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Based on the review of medical records, policies and procedures, documents, observations, tests and interviews from 2/24/15 through 2/27/15 from 8:00 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. The Governing Body failed to provide the necessary oversight and leadership as evidenced by the lack of compliance with: Patient Rights Condition (42 CFR 482.13), Medical Record Services Condition (42 CFR 482.24) which makes this condition not met: Governing Body (42 CFR 482.12). (Cross refer Tags A115 and A431)

Based on review of policies and procedures, interview with the Director of Nursing (employee # 1), Nursing Supervisor (employee # 7) and Nursing Coordinator of Intermediate Medicine (employee # 40) during the validation survey performed on 2/24/15 through 2/27/15 it was determined that facility failed to ensure promote each patient's rights to be free from unnecessary physical and chemical restraints, to receive care in a safe setting and to informed Medicare patients their right to appeal facility ' s discharge which makes this condition 482.13 Patient Rights Condition of Participation "Not Met". (Cross refer Tag A 0117, A0132, A 0144, A0159, A 0160, A0161, A 0166, A 0167, A 0168, A 0170 and A 0172).

7. RR # 39 is a 76 years old female patient admitted to the Medicine unit on 02/18/15 with a diagnose of Infected ulcer on left leg. During RR performed on 2/26/15 at 1:40 pm The Important Message from Medicare form was not in the clinical record. The Nursing Coordinator (employee # 40) obtains a copy from the patient and places it on the clinical record.

During interview with the Director of Utilization program (employee # 22) performed on 2/27/15 at 2:00 pm, she stated: "The importance notice is discussed to the patient while doing his/her admission process. The patient has to sign one form and a copy of it is given to him/her. Additional form is available in the clinical record to be signed 24-48 hours before patient's discharge at home".

a. However, the facility failed to establish an effective mechanism for tracking and monitoring the availability of this form in the clinical record. The facility failed to ensure that this form is discussed with the patient before his/her discharge home.


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Based on medical record reviewed, it was determined that the facility failed to provide Medicare recipients "An Important Message from Medicare" (IM) at the admission and two days before discharge to execute their rights to appeal facility ' s discharge, failed to sign, date, provide the two forms, or provide the second form and inform patients of the IM requirements for 7 out of 60 records reviewed (RR) (RR. #12, #13, #14, #16, #18, #19 and # 39).
Findings include:

1. R.R. #12 is an 83 years old male who is admitted on 07/29/14 with a diagnostic of Chronic Obstructive Pulmonary Disease (COPD) and Osteoarthritis. The record was review on 02/26/15 at 1:39 pm. The Important Message from Medicare was provided upon admission however the two days prior discharge Important Message from Medicare was not provide. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

2. RR # 13 is a 69 years old female who was admitted on 09/21/2014 with a diagnosis of Uremic Syndrome, Diabetes Mellitus, High Blood Pressure, Mayor Depressive disorder and End Stage Renal Disease. The record was reviewed on 02/26/2015 at 2:00 pm. The Important Message from Medicare was provided on 09/26/2014 however, The Important Message from Medicare was given 5 days after admission. The patient was discharge on 09/30/2104. The facility failed to provide the second IM two days in advance of patient According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

3. R.R. # 14 is an 86 years old male who is admitted to on 10/27/14 with a diagnosis of Acute Coronary Syndrome, High Blood Pressure, Diabetes Mellitus, Osteoarthritis and Coronary Artery Disease. The first Important Message from Medicare was provided upon admission as observed during the R.R. on 2/26//2014 at 3:50 pm. The patient was discharge on 11/06/2014. The facility failed to provide the second IM two days in advance of patient According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

4. R.R. # 16 is a 66 years old female who is admitted on 10/27/14 with a diagnosis of Intermed Coronary Syndrome, Influenza B and Coronary Artery Disease. The record was reviewed on 02/27/2015 at 8:44 am. The first Important Message from Medicare was provided on 10/28/14. The patient was discharge on 11/06/2014. The facility failed to provide the second IM two days in advance of patient According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

5. R.R. # 18 is a 72 years old male who is admitted on 08/27/14 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The record was reviewed on 02/27/2015 at 12:45 pm. The Important Message from Medicare was provided upon admission however the two days prior discharge Important Message from Medicare was not provide. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given 2 days before patient ' s discharge providing the rights to appeal their discharge.

6. R.R. # 19 is a 71 years old male who is admitted on 08/27/14 with a diagnosis of Decompensated Chronic Obstructive Pulmonary Disease (COPD), Chronic Hypoxemia, and Diabetes Mellitus. The record was reviewed on 02/27/2015 at 1:55 pm. The Important Message from Medicare upon admission and the two days in advance of patient discharge were not provide. One IM was found on the record in blank. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided a standardized notices, "An Important Message from Medicare" (IM). The IM is to be given at the admission and 2 days before patient ' s discharge providing the rights to appeal their discharge.

Based on records review accompanied by the Emergency Room Nursing Manager (employee #39), the Nursing Department Coordinator ( employee # 41) the Nursing Supervisor of Intermediate Medicine (employee # 7) and Nursing Coordinator of Intermediate Medicine (employee # 40) during the validation survey process performed on 2/24/15 thru 2/27/15 from 8:00 a.m. to 6:00 pm, it was determined that the facility failed to ensure that the advanced directives form for DNR (Does Not Resuscitate) are part of the clinical record after patient/caregiver discussed and signed it in the presence of the physician, for 2 out of 60 records review (RR #27 and #28).

Findings include:

1. During RR # 27 performed on 2/26/15 at 11:00 am it was found that the ESRD patient came to the Emergency Room on 11/11/14 at 11:40 pm due to dark feces, epigastric pain and low blood pressure. During the medical evaluation, patient's daughter signed a DNR. Patient has cardiac complications and patient's daughter revoked the DNR at 8:00 am on 11/12/15. The physician declared that patient passed away at 9:00 a.m. on 11/12/15. However, no physician's progress note was found explaining the reasons that patient's daughter revoked the DNR.

2. During RR # 28 performed on 2/26/15 at 11:45 am it was found that patient arrived on 2/1/15 at 3:00 pm at the Emergency Room in an ambulance attended by paramedics performing a CPR over the patient. After the physician received and provided treatment to the patient, she passed away. The physician wrote on his progress notes that family signed a DNR form on 2/1/15 at 3:00 p.m. but the form was not found on the clinical record.

3. The facility failed to ensure that the DNR form is part of the clinical record after patient or caregiver has discussed and signed it in presence of the physician. The facility failed to ensure that the physicians ' writes a progress note with a justification of caregivers revoking a previous signed DNR form.

Based on the review of incident and accident document with the nursing supervisor (employee #37) and interview, it was found that the facility failed to promote the right of each patient to receive care in a safe setting.

Findings include:

1. Review of an incident and accident reports on 2/27/15 from 9:55 pm through 11:20 am with surgery ward nursing supervisor (employee #37) the following was identified:

a. A 73 years old female patient with diagnosis of Right Knee Osteoarthritis admitted on 2/16/15 that was transferred to surgery ward fell down to the floor accordingly with incident and accident reports reviewed on 2/27/15 at 10:00am. Surgery ward nursing supervisor (employee # 3) stated on interview on 2/27/15 at 10:00 am it was identified that this patient had risk to fall down after the fall risk assessment performed during admission. Patient ' s relatives stated that they want to be near the patient on an ongoing basis to prevent that patient from falling down, and they begin to accompany the patient in her room. On 2/18/15 7:30 pm patient relative went down to the lobby, because another patient relative will go up to continue accompany the patient during the shift. After patient relative went down, patient felt down from the bed to the floor and calls nurse by nursing call system to inform that she felt down. Facility failed to ensure that patients who are identified as risk for fall, due to their health condition are supervised on an ongoing basis to prevent falls and ensure that if patients are accompanied with patient relatives and patients relatives leave the room premises they informed nursing personnel in order to prevent falls.

b. A 55 years old female patient who was admitted on 2/13/15 with a diagnosis of Chronic Obstructive Pulmonary Disease refer that Primaxin 500 mgs I.V. was wrongly administered to her on 2/26/15 at 2:00 am during 11-7 shift. Surgery ward nursing supervisor (employee # 37) stated on interview on 2/26/15 at 4:50 pm that during 11-7 shift on 2/26/15 a nurse from intensive care unit was transferred to surgery ward due to absence of a surgery nurse to perform duties. The ICU nurse transferred to surgery ward stated that while he was performing medication pass patient located on room # 373-A did not tell him her name or identified herself. He wrongly connect Primaxin 500 mgs I.V. to this patient and when went outside the room identify that the Primaxin 500 mgs I.V. connected to the # 373-A belongs to another patient and proceed to remove the piggy. ICU nurse involved in the situation stated that only a few amount of the piggy bag contents was received to the patient. Facility failed to ensure that nursing personnel identify correct patient before administrating medications in order to prevent medication administration errors.

Based on review of policies and procedures (P&P) related to the restraint protocol, it was determined that the facility failed to ensure that all forms of restraints definitions are included on the facility's restraint protocol, related to the use of side rails to prevent patient from voluntary getting out from bed.

Finding includes:

1. The facility's P& P , was reviewed on 2/26/15 at 9:00 am with the Director of nursing (employee# 1) and the following was identified:
a. The use of side rails to prevent patient from falls are not considered as a restraint by the facility if used in alert and oriented patients accordingly with information provided by the Director of nursing (employee#1 ) on 2/26/15. She also stated that facility did not know that the side rails were consider restraint, when the four side rails are up and the patient can not easily remove the device to get out from bed. The bed side rails fully up are used to prevent falls in patients admitted at the facility and they use bed side rails in every patient with high potential risk to fall.
2. Facility's P& P , did not include in their restraint definitions the use of side rails that prevent patient from voluntary getting out of bed as a restraint device.
3. The facility's restraint protocol does not address the use of four side rails as a method of restraint when medically needed.
4. Facility failed to keep in mind, patient's physical condition in order to maintained free from devices that prevents them from freely exiting the bed.
5. Facility did not employ side rails as a device of what constitutes a restraint .

Based on review of the policies and procedures (P&P's) for restraint, records review and an interview performed to the Director of Nursing (employee #1) on 02/27/15 at 2:00 p.m. it was determined that the facility failed to develop a Protocol for chemical restraints, for 1 out of 60 records reviewed (RR#29).

Findings include:

1. during review of P&P's for restraint on 02/27/15 at 1:30 p.m. the procedures fail to have the following items:

a. definition of chemical restraint

b. handling of patients with an order of chemical restraint

c. which medications are allow to be use in patients with chemical restraint and if it is required a consult to the Psychiatrist

d. observations and interventions performed by the nursing staff

e. time frame for a re-evaluation while patient is on chemical restraint

f. documentation of specific observations that the physician and registered nurse have to include in the progress notes.

2. On step #10 of the P&P's for restraint, it says: "The maximum time for restraint will be 4 hours in adults and 2 hours in children and it is highly recommended that patient will be in sedative medications to provide appropriate medical care".

a. This procedure using sedative medications does not comply with the requirements for chemical restraint.

3. During RR #29 performed on Intermediate Medicine on 02/25/15 at 4:20 pm accompanied by the Nursing Department Coordinator (employee #41), Nursing Supervisor (employee # 7) and Nursing Coordinator of the clinical unit (employee #40) it was found that patient was admitted with a diagnose of Pleural Effusion and Anemia that required blood transfusions and had physical restraint order on 2/22/15 initiated at the Emergency Room because she was disoriented and wanted to take out the blood transfusions IV lines. Also, the physician ordered Xanax 0.5 mg by mouth at hour sleep (HS) but no evidence was found if the medication was used for controlling patient's anxiety or used as a sedative. Xanax is a benzodiazepine that can be used as a sedative or as an anxiolytic, according to the drug reference book.

a. The facility failed to have a Chemical Restraint Protocol that rules the use of medications on patients with chemical restraints.

Based on review of the policies and procedures (P&P's) for restraint and an interview performed to the Director of Nursing (employee #1) on 02/27/15 at 2:00 p.m. it was determined that the facility failed to ensure the use of hand mitts as a physical restraint device.

Findings include:

1. During interview with employee #1 on 2/27/15 at 2:00 pm she talks about the new acquisition of hand mitts for physical restraint to avoid patients to remove the nasogastric tube, gastrostomy or other medical surgical devices. As observed, the hand mitt will not allow patients to move their fingers freely and this action should be considered a type of physical restraint. No policies and procedures were found on the Physical Restraint Protocol for the use of hand mitts.

2. During sample records review of patients admitted on the Emergency Room, Surgical Unit, Intermediate Medicine and Intensive Care Unit performed from 2/24 thru 2/27/15 from 8:00 am to 5:00 pm it was found that the chemical restraint is not included as a problem on the plan of care and lack of interventions for patients in chemical restraint.




34043


Based on records reviewed (R.R), it was determined that the facility failed to include a written care plan for restrain in 1 out of 60 records reviewed (R.R #12).

Findings include:

1. R.R. #12 is an 83 years old male who is admitted on 07/29/14 with a diagnostic of Chronic Obstructive Pulmonary Disease (COPD) and Osteoarthritis. The record was review on 02/26/15 at 1:39 pm. During the record review no evidence was found of Physician order for restraint, Restraint protocol sheet, and Patient plan of care of restraint. The restriction note " Restricción Del Paciente " dated on 07/31/2014 have evidence of patient restriction by four extremities with soft restraint. On the 7am to 3pm shift the restriction note of 7/31/2014 did not provide evidence of the patient assessment only has a note on the comment area that state patient in company of a family member " Paciente en compania de familiar " .
a. The facility failed to include a written plan of care for restraint.

2. RR # 10 is a 90 years old patient with a diagnosis of Bronchopneumonia connected to a respiratory ventilator. He was admitted on 2/20/15 and the first restraints orders began at the Emergency Room. During RR performed on 2/26/15 at 5:00 pm the following was found:

a. On 2/20/15 at 5:00 pm the physician ordered soft restraint in both arms because the patient was anxious and the reason for restraint was to avoid interruption in the treatment provided. However, the physician did not specify issues that patient can cause to interrupt his treatment. The time frame for restraint was 12 hours but physician marked 5:00 pm to 5:00 pm which turns the time frame in 24 hours.

b. The " Restriccion del paciente " Patient's Restraint Form where the nursing staff writes their interventions it was found lack of documentation on the following sections: Type of restraint, restraint areas, restraint order and alternate measures before restraint. Every work shift has a section where the RN has to use a code for writing their assessments and interventions every 2 hours but the RN of the 11pm to 7am shift on 2/20/15 did not write her assessment. The RN of 3 pm/11pm shift did not use the whole code to write her assessments and interventions.

c. No physician's order for restraint was found on 2/21/15. The nursing staff nor the physician did not notice that the restraint order from 2/20/15 remained for more than 24 hours when it was ordered for 12 hours.

d. The physician who admitted the patient wrote the restraint order on 2/22/15 at 9:30 pm. The time frame for this ordered is 12 hours but the physician established with a mark 9:30 pm to 9:30 pm, turning it in 24 hours. As alternate measures before restraint he marked use of medications but did not specify which medications the patient is taking.

e. Since 2/23/15 the physician's order time frame for restraint is 24 hours but was observed the same pattern of incomplete information on the order and on the nursing's restraint progress notes.

3. The same patient, during observational tour to the Intensive Care Unit on 2/26/15 at 5:00 pm, the patient had soft restraints on both wrists and the side rails were all up. His room is front of the nursing station and nursing staff has visibility to the patient. During survey process and as observed the patient was not anxious; he was always looking at the room ceiling. During RR on 2/26/15 at 5:00 pm, the physician and nursing staff said that patient is uncooperative and anxious. No alternate measure were implemented such as loosen the physical restraint to evaluate patient's attitude.

4. The facility failed to ensure the implementation of the restraint protocol as required by the federal regulations.


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Based on records reviewed (R.R) and policies and procedures (P&P's) related to restraint, performed on 2/24 thru 2/27/15 from 8:30 a.m. to 4:30 pm it was determined that the facility failed to ensure the implementation of the restraint protocol where physician's order are written and patient re assessments are performed by the nursing staff for 2 out of 60 records reviewed (R.R #10 and RR # 12).

Findings include:

1. R.R. #12 is an 83 years old male who is admitted on 07/29/14 with a diagnostic of Chronic Obstructive Pulmonary Disease (COPD) and Osteoarthritis. The record was review on 02/26/15 at 1:39 pm. During the record review no evidence was found of Physician order for restraint, Restraint protocol sheet, and Patient plan of care of restraint. The restriction note " Restricción Del Paciente " dated on 07/31/2014 have evidence of patient restriction by four extremities with soft restraint. On the 7am to 3pm shift the restriction note of 7/31/2014 did not provide evidence of the patient assessment only have a note on the comment area that state patient in company of a family member " Paciente en compañia de familiar ".
a. The facility failed to include the physician order as per the facilitys' protocol.

Based on records reviewed (R.R), it was determined that the facility failed to include physician order for restraint in 1 out of 60 records reviewed (R.R #12).

Findings include:

1. R.R. #12 is an 83 years old male who is admitted on 07/29/14 with a diagnostic of Chronic Obstructive Pulmonary Disease (COPD) and Osteoarthritis. The record was review on 02/26/15 at 1:39 pm. During the record review no evidence was found of Physician order for restraint, Restraint protocol sheet, and Patient plan of care of restraint. The restriction note " Restriccion Del Paciente " dated on 07/31/2014 have evidence of patient restriction by four extremities with soft restraint. On the 7am to 3pm shift the restriction note of 7/31/2014 did not provide evidence of the patient assessment only have a note on the comment area that state patient in company of a family member "Paciente en compania de familiar ".
a. The facility failed to include the physicians' order for restraint.

Based on records reviewed (R.R), it was determined that the facility failed to consult the attending physician for the restraint order in 1 out of 60 records reviewed (R.R #12).

Findings include:

1. R.R. #12 is an 83 years old male who is admitted on 07/29/14 with a diagnostic of Chronic Obstructive Pulmonary Disease (COPD) and Osteoarthritis. The record was review on 02/26/15 at 1:39 pm. During the record review no evidence was found of Physician order for restraint, Restraint protocol sheet, and Patient plan of care of restraint. The restriction note "Restricción Del Paciente" dated on 07/31/2014 have evidence of patient restriction by four extremities with soft restraint. On the 7am to 3pm shift the restriction note of 7/31/2014 did not provide evidence of the patient assessment only have a note on the comment area that state patient in company of a family member "Paciente en compania de familiar".
a. The facility failed to consult the attending physician for the restraint.

Based on records reviewed (R.R), it was determined that the facility failed to re-evaluate restraint by a physician after 24 hours of the first restraint order in 1 out of 60 records reviewed (R.R #12).

Findings include:

R.R. #12 is an 83 years old male who is admitted on 07/29/14 with a diagnostic of Chronic Obstructive Pulmonary Disease (COPD) and Osteoarthritis. The record was review on 02/26/15 at 1:39 pm. During the record review no evidence was found of Physician order for restraint, Restraint protocol sheet, and Patient plan of care of restraint. The restriction note " Restricción Del Paciente " dated on 07/31/2014 have evidence of patient restriction by four extremities with soft restraint. On the 7am to 3pm shift the restriction note of 7/31/2014 did not provide evidence of the patient assessment only have a note on the comment area that state patient in company of a family member "Paciente en compañia de familiar". Patient order start on 7/31/14 at 7:00 am to 8/02/2014 at 6:00 am.
a. The facility failed to re-evaluate face to face the patient by a physician after 24 hours of the first restraint order.

Based on review of the facility's hospital-wide quality indicator plan and patient satisfaction survey with the facility's quality assurance officer (employee #12) and interviews, it was identified that the facility failed to maintain measurable improvement in indicators for which there is evidence that it will improve health outcomes in the care and management of peritoneal dialysis and on-going quality assurance activities to ensure facility's patient satisfaction status.

Findings include:

1. Hospital-wide facility quality indicator plan and patient satisfaction survey results were reviewed with facility's quality assurance officer (employee #12) on 2/26/15 and 2/27/15 from 2:30 through 4:00 pm the following findings are related with this review:

a. Quality and Quality Indicators to measure the appropriateness of management and care provided to End Stage Renal Disease patients to whom facility provide peritoneal dialysis when admitted to the hospital due to an acute condition were not developed not followed.

Director of Nursing (employee #1 ) stated on interview on 2/25/15 at 1:55 pm that when End Stage Renal Disease patients are admitted to the facility, nursing personnel that had been previously certified as competent to provide peritoneal dialysis modality performed the procedure accordingly with physician prescription and orders.

However facility did not measure, analyze, and track quality indicators and other aspects of performance in order to determine if processes of care, operations and services provided to End Stage Renal Disease patients to whom facility provide peritoneal dialysis comply with standards of practice.

b. Review of the facility's emergency services patient satisfaction survey results of natural year 2014 on 2/27/15 at 2:53 pm with the facility's quality assurance officer (employee #12). The facility established that 95% as outcome goal to be reach of patient satisfaction scores with services rendered at the emergency room. For natural year 2014 promptness of general services, nursing and physician services and pain management did not reach 95% outcome goal established by facility. Evidence was provided by facility of a general investigation and analysis of scores attained based on patient responses. However evidence of improvement of processes based on each one of the areas were scores is less than facility established goal was not found documented and included as part of the facility efforts to improve patient's perspective of services rendered at the emergency room department.
c. Review of the facility's hospital services patient satisfaction survey results of natural year 2014 on 2/27/15 at 3:23 pm with facility's quality assurance officer (employee #12). The facility established that 96% as outcome goal to be reach of patient satisfaction scores with services rendered. For natural year 2014 promptness of admission process, nursing required services pain management, physician services and discharge process did not reach 96% outcome goal established by the facility. As part of this hospital patient satisfaction survey facility included in the scores attained; summary of patient comments of their perspective with services received. In the hospital satisfaction survey patients included comments that indicated the need in improvement on some emergency room direct care and administrative processes that are based on their perspective and experience while receiving services at the emergency room before being admitted to the hospital.
On those comments patients report delay on pain management, over crowed status on emergency room, lack of information or incomplete information provided of admission process and billing process, and delay in nursing required services at emergency room. One patient comment that if his wife need to receive treatment at the emergency room he consider to go to another facility, that he and his wife are satisfied with hospital services but not satisfied with emergency room services.
Evidence was provided by facility of a general investigation and analysis of scores attained based on patient responses. However evidence of improvement of processes based on each one of the areas were scores is less than facility established goal was not found documented and included as part of the facility efforts to improve patient's perspective of services rendered at the emergency room department.
General investigation of each one of patients ' comments was not found documented and included as part of the facility efforts to improve patient's perspective of services rendered in the facility. Evidence of satisfaction scores and perspectives of hospitalized patients who are admitted from emergency room or received services on emergency room who affect hospital satisfaction survey results were not deeply analyzed in order to establish improvement processes on each of the areas identified by patients.


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2. The facility does not have an effective mechanism to analyze, track selected indicators and establish a monitoring plan with the interventions that reflects improvement on the ER services.

a. The Nursing Manager (employee #1) and the Nursing Clinical Supervisor (employee # 17) collect data to be analyzed and discussed with the Quality Improvement Program (QIP). The data report from December 2014 shows the following indicators with their annual results:

1. LWSBS ( " Paciente Abandonó Sala de Emergencia Sin Ser Evaluado " ) patient elope ER without an evaluation- 39 cases

2. Elopement- ( " Paciente Atendido Por El Médico Y Luego Abandonó La Sala De Emergencia/ Areas Clínicas Sin Notificar " ) patient that was seen by the physician and elope ER /Clinical Areas without notification- 149 cases

3. AMA ( " Paciente Se Fue De Alta En Contra Del Consejo Médico Y Firmó Exoneración " ) patient disgharge against medical advise and signed the exoneration form- 160 cases

4. Most of patient's reasons for causing the above indicators are: they do not want to wait for results, do not want to be reevaluated because they have to wait for a long period, refusal to ordered treatment, and has been waiting too long for a bed at the clinical unit, physicians and nurses offering late treatment, among other reasons.

5. The ( " Equipo Flujo Eficiente de Pacientes de Sala de Emergencias " ) Team Efficient Flow Movements of Patients in the Emergency Room perform weekly meetings where they discuss the results and establish interventions for improvement. On a monthly basis they develop reports for the QIP. They develop a flowchart indicating the patient movements since his/her arrival to ER until his/her disposition.

The flowchart indicates that patient's Triage evaluation should be in 15 minutes but real time is 23 minutes, physician's evaluation should be in 30 minutes and real time is 47 minutes, orders signed and care provided by nursing staff should be in 30 minutes but real time is 43 minutes, availability of results should be in 30 minutes but real time is 31 minutes for radiologic results and 1hour for laboratory results, physician reevaluation should be 45 minutes but real time is 1.07 hours, admission process should be 1 hour but real time is 2.14 hours, transfer to the clinical unit should be 1 hour but real time is 5.18 hours.

a. The Medical Director of the facility and the Medical Director of the ER have discussed these issues but on dated minutes of the medical faculty meetings do not show specific interventions for improvement. For example: they mention that the radiology physician will offer an education to the ER physicians related to radiographic interpretations.

According to interview perform with the Hospital Medical Director (employee # 22) on 2/25/15 at 10:45 am, he stated: " On medical staff meetings of the emergency room we have discussed some issues that affect the services provided. The radiology physician will offer training to the ER physicians of how they are going to read the radiographies and the patient does not has to wait so long for a radiology result. Also, on every work shift a radiology physician will be performing radiologic interpretations from home. We also, discussed the time frame of the medical reevaluation and we are hoped to have improvement".

However, on the work instruments of the ER team does not show the radiographic interpretations from home as a resource to have fast results and the patient does not have to wait so long for a radiologic result.

c. The same issues are discussed in the ER meetings with the nursing staff and the report does not show steps of how they are going to work with the staff for better improvement. On the January 23rd of 2015 report, the Director of Nursing (employee #1) discussed with the nursing staff that late duties performed by them such as: taking late blood and urine samples, late administration of medications, omissions on treatment, etc.; affect the services and these are some reasons for denial of days. Employee #1 mentions the lack of nursing personnel as other reason of why the ER services are affected.
However, no interventions for improvement were found. Other issues like, deficiencies in hand washing procedures, disinfecting rubber stopper at the IV lines, heparin ports and IV ports, taking physician's orders too late, labeling the IV lines, to change the sharp containers, to identify patients at fall risks, notify the surgical services if a patient has MRSA, MDRO or other infectious diseases and other indicators have been repeated for five months and no improvement was seen.

Based on observational tour, interview with nursing staff of the Emergency Room (ER) and review of administrative documents performed on 2/24 and 2/25/15 from 8:00 am thru 4:30 pm with the Nursing Manager (employee # 39) it was found the facility failed to have an adequate amount of registered nurses at the ER to provide care to patients as needed.

Findings include:

1. The ER adult section has six areas: Treatment and Admissions I with 21 beds Admissions II with 8 beds, " Cernimiento " Screening Room with 4 cubicles, 2 Isolation rooms, and 2 CPR rooms areas. In these areas patients were observed receiving emergency treatment care and patient's with admissions orders that are waiting for available beds in the hospital clinical units. The pediatric emergency room has 3 treatment areas with a total of 17 beds and 1 Isolation room with patients receiving emergency care and patients with admissions orders.

According to interview performed to employee # 1 and employee #39 on 2/26/15 at 3:00 p.m. the staffing pattern prepared for the Emergency Room it has 14 less nurses for adult and pediatric treatment areas. This situation has caused the following issues that were observed during the survey process:

a. According to the nursing assignment review performed on 2/26/15 at 3:00 pm, employee #39 distributes the nursing staff on adults and pediatric areas as follows: 9 or 10 RN on 7am/ 3pm work shift providing care to 40 or more patients. On the 3pm/11pm work shift the distribution is 9 RN's on the same areas and on the 11 pm/7am work shift 7 RN's are assigned. The admissions areas were created to put patients with admissions orders that are waiting for an available bed on the clinical unit. However, during the survey process it was observed that patients were in different cubicles around the ER.

b. On the CPR room there was a patient with admission order for Intensive Care unit. The patient has 2 IV (intravenous) fluids by IV pump with medications for hypertension control, Foley catheter, cardiac monitoring and oxygen cannula. The RN assigned to this room has to interrupt the care provided to this patient because he has two other patients on the Admissions I area providing care according to physician's order: inyectable medications administration, pain management, coordination with the laboratory services and radiologic services. According to Federal and State laws the patients with admission orders and remain in the ER have to receive the same care as if is admitted on the clinical unit, but the nursing staff has difficulties complying with their duties.

c. During RR # 26 it was found a physician's order from 2/24/15 at 1:00 am and it was countersigned by the RN at 6:00 am, 5 hours later. During interview with this patient on 2/25/15 at 10:10 am, she stated: "The physician saw me yesterday. It was later than 11 pm and I came with pain and possibly urinary tract infection. I had to wait for treatment until early morning. The nurse put me the (IV) cannula, put medications to run on the (IV) line and the physician ordered the admission. Today, I received breakfast at 10:00 am and lunch will arrive at 1:00 pm. The nursing staff is the one that I see putting the food trays on each cubicle. I have to call the nurse when the medication has to be administered. The staff attitude is good but their performance is poor. Treatment care is always late."

d. For the pediatric area the 11 pm/7am shift is worked by only one RN that has to receive patients at the triage area, has to provide care to patients on the treatments areas with emergency care or with admission orders. In occasions, one nurse from the adults ' area provides help to this pediatric RN. On 2/25/15 at 10 am an observational tour was performed on the ER with employee #39 and the census on the pediatric area of the ER was 31 pediatric patients with admissions orders and all were attended by only one RN.

e. On the observational tour at the ER on 2/25/15 at 10:00 am it was observed that one RN assigned to the Triage area left the Triage to provide care to patients on the adult's treatment area. On the triage area, there are two rooms and on the nursing assignment it was observed two RN's assigned to these areas. However, it was observed that both RN's were providing care to patients with emergency care and with admissions order, leaving the Triage alone.

f. The nursing staff does not perform an emergency assessment on the Triage according to the facility's P&P's.

1. During observational tour on 2/25/15 at 10:30 am at the waiting room of the ER it was observed a female crying talking with a clerk sitting on a side of the waiting room. The surveyor asks the patient the reason for her sadness and she stated: "I'm in much pain and I can not tolerate it". The patient arrived to the ER before 10:00 am and was not attended by the Triage Nurse. The surveyor went to the Triage area and there was one nurse (employee #46) evaluating a patient. The other Triage room was empty. After the RN finished with the patient she did not noticed that a patient at the waiting room was crying and bending over. Also, the frosted glass window does not allow the RN to have a good visibility to the waiting room and can not determine how patients look after arriving to the ER.

2. The surveyor asked employee #46 how she classifies patients at the Triage, she stated: "emergency is when a patient has chest pain and shortness of breath". Employee # 46 did not mention other signs and symptoms. After going to the waiting room and seen the patient then she called her and initiated the evaluation to determine the care to be provided. When asked about the patient's classification she mentioned: "is an emergency because she has severe pain". According to P&P's review a patient classified at the Triage as an emergency has to be attended immediately by the RN and Physician. However, this patient had to wait almost 1 hour since her arrival at the ER to receive immediate care.

3. Patient # 24 arrived at the ER on 2/23/15 at 11:00 pm with his wife and daughter. According to interview with patient's daughter performed on 2/24/15 at 1:35 pm, she stated: "last night we arrived with my dad and he was not feeling well. He was on much pain and bending over. We went to the desk located at the corner and talked with the man there. He wrote my dad's name on the computer and we had to wait. Dad was sitting in a chair but was bending because of pain. My mom had to go to the Triage area to request assistance to the nurse because she was afraid that dad falls down at the waiting room. My other sister came and talked with the nurse requesting a wheelchair but we did not receive an answer. My mom was very angry and she entered through that door and requested out loud where were the nurses and the physicians that her husband was in a bad condition and was vomiting blood. Then, a nurse came faster with a wheelchair and put dad in a cubicle. More than 30 minutes has passed waiting for a nurse to attend my dad".

During RR performed after the interview, the RN classified the patient as an emergency. He showed pain in a scale of 9-10 and physician ordered Demerol 25 mg intramuscular (IM). The admission diagnose was Upper Gastrointestinal Bleeding. Patient continued receiving treatment as ordered by the physician, such as: Phenergan 25 mg IV, Rocephin 1 gram IV, a nasogastric tube connected to intermittent suction and a Foley catheter that was not inserted after it was ordered. Employee # 39 talked with the RN assigned to patient's care and she notified that patient was alert on 2/25/15 afternoon and he does not want the Foley.

4. The nursing staff does not show knowledge of the Triage classification according to the three categories that the facility has established.

g. The nursing staff is not aware of patients in an Isolation room. The nurses ' failed to review the clinical record for isolation orders with specific precautions, (Cross reference TAG A 0749).

h. The nursing staff failed to perform the crash cart daily check using the comparison list that the Pharmacy services put on the cart. Expired IV fluids were found on two crash carts, (Cross Reference TAGS A 0505 and 0749).

i. The nursing staff is not administering medications at the frequency established by the physician and signed it before administering to the patient, (Cross Reference TAG A 0405).

j. The facility failed to ensure that the services at the Emergency Room are provided in a safely manner with sufficient nursing staff and care provided according to professional standards of practice.

Based on observation and medical record review (R.R.) with Medicine I supervisor (employee #7), it determined that the facility registered nurse failed to assess and evaluate nursing care for each patient due to lack of documentation patient assessment accordance to the standard of practice for 2 out of 60 record review (R.R. #52 and #60)

Findings include:

1. R.R. #52 is a 60 year old male admitted to the facility on 2/25/15 with a diagnosis of Incicional Hernia. During the record review performed on 2/26/15 at 11:50 am it was found that the registered nurse performed the initial assessment to patient arrive to medicine I ward AA from recovery room on 2/25/15 at 8:00 pm. However no evidence was found that the registered nurse assess and identified the post operative area and bandage status according to nursing standard of practices.

2. R.R. #60 is a 55 year old female admitted to the facility on 2/13/15 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus. During the record review performed on 2/26/15 at 3:50 pm it was found that the registered nurse performed the initial assessment when patient arrive to Surgery II from emergency room on 2/14/15 at 2:30 pm. The patient has a diagnosis of Diabetes Mellitus the nursing personnel registered on the diabetic chart in the "Registro Diabetico Glucosa en Sangre", Diabetic Register Blood Glucose.

It was found that on 2/13/15 at 8:29 pm the glucose level (Dxt) was 400 mg/dl, on 2/14/15 at 6:18 am Dxt= 281 mg/dl, at 10:22 am Dxt=398 mg/dl, at 1:37 pm= 320 mg/dl, at 4:00 pm Dxt = 262 mg/dl. On 2/15/15 at 4:00 pm Dxt = 208 mg/dl, at 9:00 pm = 288 mg/dl. On 2/16/15 Dxt = 206 mg/dl,. On 2/17/15 at 11:00 am Dxt = 208 mg/dl, at 9:00 pm Dxt 209 mg/dl.

On 2/18/15 at 11:52 am Dxt = 219 mg/dl, at 4:00 pm 298 mg/dl. On 2/19/15 at 4:39 pm Dxt = 231, at 7:59 pm Dxt 451 mg/dl. On 2/20/15 at 12:00 am Dxt = 370 mg/dl, at 6:00 am Dxt = 339 mg/dl at 11:00 am Dxt 413 mg/dl, at 4:00 pm Dxt = 348, at 9:00 pm Dxt not registered.

No evidence was found that nursing personnel performed the Dxt level on 2/21/15, 2/22/15, 2/23/15.

On 2/24/15 at 12:00 am Dxt = 360, at 6:00 am Dxt = 307 mg/dl, at 8:00 am 300 mg/dl, at 11:00 am Dxt = 353 mg/dl at 10:21 pm Dxt 350 mg/dl.

On 2/25/15 at 12:00 am Dxt 430 mg/dl, at 6:00 am Dxt = 279 mg/dl at 8:00 am Dxt = 255 mg/dl at 11:00 am Dxt = 372 mg/dl at 4:00 Dxt = 311 mg/dl at 9:00 pm Dxt = 419 mg/dl.m

On 2/26/15 at 12:00 am Dxt = 482 mg/dl, 6:00 am Dxt = 348 mg/dl, at 8:00 am Dxt = 255 mg/dl and at 11:00 am Dxt= 360 mg/dl.

The nurse ' s progress note performed on 2/13/15 at 3-11 and 11-7 shift, through 2/20/15 at 7-3 shift and on 2/21/15 at 3-11 shifts through 2/26/15 7-3 shift the nurse documented that the patient did not have altered glucose.

The facility ' s nursing personnel failed to document in the nursing progress nurse the glucose level alteration, the nurse intervention to resolve the problem, reassess the Dxt level after the intervention and the patient physician notification of patient glucose level accordance to standard nursing practices.

Based on observation and record review (R.R.) with the DON (employee #1) it was determined that the facility failed to ensure that the registered nurse develops and keep currents patient nursing care plan accordance to patient needs for 3 out of 60 records review (R.R. # 51, #53 and #60)

Finding included:

1. R. R. #51 is an 80 years old male admitted on 2/25/15 with a diagnosis of Buttock Celullitis. During the enterostomal nurse evaluation on 2/26/15 at 10:00 am it was observed that patient has a Foley catheter. During the record review performed on 2/26/15 at 10:45 am with the DON (employee #1) and Medicine II supervisor (employee #36) it was found that the physician place and telephone order on 2/25/15 at 8:00 pm of Foley Catheter, the physicians ' order does not provide the size or Foley number. The nurse ' s note performed on 2/26/15 in the 3-11 shift do not provide evidence of the Foley catheter justification, insertion, number and amount of urine and color.

Evidence was provided of a Skin assessment and position change sheet filled by the licensed Practice Nurse (LPN) and documented on 2/25/15 at 6:55 pm that patient was with bulls in the left and right thigh. Foley catheter was place and urinalysis and urine culture. However the registered nurse failed to developed and activated the patient care plan for the urinary system due Foley catheter needs and documented the Foley # and urine characteristic and output accordance with nursing standards of practice.

2. R.R. #53 is a 76 years old female admitted on 2/23/15 with a diagnosis of Left knee Osteoarthrosis. During the record review performed on 2/26/15 at 2:15 pm evidence was found that patient was post operated total left knee replacement and no evidence was found the the registered nurse developed and implemented a plan of care. The plan of care was an interdisciplinary plan of care; nursing personnel left it in blank. The registered nurse personnel failed to identified patient need and developed a plan of care to patient needs as Endocrine system due to glucose level high, Urine system due to Foley catheter, intergumentary system due to left knee replacement incision, musculo skeletal system due to pain and post operative phase.

3. R.R. #60 is a 55 year old female admitted to the facility on 2/13/15 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus. During the record review performed on 2/26/15 at 3:50 pm it was found that the registered nurse performed the initial assessment at patients ' arrival to Surgery II from emergency room on 2/14/15 at 2:30 pm. The registered nurse developed and implemented the Plan of care for Pain management Respiratory system alteration due to respiratory difficulty and cough and Increase Glucose level. However the registered nurse failed to reassess the patient needs according to nursing standards of practice and facility policies and procedure that states that it was to be re-evaluated daily.

4. A mechanism to ensure that nurses who administer medications know how to act upon deviations and irregularities in medication administration was not followed not performed accordingly with the following findings:

a. A 55 years old female patient who was admitted on 2/13/15 with a diagnosis of Chronic Obstructive Pulmonary Disease refer that Primaxin 500 mgs I.V. was wrongly administered to her on 2/26/15 at 2:00 am during 11-7 shift. Surgery ward nursing supervisor (employee # 37) stated on interview on 2/26/15 at 4:50 pm that during 11-7 shift on 2/26/15 a nurse from intensive care unit was transferred to surgery ward due to absence of a surgery nurse to perform duties. The ICU nurse transferred to surgery ward stated that while he was performing medication pass patient located on room # 373-A did not tell him her name or identified herself. He wrongly connect Primaxin 500 mgs I.V. to this patient and when went outside the room identify that the Primaxin 500 mgs I.V. connected to the # 373-A of another patient and proceed to remove the piggy. ICU nurse involved in the situation stated that only a few quantities of the piggy bag contents were received by the patient. Once the nurse identify the administration medication error he did not take the piggy bag with the Primaxin; because patient involved in the medication error want to keep the piggy bag as her evidence.

Accordingly with information provided by Director of Nursing (employee #1 ) on 2/26/15 at 4:55 pm in cases were medication errors that involved intravenous medication administration, the intravenous medication or piggy bag is removed from primary intravenous lines and maintained as facility ' s ' evidence until investigation was finished. The situation is explained to the patient and if the patient request a copy of the circumstances or the medication irregularity incident facility provides it once they worked and analyze the situation with risk management and pharmacy.

b. A 62 year old female patient admitted on 2/20/15 with a diagnosis of Acute Bronchitis. On 2/27/15 during survey procedures tour she refer that during the administration of Ambien tablet 10 mgs oral at hour of sleep on 2/24/15 the tablet was broken in two pieces when the nurse remove from package. That the nurse proceeds to administer the medication and she experienced burning sensation and a laceration on her mouth.
Accordingly with information provided by Surgery Department Nursing Supervisor (employee # 37) on 2/26/15 at 5:59 pm this patient is currently treated for an irritation and inflammation of the mucous membranes of the mouth and throat, with Lidocaine Viscous solution at 1% and Benadryl mix to mouthwash 4 times a day. She also stated that the burning sensation that the patient experienced after the administration of the broken Ambien was due to the irritation and laceration status of her mouth.
Accordingly with Drugs.com the effect of Zolpidem tablets may be slowed by ingestion and that is why medications had special preparations. Tablets have coatings designed to protect gastrointestinal tract from the medicine until reach the stomach were the medication are slowly released.
After the investigation of the situation Surgery Department Nursing Supervisor (employee #37) on 2/27/15 at 9:00 am stated that the nurse involved in the administration was interviewed and a disciplinary action was taken against him, due to the lack of precaution taken before the administration of a medication broken in two pieces. The medication could provoke undesirable effects on a patient who had irritation and inflammation of the mucous membranes of the mouth and throat.


20423


5. Based on observation performed on 2/26/15 at 9:15 am during the drug pass on 4th floor Medicine II ward B with supervisor (employee #36) and DON (employee #1) it was determined that the facility failed to administrated medication accordance to physicians ' orders and accepted standards of practice for 3 out of 60 record review (R.R. #53, #55 and #60).

a. On 2/26/15 at 9:15 am it was observed registered nurse employee #5 with the medication cart in the hall way near room 413. He proceed to remove medication from the medication cart for the patient at room 413 B. the employee #5 sign the medication administration record (MAR) previous to administrated the Medication Protonix 160 mg IV and Cipro 400 mg IV.

b. R.R. #53 is a 76 years old female admitted on 2/23/15 with a diagnosis of Left knee Osteoarthrosis. During the record review performed on 2/26/15 at 2:15 pm evidence was found that patient was post operated total left knee replacement and the surgeon ordered cover with regular insulin if dextrose (Dxt) was over 180-230 mg/dl administrated 4 unit of regular insulin, if it was over 231-280 mg/dl administrated 8 unit of regular insulin, it was over 281-330 mg/dl administrated 12 unit of regular insulin and if it was over 330 mg/dl call and notified to physician.

The diabetic register sheet (Registro Diabetico) provide evidence that on 2/24/15 at 9 am the Dxt was 184 mg/dl, on 2/25/15 the Dxt was 190 mg/dl, at 5:00 Dxt was 208 mg/dl, at 9:00 pm Dxt was 193 mg/dl and on 2/26/15 at 11:00am the Dxt was 196 mg/l. However no evidence was found in the medication administration register (MAR) of insulin cover as ordered by the physician.

Interview with patient registered nurse employee #8 states on 2/26/15 at 2:30 pm that patient refuse to administrate insulin due to she is not diabetic and do not want to drop the dextrose level.

However no evidence was found that the nursing personnel notified the physician of the dextrose level and that patient refuse insulin.

Evidence was found that physician ordered on 2/25/15 Tramadol 1 tablet per mouth (PO) every 6 hour for pain and as necessary (PRN). The patient was receiving physical Therapy exercise as post operative treatment, as evidence in the physical therapist progress note on 2/26/15 at 3:05 pm and 2/26/15 at 12:30 pm, the physical therapist performed pain assessment and measure 6 in al scale of 10 both days. No evidence was found in the MAR that the Tramadol was administrated any time during the hospitalization. During interview with patient on 2/26/15 at 2:40 pm she state that not was receiving insulin and did not refuse insulin, when receive physical therapy she has pain but not she did not receive pain medication. Nursing personnel failed to administrated medication accordance to physician order and notified the physician and document when patient refuse.

3. R.R. #55 is a 69 years old female admitted on 12/18/15 with a diagnosis of Stroke in evolution. During the record review performed on 2/27/15 at 9:15 am it was found that the physician ordered on 2/23/15 at 4:52 pm Vancomycin 1 gram IV, diluted in 250 ml of NSS to infuse in 2 hour every 12 hour First dose now. Evidence was found in the Medication Administration Register (MAR that the first dose of Vancomycin was provided at 9:00 pm. The facility nursing personnel failed to follow the physician prescription as ordered.

4. R.R. #60 is a 55 year old female admitted to the facility on 2/13/15 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus. During the record review performed on 2/26/15 at 3:50 pm it was found that the registered nurse performed the initial assessment to patient when arrive to Surgery II from emergency room on 2/14/15 at 2:30 pm. The patient have a diagnosis of Diabetes Mellitus, the nursing personnel registered her on diabetic chart in the "Registro Diabetico Glucosa en Sangre", Diabetic Register Blood Glucose.
It was found that on 2/14/15 at 6:18 am Dxt= 281 mg/dl, at 10:22 am Dxt=398 mg/dl, at 1:37 pm= 320 mg/dl. On 2/16/15 at 6:30 pm Dxt = 201 mg/dl.
On 2/18/15 at 11:52 am Dxt = 219 mg/dl.
On 2/19/15 at 4:39 pm Dxt = 231.
On 2/20/15 at 11:00 am Dxt 413 mg/dl, at 9:00 pm Dxt not registered.
On 2/25/15 at 4:00 Dxt = 311 mg/dl, at 9:00 pm Dxt = 419 mg/dl.
On 2/26/15 at 12:00 am Dxt = 482 mg/dl, 6:00 am Dxt = 348 mg/dl, at 8:00 am Dxt = 255 mg/dl and at 11:00 am Dxt= 360 mg/dl.
a. The Medication Administration register (MAR) did not evidence that the registered nurse follow the physician order of Regular insulin cover as ordered on 2/13/15 and reevaluation on 2/20/15.
b. Nursing personnel failed to administrated medication accordance to physician orders and notified the physician and document when patient refuse.


33356


Based on the review of the medications administration record and observational tour performed at the Emergency Room (ER) on 2/24 and 2/25/15 from 8:30 am to 4:30 pm, it was found that the facility failed to ensure that the ordered medications are given on a specific hour in accordance to facility's rules and regulations, standards of practice and Federal and State laws for 3 out of 60 records reviewed (R.R. #53, #55 and #60)

Findings include:

1. During an observational tour on Admissions II treatment area at the ER on 2/24/15 at 10:30 am it was found a Synthroid 25 mcg tablet over the counter at the nursing station. When the surveyor asked the registered nurse (RN) about it, he could not explain why that medication was there. The tablet was covered by its original wrapping and on a corner it was observed that someone wrote "6 am". The medications administration record was observed and only one patient admitted to this treatment area has a physician's order for the administration of Synthroid.

a. It was found that the RN that was providing care to patient # 43 at 6:00 am signed as given this medication.

b. The RN that was providing care at 10:30 am asked the patient if he remembered to take the Synthroid tablet at 6:00 am. The patient's answer was that he does not remember.

2. The manufacturer recommends that Synthroid as a single dose should be taken preferably on an empty stomach, one-half to one hour before breakfast. Its absorption is increased on an empty stomach. Facility's policies and procedures (P&P's) establishes the same recommendation but the nursing personnel failed to follow the procedure. The RN did not give an explanation of why this patient did not receive his medication at 6:00 am.
3. The facility failed to ensure that the nursing staff administers the medications according to their P&P's based on standards of practice, physician ' s orders and Federal and State laws.

3. During observational tour on the ER performed on 2/24/15 at 1:00 pm accompanied by the Nursing Manager (employee #39), on the " Cernimiento " Screening Area it was observed an RN preparing three injectable medications. He put the three medications over the counter without a label on each, indicating patient's name, and name of the medication with the dose and route to be administered and hour of administration.

According to interview on 2/24/15 at 1:00 pm with employee # 39, he stated: "the RN has to label the three medications according to the P&P's for medications administration."

a. The facility failed to ensure that nursing staff prepare and administer medications under safety measures according to facility's rules and regulations, standards of practice and Federal and State laws.

Based on medical records reviews (R.R.) from 2/26/15 thru 02/27/15 with the Director of Nursing (DON) (employee #1), it was determined that the facility failed to ensure that the nursing staff comply with policies and procedures (P&P's) established for verbal orders and orders made by telephone for 1 out of 60 records reviewed (RR #53).

Findings include:

R.R. #53 is a 76 years old female admitted on 2/23/15 with a diagnosis of Left knee Osteoarthrosis. During the record review performed on 2/26/15 at 2:15 pm evidence was found that patient was post operated of total left knee replacement the physician performed an verbal order on 2/23/15 at 9:15 am of Morphine 15 mg, Lidocaine 1% 20 ml, Toradol 60 mg and no evidence was found that the physician counter sign the verbal order.
The facility's registered nurse failed to ensure that physician sign the verbal order consistent with facility policies and procedure (Documentación de ordenes verbales o trelefonicas), Telephone or verbal order documentation that evidence that verbal order was to be sign by the physician between 24 hour after performed.

Based on the observational tour of the medical records department on 02/25/15 from 10:40 am accompanied by the Information Management Director (employee #34) through the central file area, alternate storage area, and review of the policies and procedure's manual), it was determined that the facility failed to maintain inactive medical records on a safety and secure storage room, complete discharge summaries closer to the patient discharge, complete the medical history and physical examination 30 days prior surgery and document pertinent treatment orders and important information related to patient health condition. (Cross reference Tags A-0438, A-0461, A-0467 and A-0468) All of which makes this condition "Not Met".

Based on observations during the tour on the inactive record department on 2/25/15 at 10:40 am, it was determined that the facility failed to ensure that inactive medical records are filed under proper safety conditions.

Findings include:

1. On 2/25/2015 at 10:40 am the surveyor and Information Management Director (Employee #34) arrive to a building outside the hospital structure. In that building are located the hospital inactive medical records. The building is divided for multiples areas. In those areas are located the boxes of Doctor Hospital Manatí inactive record, Nuclear medicine inactive records, X rays department inactive records , Doctor Hospital San Juan inactive records and Doctor Hospital Bayamon inactive records.
On the hallways there are boxes of billing records. Also is a room with old furniture and medical equipment. On the building it has an estimated over a thousand boxes of inactive medical records of different areas and hospitals. The building was dirty, not organized, electric cables uncover, wet floors, rusty water pipes, exit door block, death animals (one lizard and one iguana), humidity on the ceiling tiles and there were missing ceiling acoustic tiles. Facility failed to ensure that all inactive medical records are filed and maintain under proper safety conditions.

Based on medical records reviewed (R.R.) with the Medicine I supervisor (employee #7), it was determined that the facility failed to ensure that the medical history and physical examination (H&P) is documented by a physician for each patient and updated prior to surgery or procedure requiring anesthesia services when the H&P was performed within 30 days before admission or registration for 1 out of 60 medical record reviewed (R.R#52).

Findings include:

1. R.R #52 is a 60 year old male admitted to the facility on 2/25/15 with a diagnosis of Incicional Hernia. During the record review performed on 2/26/15 at 11:50 am it was found that the patient entered to the operating room on 2/25/15 to perform a Repair of Incicional
Hernia and requiring anesthesia services.

However the H&P was performed by the patient's physician on 1/22/15, thirty-four (34) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

Based on records review performed from 2/24 thru 2/27/15 from 8:00 am to 6:00 pm it was determined that the facility failed to ensure that the content of clinical record is complete and contains pertinent treatment orders, documentation and other important information related to patient's health condition for 7 out of 60 records review, (RR #24, #25, #26, #29, #30, #32 and #35).

Findings include:

1. During RR # 24 performed on 2/24/15 at 1:35 pm, it was found that the patient came with severe abdominal pain and vomiting blood. He showed pain in a scale of 9-10 and physician ordered Demerol 25 mg intramuscular (IM). The admission diagnose was Upper Gastrointestinal Bleeding and continued receiving treatment as ordered by the physician, such as: Phenergan 25 mg IV, Rocephin 1 gram IV, and nasogastric tube connected to intermittent suction. There was a Foley catheter order but the physician did not specify frame of the nasogastric tube, ordered Intake and Output (I&O) but did not specify how many hours will be monitored I&O.

a. The physician used a small space to write the whole order where he did not write in a chronological sequence each treatment order. He did not use the second form for physician's orders.

b. During observational tour performed on 2/25/15 at 1:30 pm with employee #39 it was observed that patient did not have the Foley catheter as ordered by the physician on 2/24/15 at 11:10 pm. Employee # 39 talked with the RN assigned to patient's care and she notified that patient was alert and he does not want the Foley. No information was found on the clinical record of the interventions performed by the nursing staff on 11 pm/7am working shift. When the physician ordered was reviewed, besides the nasogastric tube insertion the physician wrote irrigation but the order was incomplete and the nursing staff got confused. However, no efforts were seen on the nursing documentation of consulting the order with the physician and putting the Foley catheter after it was ordered. The nursing staff waited 14 hours to determine if it was necessary to insert the Foley catheter.

2. During RR # 25 performed on 2/24/15 at 3:16 pm, the patient was admitted on 2/22/15 due to diagnose of Impetigo. The 2 years old boy is receiving antibiotic treatment and there are pending results of some cultures due to suspicious diagnose established by the pediatrician as community MRSA. However, no physician's order was found for the use of an Isolation room with contact precautions, (Cross Reference TAG A 0749).

3. During RR # 26 performed on 2/25/15 at 10:10 am it was found a physician's order from 2/24/15 at 1:00 am countersigned by the RN at 6:00 am, 5 hours later, (Cross Reference TAG A 0392).

a. This female patient was admitted on 2/24/15 and the diagnose was Complicated Urinary Tract Infection (UTI). The physician failed to evaluate patient's pain using the Wong-Baker pain scale and to write patients diagnose on the progress note of 2/25/15 8:00 am.

4. During RR # 29, the female patient was admitted to the Intermediate Medicine Unit with a diagnose of Pleural Effusion and Anemia. This patient initiated treatment with 2 blood transfusions on 1/19/15 while she was at the Emergency Room. When the transfer note was reviewed, the ER nurse did not notify that the patient received blood transfusions and if the patient had adverse reactions. On the plan of care, the low hemoglobin levels problem was not identified nor the interventions that the nursing staff has to perform to help patient's improvement with her hemoglobin levels.

5. During RR # 30 it was found that patient suffers seizures after a stroke. He is taking Dilantin liquid 4 ml by gastric tube twice a day. He was admitted on 2/22/15 due to Stage IV sacral ulcer. However, after the stroke he is taking Dilantin but no previous results of Dilantin levels were found on the clinical record. The physician did not considered to order Dilantin levels during the admission process to determine therapeutic dosage of this medication.

6. During RR # 32 performed on 2/26/15 at 4:00 pm it was found that patient receives hemodialysis on an ambulatory renal center. He was admitted on 2/24/15 due to Bronchitis. The nursing assessment was reviewed and it lacks for information related to the hemodialysis treatment such as: name of the treatment center where he goes, previous parameters of the hemodialysis treatment: BFR, ultrafiltration, dry weight, IV access (he has an arterio-venous fistula) on his left arm, contact person at the hemodialysis center. No evidence was found of a request for a copy of the hemodialysis plan of care. Only the Medical Social Worker wrote on her progress note of 2/26/15: " patient goes to the hemodialysis center in Arecibo". She did not specify which of the hemodialysis companies provides the service.

According to interview with the patient performed the same day at 4:40 pm, he stated: "I don't remember the name of the hemodialysis center. I know that is located in front of the sea!" No evidence was found of the interventions performed by the nursing staff to obtain the hemodialysis center name.

7. During RR # 35 performed on 2/27/15 at 9:00 am, this male patient went to the Emergency Room on 2/6/15 because he had swallowing difficulties. This patient has history of Diabetes and Hypertension. The physician ordered treatment with Kenalog 40 mg Intamuscular (IM) and an IV solution with 0.9 Normal Saline to run at 80 ml/hr. The physician did not mention what condition caused the swallowing difficulties. He just ordered transfer to a supraterciary hospital with the diagnose of Dysphagia. No evidence of radiologic and laboratory studies were found on the clinical record nor other pertinent documentation was found on the transfer note.

Based on sixty records review (RR), accompanied by nursing staff during survey process from 2/24 thru 2/27/2015 it was found that the facility failed to observed that discharge summaries are written closer to the discharge of the patient, as found on 2 out of 60 records reviewed, (RR # 30 and # 33).

Findings include:

1. During RR # 33 performed on 2/27/2015 at 1:05 pm, an 89 years old patient that was admitted on 2/10/2015 due to Urinary Tract Infection. The primary physician wrote on the discharge summary form a brief history and physical findings of the patient even knowing that patient has not complete treatment and has to wait patient response to the care provided.

2. During RR# 30, performed on 2/27/2015 at 2:00 pm, a 36 years old patient admitted on 2/22/15 due to Infected Stage IV sacral ulcer. This patient has history of seizures which requires taking Dilantin 4 ml twice a day by gastrostomy, is disoriented and has pending evaluations with the Psychiatrist. The discharge planning program is coordinating services with the "Departamento de la Familia " Family Department to relocate the patient on a foster home due to his condition and his mother cannot provide the care that the patient needs.

However, during RR it was found that the primary physician began to write the patient's condition at discharge even knowing that patient has not completed treatment and there is no final decision of where is going to live and what provisions the patient needs for follow up care.

According to P&P's review known as Analisis and Clinical Content on the Clinical Record establishes that the discharge summary should be documented at patient's discharge.

Based on the review of documents, observational tour with the Pharmacist (employee #21), it was determined that the facility failed to ensure that pharmaceutical services are administered in accordance with accepted professional principles related lack of processes to ensure a safe and appropriate use of medications.

Findings include:

1. During the initial observational tour with the pharmacist (employee #21) on 2/24/15 from 10:18 am though 11:46 am the following was identified:

a. In the Intensive Care Unit (ICU) physician's orders and medication administration record (MAR) was reviewed in order to evaluate transcription of orders and related procedures. During the review it was identified that on 2/22/15 10:10 am for an ICU patient physician order of Magnesium Sulfate 2 grams in 100 ml/.9 Nss to run in one hour for one dose. The order was not transcribed to the MAR or documented as administered to the patient. No documentation was found on the patient medical record or MAR related of the status of the physician's order of 2/22/15 at 10:10 am of Magnesium sulfate.

On 2/22/15 at 12:45 PM a telephone order was taken by a nurse to administer Magnesium Sulfate 2 grams in 50 ml/of sterile water to run in one hour for one dose. This order was transcribed to the MAR and documented as administered to the patient.

Pharmacist (employee #21) stated on interview on 2/24/15 at 10:55 am that Magnesium Sulfate is on shortage in the medical industry and facility only had available Magnesium Sulfate 2 grams in water and that this was informed to medical faculty on previous months in order to ensure that physicians order accordingly with available presentation or call pharmacist to request specifications.

The facility pharmacy services failed to identify that Magnesium Sulfate presentation that is on shortage in the medical industry are ordered in order to promptly intervene and request specifications in order to ensure that patients on need of those medications received the available presentation or pharmacy services follow procedures to attain the medication if is necessary for a patient receiving services at the hospital ICU.


34043


2. During the inspection of CT 1 emergency cart with the X ray department supervisor (employee #32) if was determine that the facility fails to maintain the emergency cart medications in accordance with accepted professional principles.
a. On 2/24/2015 at 11:06 am the emergency cart of the CT 1 was inspected. During the inspection with the X ray department supervisor the surveyor identified that the Lidocaine 2% 100 mg vial was expire on 2/01/2015. Facility fails to maintain the emergency cart medications in accordance with accepted professional principles.

Based on the review of documents, observational tour with the Pharmacist (employee #21), it was determined that the facility failed to ensure that drugs and biological must be kept in a secure area, and locked when appropriate.

Findings include:

1. During the initial observational tour with the pharmacist (employee #21) on 2/24/15 from 10:18 am though 11:46 am the following was identified:

a. Emergency medication box to be use to transfer patients from ICU, that contains
Medical surgical materials and intravenous sodium bicarbonate, epinephrine and 50% dextrose was observed located on a medication room area that was observed unlocked. The facility failed to ensure safe storage of drugs and biological to protect these medications from non authorized persons.

Based on observational tour accompanied by the Nursing Manager (employee #39) of the Emergency Room (ER) during survey process performed on 2/24 and 2/25/2015 from 8:30 am to 4:40 pm, it was found that the facility failed to ensure that the outdated drugs and biological are not available for patient use in 2 out of 4 crash cart at the ER.

Findings include:

1. The Pharmacy services develop medication lists for all the crash carts that are available on adults and pediatrics treatment areas of the ER. This list has the injectables, oral tablets, oral liquids medications and the maximum quantity of each medication available on the crash cart, as well as the medications located on the refrigerator.

On a monthly basis, the Pharmacy services sends assigned staff to review the crash cart medications with a comparison system where they determine which medication and IV fluids are outdated. The available medication lists that the nursing staff has do not include the expiration date of the medications nor the IV fluids. The cart remains closed with a lock until it is open during an emergency. While the cart is lock, the nursing staff, in every work shift, documents on the list "closed cart". They do not have the practice to open the cart to verify and compare the physical presentation of the medications vs. the ones named on the list. The Pharmacy services put a red label over the cart notifying the medication that is going to be expired on the current month.

a. During observational tour performed on 2/24/15 at 9:30 a.m. at the Admissions II treatment area (adults ' patients) the surveyor request to open the crash cart #3. Over it was a red label indicating that one medication is going to be expired (Calan IV). However, on a comparison exercise performed with employee # 39 it was found that two more medications, Cordarone 150 mg/3ml and Vasopressin 20 units/ml, are going to be expired on February. Employee # 39 did not know about this situation.

b. At the same area, on 2/24/15 at 9:30 a.m , on crash carts #3 and #4, it was found four (4) Normal Saline 0.9% of 500 ml and two (2) Normal Saline 0.9% of 250 ml that had expire on December 2014 and January 2015, respectively, (Cross Reference TAG 749).

c. On an observational tour performed at the pediatric treatment area on 2/24/15 at 3:00 p.m, the surveyor spoke with 3 registered nurses (employees #42, #43 and #44) that were located at the medications room and during interview they stated: " It is prefer that the nursing staff have participation on the medications comparison exercise because we can review where each medication is located as well as the medical surgical equipment. Also, we can accurately identify the expiration date of each medication and compare it with the comparison list. We have to be aware when the medications expire because if for any reason the pharmacy staff does not take it on time we can do it".

2. The Pharmacy Services failed to establish a secure mechanism where the nursing staff share the responsibility of identifying the medications on the crash cart and compare them with the medications lists in a manner that the nursing staff performs immediate interventions when an outdated medication or biological should not be available for patient use.

Based on observations during the tour on the X-ray inactive record department, it was determined that the facility failed to ensure that X-ray films and reports are filed under proper safety conditions.

Findings include:

On 2/24/2015 at 3:15 pm the surveyor and Radiology Supervisor (Employee #32) arrive to a building outside the hospital structure. In that building are located the hospital inactive medical records. On the x ray inactive record area were found multiples boxes in different shelf. The X-ray films were coming out of the boxes. The area was dirty, not organized, electric cables uncover, humidity on the ceiling tiles and there were missing ceiling acoustic tiles. Facility fails to ensure that inactive X- ray films and reports are file under proper safety conditions.

Based on the kitchen observational tour with the administrative dietitian (employee #25), review of policies/procedures and food code guidelines, it was determined that the facility failed to operational procedures to ensure that insect control devices are installed accordingly with food code chapter 6 (Section 6-202.13 Physical Facilities Insect Control Devices Design and Installation) that refrigerator and freezer floors are in good condition

Findings include:

1. The kitchen was visited with the administrative dietitian (employee #25) on 2/25/15 from 10:34 am through 12:19 pm the following was determined:

a. At the side of the tray line area were steam tables are located and tray line assembly was performed it was observed a light insect attraction lamp. This device was located about five or six feet near tray line area were steam tables are located. Food code chapter 6 (Section 6-202.13 Physical Facilities Insect Control Devices Design and Installation) requirements establish that insect control devices that are used to electrocute or stunt flying insects must be installed outside and far from areas were food is being prepared to prevent that insects fragments being impelled onto or falling on exposed food, equipment, utensils and single use articles. The facility failed to maintain insect control devices outside food and single use articles premises.

b. Freezer and refrigerator floor was observed in need of maintenance with brownish rust spots.

c. In the formula room the relative humidity and temperature was not measured, nor registered by kitchen personnel.

d. In the dry food storage area the relative humidity and temperature digital device was found off. The kitchen supervisor (employee #38) stated that maybe the batteries do not have charge.

Based on tests performed on equipment and observations made during the survey for the physical environment with the Safety director (employee #14) and safety officer (employee #11) and interview, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well-being of patients receiving services related to sinks in the intensive care unit (ICU), patient's rooms are not equipped with window operators, and nursing staff do not have a device to open bathroom locks in observation area #2 of the emergency room, broken beds, nurses call without cords, broken cooler used for storage ice in the emergency room area and the lack of exhausted fan in the maintenance room .

Findings include:

1. The adult intensive care unit (ICU) was visited on 2/24/15 at 3:45 pm and provided evidence that there is one hand washing sink for seven cubicles instead of one for every three cubicles (for open cubicles). Employee #14 stated during an interview on 2/24/15 at 4:00 pm that the facility is going to expand the ICU and during the expansion they will install sinks, walls and doors to the existing ICU cubicles.

2. All patient's sleeping rooms visited from 2/24/15 through 2/26/15 from 9:00 am until 5:00 pm provided evidence that they do not have operators to open and close the windows and some windows have locks on them which would not allow patients to obtain fresh air in the event of an emergency or if they desire. The facility is designed with a central air conditioning system and each room has a thermostat, however in the event of a fire or explosion where electrical power is lost and smoke fills the hallways or enters the rooms patients would not have access to fresh air. According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) Appendix A 3.1.1.3 states that window use is essential for life safety reasons and in the event of mechanical ventilation system failure.

3. The emergency room (adult and pediatric) was visited on 2/24/15 from 10:00 am until 3:00 pm and the following was observed:

a). Patient's bathrooms in the emergency room area can be locked from the inside and personnel do not have readily accessible keys or a device to open the door.

b). Patient ' s bathrooms in the emergency room the nursing call without pull cord.

c). One sink located on adult area in cubicle #10. Facility failed to ensure this patient areas ' compliance with one sink for every three cubicles to promote hand washing between patients, employee and visitors.

d). In the adult and pediatric waiting area "Cernimiento" Screening, there is an open area were respiratory therapy are provided to patients. In this area facility had four regular chairs were they locate the patients while personnel provide respiratory therapy treatment. Curtains to provide privacy for patient while receiving treatment were not observed in the pediatric area, one single curtain was observed in the adult area.

e). Isolation room #II the air conditioning duct cover with rust was observed.
f). The isolation anteroom #II the cabinet do not have the handles to open the doors and drawers.

g). The plastic laminate of the oxygen sign of the isolation room #II it was observed broken.

4. In the pediatric area of the emergency room it was observed the following:

a). The isolation anteroom was used to storage two stretchers. The facility failed to maintain entrance hall for the isolation room free of unnecessary equipment.

b). Observation area it was observed four cubicles with two cribs the separation is less than 6 feet. No individual curtain for privacy between each patient was observed.

c). In the clean utility room it was observed a baby weight scale over the counter covered with a white paper, also was used to storage 6 regular chairs. A small space was observed between the chairs and the counter where the baby weights scale it is located.

The surveyor asked employee #18 emergency coordinator If they weigh babies in this room? She states " Yes we use this room to weigh the babies " .

d). In the dirty room it was observed three Intravenous stand bases with peeling paint.

5. In the area II of the emergency room (adult) it was observed the following:

a).Nurse call cord system on room #1, #2 was hanging on the wall. It was observed patient can not reach the cord. This room does not have visibility from the nursing counter.

b).The Formica of the nurse counter was observed broken. The nurse who was sitting in this area does not have the visibility to observe the patient on room #1 and #2 because the column located in front of the counter obstructed his visibility.

c).In the medical room the counter have a side with wood exposed (not covered with Formica) and over the counter the Formica broken was observed

d).A wall covered with tiles has a big hole.

e).Exhausted fan located on bathroom uses for women and men does not function.

f).Soiled room with dirty sink and full of water does not have exhausted fan and smoke detector and the soiled linen hamper was full with dirty linen and contaminated linen together.

g).A big cooler was observed in the nurse counter area full of ice. It was broken and deteriorated.

h). Patient stretcher and floor of the negative pressure isolation room were observed with rust.

i). Patient stretcher located on the pediatric isolation room was observed with rust.

6. The kitchen was visited on 2/25/15 at 1:40 pm thru 2:40 pm and the following was found:

a). Two head sprinkler covered with rust in the pantry and meat area.

b). The floor where the fridges are located it is an uneven floor with difference of material and texture is causing a water accumulation under the fridges. The result of this is that all area is covered with rust.

c). Paint from the walls in the pantry and meat room is peeling off.

d) Kitchen range hood was covered with old grease. Evidence of maintenance for the kitchen range hood was requested by the surveyor. No evidence was provided.

e) An insect electrocute lamp in front of the production line was observed with a lot of death flies and bugs.

f) All freezers floors are covered with rust.

7. The Pharmacy area in the hospital was visited on 2/25/15 from 9:30 am through 10:00 am and provides evidence of the following:

a) The walls of intravenous preparation room were not monolithic and have rust holes were found in the tiles and the grout lines were not sealed between the wall tiles which can allow dirt to enter and does not allow for proper cleaning. This room was the pantry before.

b. The filter of the fume hood with a lot of dirt.

8. Nuclear Medicine department as visited on 2/25/15 from 10:10 am through 10:25 am and provides evidence of the following:

a).The ceiling of the patient ' s bathroom with mold.

b).A hole in a wall located in the medication prepare room was observe.

9. Second Floor were Pediatric ward, OB-Gyn ward, Nursery, Intermediate I and Intermediate II was visited on 2/25/15 from 11:35 pm through 2:25 pm and provides evidence of the following:

a).Room #219 (isolation) the hallway entrance was observed a ceiling tile with mold. The door does not have a hinge and the door does not close properly.

10. Respiratory Therapy area provides evidence of the following:

a). Ceiling tiles in the treatment room was observed bended and with mold.

b). Room #202 (private room) the fridge with dust and spots, the reclining chair with broken cover and deteriorated.

c). Maintenance room without exhausted fan.

d). Room #206 B ceiling tile with mold.

e). Nursery storage shelves are wooden. The exhausted fan cover was out of place.

f). Intermediate I dirty room was used to storage four intravenous stands, dirty linen hamper with the contaminated linen side uncovered.

g). Room #357 A the bed was observed bed completely straight and fully lowered. When the surveyor performs a test to the bed reveals that the back of the bed does not rise. Patient refers he inform to the nurses about the bed but nobody respond nothing about it. Patient refers he has a lot of neck pain.

h). Room #365 A the bed was observed without four cap covers, bed railing paint peeling off. The bed was observed completely straight and fully lowered. Surveyor performs tests and reveals that the bed does not function properly.

i). Medication storage room was observed with a lot of dirt and medicine spots on the sink, cabinet ' s doors and the counter where the medications are prepared.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the safety director (employee #14) and safety officer (employee #11), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed from 2/24/15 through 2/27/15 from 9:00 am until 5:00 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS 2567 form (K 0022, K0027, K0046, K0048,K0050, K0051, K0072, K0075,K0104, K0130 and Tag K0147).

3. During observational tour on the Emergency Room performed on 2/24 and 2/25/15 from 8:00 am to 4:30 pm it was found that the Spectrum IV (intravenous) pumps are identified with a green label and written over it an X.
According to interview with employee # 39 he stated: The Biomedical employee from the company performed maintenance and put the green label with an X to identify that the IV pump was checked".
However, the biomedical employee does not identify with date, hour and initials when the maintenance check up was performed. Employee #39 can not determine when the last check was done of the IV pump.


33725


Based on observations made during the survey for the physical environment with the facility's safety director (employee #14) and safety officer (employee#11) and interview, it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to the lack of identified defibrillator receptacles when supplied by the electrical generator and maintenance carts with accessible cleaning chemicals.

Findings include:

1. Crash carts with defibrillators were observed during the physical environment tour performed from 2/24/15 through 2/27/15 from 9:00 am until 5:00 pm and it was determined that they are not plugged into an identified essential electrical system (generator) receptacle.

The facility's safety director (employee #14) stated during an interview on 2/24/15 at 12:10 pm that all defibrillators are plugged into generator supplied receptacles as specified by the electrical outlet plan. Generator supplied receptacles when connected to critical care equipment must be identified (red color receptacles or cover plates) to ensure that this equipment stays charged in the event that the essential electrical system is being used and staff are clear of their location.

2. Maintenance carts were observed from 2/24/15 through 2/27/15 from 8:30 am until 5:00 pm with cleaning chemicals on top and in the middle of the carts and did not have a cabinet on these carts where personnel can lock these cleaning solutions to limit its accessibility to non-authorized persons.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's safety director (employee #14) and safety officer (employee #11) and interview, it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff related to the lack of privacy curtains in the emergency rooms' (E.R) cubicles, lack of bathrooms in the waiting room of the E.R, lack of privacy curtains in the medication administration room of the E.R, and pharmacy departments are not designed to protect patients, staff and materials.

Findings include:

1. The emergency room (pediatric) was visited on 2/24/15 from 10:00 am until 3:00 pm and provided evidence that all observation and treatment cubicles have two cribs per cubicle. However, no evidence was found of division curtains to provide the patients with privacy during treatment (on 2/24/15 the emergency room was full to capacity).

2. The waiting area of the medication administration area in the emergency room was visited on 2/24/15 at 10:45 am and provided evidence that this area does not have bathrooms for patients.

Employee #14 stated during an interview on 2/24/15 at 10:47am that " there are bathrooms near the waiting room, patients or visitors have to ask the guard and he lets them through " .

However, no signs were found related to bathroom use, there location or to inquire with the guard. Bathrooms are an essential component of waiting areas for the emergency room and should be considered to achieve compliance with the minimum requirements of "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF).

3. The medication administration area in the emergency room was observed on 2/24/15 at 10:45 am and provided evidence of ten chairs. Four chairs were on one side of this room and the other six were on the other side. It was observed only one curtain with four oxygen regulator. The chairs did not have privacy curtains between them, also were not separated from each other by at least four feet.

4. The facility has grown in size to include new services and expand their existing services as observed on 2/25/15 at 9:50 am. However during a visit to the facility's pharmacy department on 2/25/15 at 9:50 am, it was found that the pharmacy department has not grown along with the facility. Observations of the pharmacy room provided evidence that the area was over crowded, shelves and cabinets were packed, cabinets and boxes were placed in areas forming a maze to enter and exit, seven employees working in this area.

Pharmacy services must grow in proportion with the facility, increase patient population requires an increase in size of the pharmacy to provide services efficiently and safely. The intravenous preparation room was not monolithic and has rust holes were found in the tiles and the grout lines were not sealed between the wall tiles which can allow dirt to enter and does not allow for proper cleaning. This room was the pantry before.


5. Maintenance closets throughout the hospital and off-site emergency room were observed from 2/24/15 through 2/27/15 from 8:30 am until 5:00 pm. These closets were found with chemicals to clean the facility and equipment and did not have air extractors or smoke detectors connected to the fire alarm system.

6. The emergency room pediatric area was visited on 2/24/15 at 11:35 am and provided evidence that there are five chairs that are placed in a waiting room area that are used to provide respiratory therapy to patients. The five chairs were placed side by side with no space between them and no curtains were found between the chairs. In order to provide emergency treatment to a patient at least four feet between chairs is needed to accommodate emergency staff and equipment and the curtains are needed to provide privacy during treatment.

7. The emergency room (pediatric and adult) was visited and provided evidence that there are two ice cooler containers. Ice is placed in a plastic cooler and a scoop is placed inside a plastic bag. Staff, patients and family members enter this room and extract ice from the cooler. According with Guidelines for Design and Construction for Health Care Facilities section 2.1-2.3.6 (Ice Machines) (page 38) (2010 edition) "Ice intended for human consumption shall be from self-dispensing ice makers".

Based on observations made during the survey for the physical environment with the security director (employee #14) and safety officer (employee #11) and interviews, it was determined that the physical structure and care areas failed to provide proper ventilation in the isolation room #271 located in the intensive care unit.

Findings include:

1. The intensive care unit was visited on 2/22/15 from 3:45 pm until 4:50 pm during the tour it was observed a pedestal fan on inside the isolation room #271. The surveyor takes temperature inside the room with a laser thermometer (Raynger ST) and indicates 78º F. The pedestal fan was dirty and does not have a label indicating that the equipment was inspected by the safety officer.

An interview with intensive care unit supervisor (employee # 19) on 2/22/15 at 3:55 pm revealed that the air conditioning in that room is not functioning properly.

The room was occupied with a patient who is receiving dialysis. Employee #19 states " the room is hot and the patient complains about it " .

2. On 2/24/15 at 4:00 pm employee #14 calls the engineer department and asked if someone called to inform problems with air conditioning in the intensive care unit.

Immediately maintenance employee checks the problem. Employee #14 states " the air conditioning was off " .

The employee #11 removes the pedestal fan from the isolation room and sends it to the maintenance storage.

3. According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) The facility have to provide a safety and ventilated room to reduce exposure of staff, patients and families to airborne infectious diseases according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities".

9. During observation performed on the Surgical Services Department and review of policies/procedures with the Operating Room Supervisor (employee #2), Operation room Clinic Supervisor (employee #4) and Anesthesia Supervisor (employee #3), on 2/24/15 from 10:00 am through 4:00 pm and 2/25/15 from 10:00 am through 3:00 pm it was found the following:

a. On 2/24/15 at 10:00 am in the pre-operative area it was found in the Tray cannulation non sterile gauze expose to the environment without cover.

b. On 2/24/15 at 10:10 am in the difficult intubation anesthesia car it was found a package of 200, non sterile gauze cut in half expose to the environment.

c. On 2/24/15 at 10:30 am in the operation suite #2 it was observed a chair with the vinyl ripped repaired with tape.

d. On 2/24/15 at 10:30 am in the operation suite #2 it was observed a bottle of alcohol at 70% over the anesthesia cart.

e. On 2/24/15 at 11:10 am in the medication room it was found the medication refrigerator opened without lock.

f. On 2/24/15 at 11:25 am in the procedure room (Litotripcia room) that was not in use this day, it was found a single use vial of Diprivan (Propofol) 200 milligram (mg)/20 milliliter (ml) opened and a Syringe of 10 ml with a white liquid pre served without a label with the solution name, dated and hour of served.

g. On 2/24/15 at 11:30 am in the operation Suite #5 it was observed the anesthesiologist physician performing a Spinal injection procedure. During the patient preparation it was observed the anesthesiologist physician with non sterile glove opened the Regular trash can with the hand to discard the material that was opened to perform the procedure. After open all material needed to performed the spinal injection procedure the anesthesiologist physician discard the glove and without wash his hand open the sterile glove and put on them.

h. On 2/25/15 at 10:35 am, it was observed the stretcher that transfer the patient record review #52 to the operation suite #3 with the vinyl of the mattress was ripped and repaired with tape.

i. On 2/25/15 at 10:40 am, it was observed in the operation Suite #3 the circulating RN administrating an Clyndamycin 600 mg Piggy IV to patient of R.R. #52 without clean the septum of the intravenous (IV) line.

9. During observation performed on 2/26/15 at 10:30 am in medicine I ward B it was observed the IV Nurse (employee#6) performing a central line care to patient at room #407 B. It was observed that the employee #6 after remove the bandages from the central line site she remove the non sterile glove and without washing her hand put on a pair of sterile glove to prove the central line care. Not accordance to the infection control standards of practice.


33356


Based on observational tour through the hospital accompanied by the Nursing Department Coordinator (employee # 41) during the survey process performed from 2/24 thru 2/27/2015 from 8:00 am to 5:00 pm, it was found that the facility failed to ensure and promote an ongoing program that identifies infection control issues, establishes a tracking system and evaluates their performance, based on Infection Control practices according to standards of practice, the implementation of the Center's Disease Control and Prevention (CDC) Guidelines for Health Care Facilities and the recommendations established by the Guidelines for Design and Construction of Health Care Facilities. Related to deficient practices observed on cleaning and disinfection of surfaces and floors, uses of the soiled holding room, relocation of unused equipment, management of soiled and contaminated linens, expiration date of intravenous solutions on the crash cart, hand washing procedures, physicians orders and use of PPE on patients with isolation precautions and use of multi dose vials after the used date.

Findings include:

1. On the Emergency Room (ER) observational tour with the Nursing Manager (employee #39) performed on 2/24 and 2/25/2015 it was found deficient practices on infection control measures:

a. On Admissions II treatment area (for adults patients), there is a soiled holding room. It has a sink and over and besides it was observed the following items:

1. more than 5 intravenous stands
2. one duster covered with dust
3. 2 pairs of women's shoes (from patients that were discharged home)
4. one blue dirty pad
5. two dust collectors
6. one duster covered by a yellow cloth
7. one sphygmomanometer tower out of service
8. two empty intravenous bags

b. This soiled holding room has no functional light.

c. The whole floor of this room was covered by dark dust.

d. A covered twin hamper for soiled regular and contaminated linens is located in this room sharing the same space with the other items mentioned above.

e. The facility failed to establish an ongoing monitoring program to ensure that infection control measures are implemented to avoid cross contamination. The facility failed to follow the recommendations established by the Guidelines for Environmental Infection Control in Health Care Facilities, 2003 edition, published by the Center's Disease Control and prevention (CDC) from Atlanta.

f. The facility failed to follow the uses of a soiled holding room according to the Guidelines for Design and Construction of Health Care Facilities, 2010 edition, Chapter 2.1 Common Elements for Hospitals, section 2.1-2.6.10.

g. The facility failed to follow the P&P's for keeping patient's personal belongings due to two (2) pairs of shoes that were not taken away from the soiled holding room.

2. On the ER, all covered red wastebasket, used for biohazard waste, were observed covered by a dark dust.

3. On Admissions II treatment area at ER (for adults patients) there are two (2) crash carts. On both, it was found four (4) Normal Saline 0.9% of 500 ml and two (2) Normal Saline 0.9% of 250 ml that had expire on December 2014 and January 2015, respectively.

4. On the medication room of the Admissions II treatment area, it was found a metallic pill crusher that was not clean, it had a white residue was observed on it. According to P&P's for handling the pill crusher the nursing staff has to put a pill on a medications cup and put other cup over the pill, then crush it. However, seeing the white residue on the crusher it was determined that the nursing staff is not following the procedures.

a. On the same room, paper towel for drying hands, was not available. It was observed and part of the observations performed by the surveyor, that the nursing staff dry ' s their hands over their uniform or shake their hands to eliminate part of the accumulated water, which place risk of causing cross contamination.

b. The facility failed to observe that professional staff performs hands hygiene according to the hand washing guidelines published by the CDC.

5. On one of the isolations room that is located on the hallway that goes to the adult's treatment area, it was found a feeding intravenous (IV) pump. It was not covered by a plastic wrap and employee #39 could not precisely say when its last use in the ER was.

According to interview performed to employee #39 and review of the P&P's for Cleaning Feeding IV pumps, the maintenance personnel cleans the enteral IV pump, puts a bag over the equipment and send it to the area where it was taken. On the other area, the nursing staff cleans and disinfects the enteral pump and covered it with other clean bag and keeps them in a storage room.

a. The facility failed to ensure that the nursing and maintenance personnel perform their duties according to the policies and procedures established for cleaning and disinfection of the feeding IV pump.

6. During observation tour at the Pediatric area of the ER, it was observed an isolation sign for contact precautions in one isolation room:

During RR # 25 performed on 2/24/15 at 3:16 pm, the patient was admitted on 2/22/15 due to diagnose of Impetigo. The 2 years old boy is receiving antibiotic treatment and there are pending results of some cultures due to suspicious diagnose established by the pediatrician as community MRSA. The patient continues receiving care at the ER because on the pediatric unit no beds are available. It was observed that his mother was lying on bed besides him and was not wearing the PPE (protective equipment) required for the type of isolation. Patient's mother was not wearing gown and non sterile gloves. On the medical record, no physician's order was found for the use of an Isolation room with contact precautions.

a. During P&P's review performed on 2/26/15 at 4:00 pm it was found that patients in an isolation room with contact precautions, it is require the use of gown and gloves to assist the patient on the daily activities and has to discard the used PPE after finishing the duties. The family member and professional staff have to perform hand washing procedures before and after performing their interventions with the patient. However, the family member did not follow these recommendations.

b. No evidence was found on the clinical record of the interventions performed by the Infection Control Program Coordinator.

7. During observational tour on the ER it was observed that the nursing staff does not follow the hand washing procedures according to the guidelines published by the CDC.

a. On 2/25/15 at 10:00 am the surveyor observed a Registered Nurse preparing an IV medication (Rocephin- antibiotic). The RN did not wash his hands before preparing the medication. He did not disinfected with alcohol the rubber stopper at the top of the vial and the rubber needle port on the IV bag solution. After finishing the reconciliation of the antibiotic, he did not change the gloves. Using the same gloves, he opened the door of the medication room, touched the computerized panel of the Onmicell medications cabinet, obtained a label with patient's information, opened and closed the door of the cabinet and returned to the medications cart to pick up an IV line and continued to the patient's cubicle to administer the IV antibiotic.

b. According to P&P's review performed on 2/26/15 at 4:00 pm says on the Cleansing and Disinfection of Intravenous (IV) Port, the following steps:

1. "All health professional has to clean and disinfect all IV port with a 70% alcohol swab ".
2. "The cleansing and disinfection process of the IV port will be done before:
a. medications administration
b. contrast administration
c. venipuncture for blood sample

8. The RN failed to follow the hand washing procedures and the procedures for cleansing and disinfection of the IV ports.


33725


11. During the observational tour with the safety director (employee #14) and safety officer (employee #11) on 2/24/15 through 2/26/15 from 8:30 am until 5:00 pm, the following was found in:

Emergency room (pediatric and adult) was visited on 2/24/15 from 10:00 am until 3:00 pm and the following was observed:

a. In evaluation room # 4 it was found under the sink cabinet a plastic bowl with food remains and in the sink drainage a dirty paper.

b. In evaluation room #5 under the sink cabinet it was found an open box of non-sterile gloves.
c. At 10:30 am it was observed in the middle of the hallway in front of the evaluation room #4 and #5 a mechanical ventilator covered with a red bag (biohazard bag). Nobody was watching the mechanical ventilator. Surveyor asked to employee #11 why this machine is here without any surveillance. The employee #11 states she does not know but she think maybe the equipment is dirty.
d.At 10:40 am a respiratory therapist came from the observation area and took the machine. Employee #11 asked her about the equipment and she refers that the equipment is contaminated and she is going to take it to the cleaning room.

e. The " Cernimiento " Screening Area was visited at 10:45 am and the following was observed:

1. Under the sink it was found urine samples tubes, two boxes of non-sterile gloves.
2. In the medication room it was found over the fridge an open bottle of liquid acetaminophen without label the open date and shift.
3. It was observed register nurse (employee #15) prepared the medication he is going to administer to the patient. Employee #15 did not clean and disinfect the area were the medication is going to be prepared; he did not wash his hands before preparing the medication. After finishing the reconciliation of the antibiotic, he did not change the gloves. Using the same gloves, he opened the door of the medication room, touched the computerized panel of the Onmicell medications cabinet, obtained a label with patient's information, opened and closed the door of the cabinet and returned to the medications cart to pick up an IV line and continued to the patient's cubicle to administer the IV antibiotic. He called the patient, sat him in the cubicle and asked him if he is allergic to some medications and explains all the procedure and treatment he is going to administer. However employee #15 does not disinfect the cubicle and the area were the patient is going to receive the treatment.

An interview with employee #15 at 11:00 am reveals that the cubicles, counters and equipment used in this area was disinfected by the register nurse before starts the shift. In other words this area is disinfected three times a day.
Interview performed to the infection control coordinator (employee #12) and policies review on 2/26/15 at 9:00 am indicates that every register nurse have to disinfected equipment, surface and counter after every intervention with patient.
4. It was observed register nurse (employee#16) at11:00 am performing a venipuncture procedure for intravenous fluid treatment. Two intravenous fluid lines without end cap connector and both lines touching the waste disposal full of waste beside the register nurse.
5. The Critical Area (CPR) rooms was visited 2/26/15 at 11:30 am and the following was found:
a. A Foley catheter lacked a label with the hour, Foley number, signature of the nurse and the date when the nurse inserted it (CPR #2).
b. A plastic cart with the glucometer it was observed with dirty stuck and tape residue (CPR#2).
c. Clean linen without plastic under a cabinet; over it two open bottle of water. (CPR #2)
d. The crash cart was revised at it was found an open gel tube without label the open date and the shift. (CPR #2)
e. It was observed a family patient mobile phone charging over the biohazard waste disposal. (CPR#1)
6. Observation treatment area was visited on 2/26/15 at 12:00 pm:
a. It was observed at 12:15 pm patient located in cubicle # 11 A, with active vomits throwing up in a regular bag. Next to him was another patient less than 4 feet of separation.
Interview with the infection control coordinator (employee #12) on 2/26/15 at 9:00 am reveals that emergency room has a blue bag for patient who has active vomits.
b. It was observed in the dirty room all the soiled linen in one yellow bag and the cover of the contaminate linen was opened and all the linen in only one bag.
7. Pediatric area was visited 2/26/15 at 2:00 pm
a. In the examination room #2 it was found under the sink the paper use to cover the examination trencher, seven blue pads and one open box of non-sterile gloves.
b. The chair where the patient or parent sits is of material that is difficult to clean and disinfect.
c. Respiratory therapy masks was observed label with the patient name only, lack of start date, hour and the therapist's signature (cubicle # 7) ( " Cernimiento " Screening waiting area)
d. The pantry area used by employees and patients parents was visited and provided evidence that there are big ice cooler containers. At 2:15 pm it was observed a mother filling with ice a small beach cooler with a metal scoop. She was putting her hand inside the big cooler and touching with the scoop the small cooler. When she finished filling the small beach cooler she put the scoop inside the big cooler with the clean Ice. According with Guidelines for Design and Construction for Health Care Facilities section 2.1-2.3.6 (Ice Machines) (page 38) (2010 edition) "Ice intended for human consumption shall be from self-dispensing ice makers".
Interview with employee #18 ER pediatric coordinator on 2/26/15 at 2:25 pm reveals that the diet department brings from the kitchen the Ice and fills the cooler. The scoop has a plastic bag and the procedure for use it is when the person filled the small cooler or the container has to put back the scoop inside the plastic bag and puts it over the cooler cover.
e. On Critical care area at ER (pediatric) there is one crash cart, it was found one Neo Tech ET Tube Holder expire on June 2014.
8. During the tour in observation and treatment area, it was observed an isolation sign for Doppler precautions in one of the treatment room.
During interview with employee #18 performed on 2/24/15 at 2:30 pm, she indicates that the patient was admitted on 2/21/15 due to diagnose of Flu A and B. She is waiting to be moved to room # 218. The patient continues receiving care at the ER because on the pediatric unit no beds were available until today. It was observed that the sliding door it was half open and his mother was laying his head on the patient ' s legs and was not wearing the PPE (protective equipment) required for the type of isolation. Also, the patient and patient ' s mother was not wearing the mask.
During P&P's review performed on 2/24/15 at 2:48 pm it was found that patients in an isolation room with Doppler precautions, it is require the use of mask. The family member and professional staff have to perform hand washing procedures before and after performing their interventions with the patient. However, the family member and the patient did not follow these recommendations.
9. During the observational tour of second floor on 2/25/15 at 3:45 pm it was found:
a. A hamper full of soiled linen and contaminate linen uncovered in front of room #289. It was observed beside the full hamper a glucometer, a weight scale with lift, a plastic cart with clean medical supply and in front of this plastic cart the waste container one for regular disposal waste and one for biohazard disposal waste.
10. It was observed all housekeeping cart have broom and dustpan. Interview with (employee #30) on 2/25/15 at 12:00 pm reveals that the housekeeping personnel does not use duster to sweep the patients rooms only the duster are use in the hallway and lobby. " We sweep with broom everyday patients room " . (Employee #24) confirm all the information given by employee #30.
11. During the observational tour of the Intensive Care Unit Area with the unit supervisor (employee #19), (employee #11) and (employee #14) located on second floor performed on 2/24/15 at 3:45 pm until 4:50 pm is was observed the following
a. A pedestal fan inside the isolation room #271 was observed. Acute Hemodialysis Atlantis Nurse (employee #20) of the Acute Hemodialysis agency contracted by the facility to provide hemodialysis to patients admitted to the hospital was preparing patient before connection to the hemodialysis machine to receive treatment.
During the process it was identified deviation on infection control precautions related with environment where the patient was located and principles and precautions required to prevent infections was not taken during the procedure.
Employee was not wearing the complete PPE (gown and face shield). At the moment of the intervention the pedestal fan was turned on directly to the patient during the preparation to be connected to the hemodialysis machine. The patient was observed swollen. All the equipment to be used for the connection was over the patient without a barrier, like a blue pad, to separate patient from bed linen. Just a blue pad was observed put under the left arm where the arteriovenous fistula was located.
The surveyor takes temperature inside the room with a laser thermometer (Raynger ST) and indicates 78º F. The pedestal fan was dirty and do not have a label indicating that the equipment was inspected by the safety officer. Surveyor asked employee #11 for the removal of the fan.
An intensive care unit nurse was in the room helping (employee #30) and he is the one who turn off the fan and bring it out from the room. During this entire situation surveyor was observing employee #20 performing the cannulation procedure. Employee #20 was manipulating the syringe because the edema does not permit to find access to cannulate the fistula.
It was observed how the nurse moves back and forward, side to side trying to find the access. During these movements the syringe came out and the nurse returns to insert the same syringe. Surveyor requested employee #19 to go inside the room to watch the procedure that the nurse is performing. The nurse was observed going out from the room and take new syringes without changing his gloves.
Due to the failure by the facility and personnel to provide and maintain a sanitary environment to minimize the transmission of infectious agents and to manage arteriovenous vascular accordingly with standards of practice the director and supervisor of the Acute Hemodialysis Atlantis Nurse presence was requested.
A meeting with the director and supervisor of the Acute Hemodialysis Atlantis services who are contracted by the hospital was performed on 2/25/15 at 2:25 pm where observations and findings identified were discussed in order to identify performance improvement on the process. On the meeting it was present hospital quality improvement program personnel and infection control program personnel. Acute Hemodialysis Atlantis policies and procedures related with infection control and management of arteriovenous vascular access was reviewed and discussed with Atlantis director and supervisor.
Acute Hemodialysis Atlantis director and supervisor stated that they were going to re-evaluate and certify competences of nursing personnel in charge of patient located on ICU. They also stated that were going to maintain supervision of personnel who was providing hemodialysis from their agency to be sure that infection control precautions related with environment and principles and precautions required to prevent infections and the appropriate technique to connect and manage an arteriovenous vascular was maintained.
12. Two Foley catheters lacked a label with the hour, Foley number, signature of the nurse and the date when the nurse inserted it (Room #271 and #276).
13. During the outside observational tour performed on 2/25/15 at 9:30 am the following was observed:

a. Three gray containers with biohazard waste disposal were found in the generators area without covered. The containers have label in handwriting operating room. These containers were not under a roof. The sun was directly in them.



34043


10. On 2/24/15 at 11:16 am during emergency cart inspection with the Nuclear medicine coordinator (employee # 33) at the nuclear cardiology room the following was found:

Three Electrocardiogram strip expire two on 6 /2011 and on in 6/2014
One Surgical scissor expire on 2/11/15
One Quick pace expire on 1/28/2015

Facility fails to have the medical surgical material up to date to prevent infections and communicable diseases.

Based on the review of clinical records and policies it was found that the facility failed to interview all patient for discharge planning in the first 24 hours as per Hospital Policy for 6 out of 60 record reviewed (RR) (RR # 12, #13, #14, #15, #16, and #18).

Findings included:

1. R.R. #12 is an 83 years old male who is admitted on 07/29/14 with a diagnostic of Chronic Obstructive Pulmonary Disease (COPD) and Osteoarthritis. The record was review on 02/26/15 at 1:39 pm. No evidence was found of the initial interview for discharge planning in the medical record.

2. RR # 13 is a 69years old female who was admitted on 09/21/2014 with a diagnosis of Uremic Syndrome, Diabetes Mellitus, High Blood Pressure, Mayor Depressive disorder and End Stage Renal Disease. The record was reviewed on 02/26/2015 at 2:00 pm. No evidence was found of the initial interview for discharge planning in the medical record.

3. R.R. # 14 is an 86 years old male who is admitted to on 10/27/14 with a diagnosis of Acute Coronary Syndrome, High Blood Pressure, Diabetes Mellitus, Osteoarthritis and Coronary Artery Disease. The record was reviewed on 2/26//2014 at 3:50 pm No evidence was found of the initial interview for discharge planning in the medical record.

4.RR #15 is a 82 years old female who was admitted on 10/22/2014 with diagnostic of Non State Myocardial Infarct, High blood pressure, Chronic Obstructive Disease and Osteoarthritis. The record was review on 02/27/15 at 8:25 am. No evidence was found of the initial interview for discharge planning in the medical record.

5. R.R. # 16 is a 66 years old female who is admitted on 10/27/14 with a diagnosis of Intermed Coronary Syndrome, Influenza B and Coronary Artery Disease. The record was reviewed on 02/27/2015 at 8:44 am. No evidence was found of the initial interview for discharge planning in the medical record.

6. R.R. # 18 is a 72 years old male who is admitted on 08/27/14 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The record was reviewed on 02/27/2015 at 12:45 pm. No evidence was found of the initial interview for discharge planning in the medical record.

7. Facility failed to interview all patients for discharge planning in the first 24 hours as per Hospital Policy.

Based on observations made of the Surgical Services Department and review of policies/procedures with the Operating Room Supervisor (employee #2), Operation room Clinic Supervisor (employee #4) and Anesthesia Supervisor (employee #3), it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice for patient's care.

Findings include:

1. During observation performed on 2/24/15 from 10:00 am through 4:00 pm and 2/25/15 from 10:00 am through 3:00 pm it was found the following:

a. On 2/24/15 at 10:00 am in the pre-operative area it was found in the Tray cannulation non sterile gauze exposure to the environment without cover.

b. On 2/24/15 at 10:10 am in the difficult intubation anesthesia car it was found a package of 200, non sterile gauze cut at half exposure to the environment.

c. On 2/24/15 at 10:30 am in the operation suite #2 it was observed a chair with the vinyl ripped repaired with tape.

d. On 2/24/15 at 10:30 am in the operation suite #2 it was observed a bottle of alcohol at 70% over the anesthesia cart.

e. On 2/24/15 at 11:10 am in the medication room it was found the medication refrigerator opened without lock.

f. On 2/24/15 at 11:25 am in the procedure room (Litotripcia room) that was not in use this day, it was found a single use vial of Diprivan (Propofol) 200 milligram (mg)/20 milliliter (ml) opened and a Syringe of 10 ml with a white liquid pre served without a label with the solution name, dated and hour of served.

g. On 2/24/15 at 11:30 am in the operation Suite #5 it was observed the anesthesiologist physician performing a Spinal injection procedure. During the patient preparation it was observed the anesthesiologist physician with non sterile glove opened the Regular trash can with the hand to discard the material that was opened to perform the procedure. After open all material needed to performed the spinal injection procedure the anesthesiologist physician discard the glove and without wash his hand open the sterile glove a put on them.

h. On 2/25/15 at 10:35 am, it was observed the stretcher that transfer the patient record review #52 to the operation suite #3 with the vinyl of the mattress was ripped and repaired with tape.

i. On 2/25/15 at 10:40 am, it was observed in the operation Suite #3 the circulating RN administrating an Clyndamycin 600 mg Piggy Iv to patient of R.R. #52 without clean the septum of the intravenous (IV) line.

Based on medical records reviewed (R.R.) with the operation room clinic supervisor (employee #7), it was determined that the facility failed to ensure that the medical history and physical examination (H&P) is documented by a physician for each patient no more than 30 days before or 24 hours after admission or registration and updated prior to surgery or procedure requiring anesthesia services when the H&P was performed within 30 days before admission or registration for 2 out of 60 medical record reviewed ( R.R#52 and # 53).

Findings include:

1. R.R #52 is a 60 year old male admitted to the facility on 2/25/15 with a diagnosis of Incicional Hernia. During the record review performed on 2/26/15 at 11:50 am it was found that the patient entered to the operating room on 2/25/15 to perform a Repair of Incicional Hernia and requiring anesthesia services. However the H&P was performed by the patient's physician on 1/22/15, thirty-four (34) days before the surgery and no evidence was found that the physician performed an updated H&P previous to the surgery for any change in patient condition.

2. R.R. #53 is a 76 years old female admitted on 2/23/15 with a diagnosis of Left knee Osteoarthrosis. During the record review performed on 2/26/15 at 2:15 pm evidence was found that patient was entered to the operating room on 2/2/23/15 to perform a Total left knee replacement and requiring anesthesia services. However the H&P was left in blank by the patient physician, no evidence was found that the physician performed an H&P previous to the surgery.

Based on the review of medical records and policies/procedures of the operating room with the Operating Room supervisor (employee #2), it was determined that the facility failed to execute complete surgery informed consents that was legible to patient to ensure that the patient, or the patient's representative, is provided information necessary to enable him/her to evaluate a proposed surgery before agreeing to the surgery for 2 out of 60 medical records reviewed (R.R. #44 and #54).

Findings include:

1. R.R. #44 is a 78 years old male admitted with diagnosis of Encarceled Left Inguinal Hernia. The consent form for surgery intervention or medical procedure was signed by the patient on 2/22/15; the consent was illegible to ensure that the patient, or the patient's representative, is provided information necessary to enable him/her to evaluate a proposed surgery before agreeing to the surgery.

2. R.R. #54 is a 48 years old female admitted with diagnosis of Stroke. The consent form for surgery intervention or medical procedure was signed by the patient on 2/24/15; the consent was illegible and incomplete to ensure that the patient, or the patient's representative, is provided information necessary to enable him/her to evaluate a proposed surgery before agreeing to the surgery.

Based on observations during the tour on the Nuclear Medicine inactive record department, it was determined that the facility failed to ensure that inactive nuclear medicine reports are filed under proper safety conditions.

Findings include:

On 2/24/2015 at 3:15 PM the surveyor and Radiology Supervisor (Employee #32) arrive to a building outside the hospital structure. In that building are located the hospital inactive medical records. On the Nuclear medicine inactive record area Multiples boxes were found in wood pallets. The area was dirty, not organized, electric cables uncover, humidity on the ceiling tiles and there were missing ceiling acoustic tiles. Facility failed to ensure that nuclear medicine reports are filed under proper safety conditions.

Based on administrative documents review, Emergency Room (ER) physician's work shifts and interview with one of the ER physician's (employee # 45), performed on 2/26/15 at 11:00 am it was found that the facility failed to ensure to designate a medical director according to rules and regulations established by the State Law number 117 from December 21 of 2004.

Findings include:

1. The Emergency Room has thirteen (13) qualified physician's that provide care to patients at the adult section of the ER. There are two (2) physicians ' that are in charge of the ER medical services and participates in Medical Faculty meetings. However, these physicians are specialized in General Medicine. On the physician's roster there is only one physician that is specialized in Emergency Medicine but does not perform duties as a director.

3. According to State Law number 117 from December 21 of 2004, on chapter XX1, article 3 for Medical Staff establishes the following procedure:

a. "Level II -Secondary level emergencies rooms will be directed by a physician specialized in Emergency Medicine from an accredited university and authorized to perform professional duties in Puerto Rico under "Tribunal Examinador de Medicos" Medical Examination Board.

b- "Must be available twenty four (24) hours a day"

4. The facility failed to comply with State law regulation.

5. The Pediatric Emergency Room has pediatric physicians on two (2) shifts until 12:00 midnight. The patients that remain on ER receiving treatment are transferred to the physicians that are on the adults section of the ER. This situation caused an increased number of patients to follow up and most of these patients after been reevaluated have admission orders, increasing the care that has to be provided by the nursing staff.

a. During documentation review performed on 2/25/15 at 9:00 am with employee # 39 at 7:00 am and at 9:00 am, there were 31 pediatric patients with admissions orders under the care of one pediatric nurse and two (2) physicians of the adult section.

b. On the medical faculty minutes no evidence was found of the discussion of this situation. It was found only discussions related of delay of X-Ray services and other situations that were related to pediatric patient ' s transfers to the general medicine services.

Based on the review of five medical records, policies/procedures, 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 2 out of 5 clinical records reviewed for respiratory therapy (RR #56 and #58).

Findings include:

1. Five medical records were reviewed with Respiratory Therapy Coordinator (employee #10) on 2/27/15 from 2:15 pm till 4:00 pm provided evidence that respiratory therapists did not administer respiratory therapy treatment in accordance with the physician 's order 2 out five (RR #56 and #58). Records reviewed provided evidence that patients did not receive respiratory treatment on a timely basis.

a. R.R. #56 is a 54 years old female admitted on 2/21/15 with a diagnosis of Bronchitis. The record review was performed on 2/27/15 at 2:20 pm provided evidence that the physician ordered on 2/22/15 at 2:20 pm Free Flow Therapy (FFP) Albuterol 0.083% every 4 hour by Power Nebulizer (PN).

The respiratory therapist provide patient respiratory treatment on 2/22/15 at 8:50 pm 6 with a delay of 6 hour.

On 2/24/15 the physician ordered Albuterol 0.083% every 8 hour by PN and on 2/24/15 at 5:30 pm the physician ordered Albuterol 0.083% every 4 hour by PN . The respiratory therapist provide patient treatment on 2/24/15 at 7:00 am, then the next treatment after physician order was provided at 11:20 pm with a delay of treatment of 15 hour. No evidence was found for the justification of the delay and no evidence was found that physician was notified related to the treatment delay.

On 2/25/15 at 8:15 am the respiratory therapist provides patient treatment, the next treatment was provided at 3:00 pm 7 hour later.

On 2/25/15 at 12:10 pm the physician ordered Atrovent 0.02% By PN every 4 hour and Pulmicort 0.5 mg by PN every 12 hour. However no evidence was found that the respiratory therapist provided the respiratory treatment as ordered.

The electronic system does not provide evidence of the therapist notification of the new order. No evidence was found that the patient physician was notified related to the omission of treatment.

On 2/27/15 at 2:40 pm the employee # 10 notified the patient physician related to the omission of treatment. The respiratory therapist provide respiratory treatment with Albuterol 0.083% every 4 hour on 2/22/15 at 1:30 am, at 6:30 am, at 10:40 am an no evidence was found of the physician order for the respiratory treatment.

b. R.R #58 is a 66 years old female admitted on 2/19/15 with a diagnosis of Acute Bronchitis. The record review was performed on 2/27/15 at 2:45 pm provided evidence that the physician ordered on 2/19/15 at 11:17 pm Albuterol 0.083% Plus (+) Atrovent 0.02% by PN every 4 hour and Pulmicort .0.5 ml By PN every 12 hour. The respiratory therapist provides patient respiratory treatment on 2/20/15 at 11:00 am 12 hour later, then at 3:00 pm, at 7:00 pm the patient refuse treatment. No evidence was found the reason that has the patient to refuse, No evidence was found that the registered nurse or the patient physician was notified of the patient refuse treatment.
On 2/20/15 at 11:30 pm and on 2/21/15 at 3:35 am, at 8:00 am, at 11:30 am, at 3:00 pm, 7:00 pm the respiratory therapist provide therapy with Atrovent, no evidence was found of a physician change respiratory treatment order. The Pulmicort treatment was started by the respiratory therapist on 2/21/15 at 8:00 am; 32 hour after physician ordered the treatment. No evidence was found related to respiratory therapist justified the omission of treatment and physician notification.
On 2/22/15 at 3:50 pm the physicians ordered discontinue the Albuterol. On 2/21/15 at 11:00 pm, on 2/22/15 at 3:00 am, at 7:30 am the patient refuse treatment and no evidence was found related to the reason that the patient has to refuse and no evidence e was found of physician notification.
On 2/22/15 at 7:00 pm the respiratory treatment was provided with Atrovent, no evidence was found of the Pulmicort every 12 hour treatment was provided and no evidence was found of physician notification for respiratory treatment re- evaluation.
On 2/23/15 at 3:00 am, 11:00 am, 3:34 pm, and at 7:20 pm, the patient refuse respiratory treatment. No evidence was found physician was notified. On 2/23/15 at 3:10 pm and on 2/25/15 at 1:55 pm, the physician ordered Atrovent 1 ampule every 6 hour, Pulmicort 0.5 ml every 12 hour.
On 2/24/15 at 12:0 am, at 6:30 am, at 11:30 am, on 2/25/15 at 7:00 pm the patient refuse treatment and no evidence was found of physician notification. The respiratory therapist failed to provide respiratory therapy accordance to physician order and to maintain active communication with the patient nurse and physician related to patient refuse the respiratory treatment.

Based on observational tour throughout the Emergency Room (ER) entrance, waiting rooms and treatment areas for children and adults, policies and procedures (P&P's) review and interviews to the Nursing Department Coordinator (employee # 41) and the Clinical Nursing Supervisor (employee # 17), performed from 2/24 to 2/27/2015 from 8:30 am thru 4:30 pm, it was determined that the facility failed to ensure that posting of signs related to EMTALA Law and the Patient's Rights and Responsibilities are in all areas.

Findings include:

1. The EMTALA Law sign is located behind a security officer's desk, not visible to all patients that are sitting on the waiting room for adults. The Patient's Rights and Responsibilities sign is located in a wall closer to the Emergency Room entrance but is not visible to the waiting room.

a. The patient's Rights and Responsibilities sign is written in English but it was not found the same sign written in Spanish.

2. On the children's ER waiting room, no signs were observed.

3. On treatment area for adults, behind the Nurse's station was observed a Patient's Rights and Responsibilities sign located in the medication's room door. However, the letters are so small that cannot be read by all patients that are on the cubicles.

4. On the Admission's I Area (for Adults), is missing an EMTALA Law sign.

5. On the Screening Area (for Adults) waiting room, no signs were observed.

6. During P&P's review on 2/27/15 at 3:00 pm, on step #3 related to patient's transfer based on EMTALA'S policies and procedures, says the following: "There will be an exposed sign at the Emergency Room entrance, Admission's area, waiting room and treatment rooms of the ER that specifies the Patient's Rights related to screening and treatment due to their emergency condition including patient's in labor".

During interview with employee # 41, performed at the pediatric waiting room on 2/27/15 at 1:30 pm, she stated the following: "the physical environmental staffs are painting the waiting room walls and they moved the signs. We will coordinate with that staff to put the posting signs on visible areas as soon as they finished their duties".