hour when the equipment was started to use. Also, the facility must verify current guidelines related to respiratory equipment and the frequency of changes to ensure that they adhere to infection control standards.

4. The Respiratory Therapy Department was visited with the Director of the Respiratory Therapy Department (Employee #21) and the space used to disinfect was observed on 7/08/10 at 9:45 am. The area was observed with two acoustic wet.

Based on the review of fifteen respiratory therapists credential files (C.F) with the Director of the Respiratory Therapy Department (employee #21), it was determined that the facility failed to ensure that one out of fifteen respiratory therapists personnel meet the qualification specified and consistent with State laws related to certificate of health (C.F #9).

Findings include:

1. One out of fifteen respiratory therapists credential files reviewed on 7/09/10 at 9:20 am did not provide evidence of a health certificate (C.F #9).

Based on the review of seven medical records, policies/procedures and interviews, it was determined that the facility failed to ensure that the organization of respiratory therapy services is appropriate to the scope and complexity of the services provided for five out of seven clinical records reviewed (RR #39, #40, #41, 42 and #44).

Findings include:

1. The Respiratory Therapy Supervisor stated on 7/10/08 at 1:45 pm that the respiratory therapies are assigned and performed according with the therapy needs.

2. There is no written evidence of the respiratory therapy staff pattern to assure that the respiratory therapy staff meets the necessary needs of patients according with the type and amount of respiratory care.

3. The facility does not have a mechanism to assure when the respiratory orders are notify to the respiratory services.

4. Seven medical records were reviewed with Respiratory Therapy Supervisor from 7/10/08 at 1:40 pm still 4:00 pm of patients who received respiratory therapy and provided evidence that respiratory therapists did not administer respiratory therapy treatment in accordance with the physician 's order five out seven (RR#39, #40, #41, 42 and #44).

5. Seven medical records were reviewed on 7/8/10 from 9:30 am till 3:40 pm of patients who received respiratory therapy and provided evidence that respiratory therapist did not administer respiratory therapy treatment in accordance with physician orders for R.R #39, #40, #41, 42 and #44. Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis.

a. R.R #39 is a 78 years old female admitted on 6/28/10 with a diagnosis of Chronic Obstructed Pulmonary Disease (COPD). The record review was performed on 7/8/10 at 10:30 am and provided evidence that the physician ordered at 1:20 pm Xopenex 1.25mg and Atrovent 02% every 4 hours. On 6/29/10 respiratory therapy was given at 12:13 am (eleven hour and 40 minutes late), the next therapy was given at 3:40 am, the next therapy was given at 7:30 am, the next therapy was given at 11:05 am, the next therapy was given at 5:30 pm (two hour and 30 minutes late), the next therapy was given at 9:30 pm. On 6/30/10 respiratory therapy was given at 1:40 am, the next therapy was given at 5:00 am (50 minutes before), the next therapy was given at 9:55 am (30 minutes late), the next therapy was given at 1:50 pm, the next therapy was given at 5:10 pm, the next therapy was given at 9:15 pm. On 7/01/10 respiratory therapy was given at 1:06 am, the next therapy was given at 4:34 am, the next therapy was given at 10:20 am, and the next therapy was given at 11:45 pm (twelve hour and 45 minute late). As evidence incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

b. R.R #40 is a 97 years old male admitted on 7/6/10 with a diagnosis of Coumadin Intoxication and Hematuria. The record review was performed on 7/8/10 at 3:05 pm and provided evidence that the physician ordered respiratory therapy with Albuterol 0.3 cc and Atrovent every 6 hours by power nebulizer on 7/6/10 at 9:25 am. The nurse takes the order on 7/6/10 at 9:47 am and notifies the respiratory therapy department to provide the treatment. The assessment that was done by the respiratory therapist was incomplete on 7/6/10. The record review on 7/07/10 at 9:30 am provided evidence that the new physician order was for respiratory therapy power nebulizer with Proventyl .2 cc and 3 cc NSS every 6 hours. The nurse takes the order on 7/07/10 at 10:50 am and notifies the respiratory therapy department to provide treatment. The patient received respiratory therapy treatments at 12:12 am; the next therapies were given at 7:15 am, 12:55 pm with Albuterol 0.3 cc and Atrovent. The therapy was given at 7:10 pm with Albuterol 0.3 cc and Atrovent. On 7/8/10 therapy was given at 12:15 am with Albuterol 0.3 cc and Atrovent. The next therapy was given at 7:15 am with Albuterol 0.3 cc and Atrovent. The next therapy was given at 1:15 pm with Albuterol 0.3 cc and Atrovent. Evidence was found that the respiratory therapists did not perform the post-assessment. The patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and of incomplete patient's assessment for initial respiratory therapy treatments.

c. R.R #41 is a 68 years old female admitted on 7/3/10 with a diagnosis of Diverticulitis. The record review was performed on 7/8/10 at 3:25 pm and provided evidence that the physician ordered respiratory therapy power nebulizer with Atrovent and NSS every 4 hours on 7/6/10 at 7:00 pm. The patient received respiratory therapy treatments at 10:27 pm, the next therapy was given on 7/7/10at 2:23 am, the next therapy was given at 6:20 am, the next therapy was given 11:15 am (25 minutes later), the next therapy was given at 3:05 pm, the next therapy was given at 7:05 pm, the next therapy was given at 10:57 pm. , On 7/8/10 respiratory therapies were given to the patient at 2:36 am, 6:43 am and 11:00 am. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

d. R.R #42 is a 97 years old female admitted on 7/2/10 with a diagnosis of Urosepsis. The record review was performed on 7/8/10 at 3:40 pm and provided evidence that the physician ordered respiratory therapy with Albuterol 0.83 % and Atrovent 0.02% every 4 hours by power nebulizer on 7/2/10 at 5:00 pm. The patient received respiratory therapy treatments at 6:30 pm and 10:00 pm with Proventyl and NSS, the record revealed that the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs. The record review on 7/03/10 at 6:00 pm provided evidence that the new physician order was for respiratory therapy by power nebulizer with Atrovent .02% and 3 cc NSS every 6 hours. The nurse takes the order on 7/03/10 at 7:35 pm and notifies the respiratory therapy department to provide treatment. On 7/3/10 at 1:38 am, 5:32 am, 9:40 am, 11:05 am, 2:43 pm, 7:07 pm and 10:20 pm the record revealed that the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.

e. R.R #44 is a 78 years old female admitted on 7/3/10 with a diagnosis of Bronchitis. The record review was performed on 7/8/10 at 10:10 am and provided evidence that the physician ordered respiratory therapy with Proventyl .3cc and NSS every 6 hours by power nebulizer on 7/3/10 at 10:40 am. The patient received respiratory therapy treatments at 1:50 pm and 7:48 pm. On 7/4/10 the patient received respiratory therapy treatments at 1:00 am, the next therapy was given at 7:40 am, and the next therapy was given at 6:20 pm (10 hours and 40 minutes later). On 7/5/10 the patient received respiratory therapy treatments at 12:00 am, the next therapy was given at 6:03 am, the next therapy was given at 9:30 am (2 hours and 30 minutes before), the next therapy was given at 3:55 pm, and the next therapy was given at 9:35 pm. On 7/6/10 the patient received respiratory therapy treatments at 4:03 am, the next therapy was given at 10:05 am, and the next therapy was given at 4:06 pm. On 7/7/10 the patient received respiratory therapy treatments at 12:59 am (9 hours later), the next therapy was given at 6:37 am, the next therapy was given at 12:53 pm, the next therapy was given at 6:48 pm. Evidence was found of incomplete patient's assessment after respiratory therapy treatments and the patient did not receive respiratory therapies in accordance with the physician ' s order and the patient ' s respiratory needs.