Bayamon Medical Center

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 47384 Tests to equipment, interviews and observations made during the survey for Life Safety from fire with a facility Engineering Director (employee #24), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101 and an Immediate Jeopardy was identified. Based on a recertification survey, observation with emergency Engineering Director (employee #24) and Safety Officer (employee #22), on 08/22/2024 at 11:45 AM it was determined that the facility failed to prevent patients from harm. This constitutes an Immediate Jeopardy to 71 out of 154 patients admitted at the facility. IJ began: 08/22/2024 at 11:45 AM through 2:30 PM Facility Notified: 08/22/2024 at 2:42 PM IJ template provided to the facility. Removal Plan Received: 03/20/2024 at 6:30 PM Accepted by surveyor: 08/22/2024 at 6:40 PM”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 20423 Based on records reviewed (R.R), Do Not Resuscitate (DNR) Policies and Procedures, it was determined that the facility failed to ensure that patients or their representatives formulate advance directive and comply with these directives related to written DNR or “Do Not Intubate” (DNI) orders in accordance to the patient’s signed consent for DNR or DNI for 2 out of 8 records reviewed (R.R #40 and #41 ). Findings include: According to the facility’s policies and procedure related to the DNR or DNI order reviewed on 08/21/2024 at 10:00 AM it states in page #2 items #6, #9 and #12 “The DNR/DNI consent must include the name and signature of the physician who directed the patient and/or family member, guardian, or caretaker. The physician will document the taking of consent and place the medical order in the clinical record. The consent, the order, and the progress note must be signed by the primary physician. The primary physician will document the patient’s DNR/DNI status in his or her progress note on a daily basis. The professional nurse will document the DNR/DNI order in the clinical record and activate the corresponding care plan. The facility failed to inform patients or their representatives that they have the right to formulate advance directives and comply with these directives related to DNR and DNI order requests as reviewed on 08/21/2024 from 9:00 AM till 1:00 PM: 1.R.R #40 is a 75-year-old male who was admitted on 08/04/2024 with a diagnosis of Left Lare Pleural Effusion. On 08/21/2024 at 9:47 AM the record was reviewed with the Infection Control Coordinator (employee #20). It was found that the patient’s representative signed a DNR consent on 08/14/2024 at 13:47 PM. Evidence was found of the physician’s written DNR order on 08/14/2024 at 17:50 PM. There is 4-hour difference from the DNR consent and the DNR order. No evidence was found in the physician progress note of the justification the DNR/DN and patient or relative orientation. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 AM and the following was found: a. The nurse failed to identify the patient treatment Kardex that patient have a DNR/DNI order. b. The nurse failed to document the activation of the plan of care for DNR. c. On 08/14/2024, the nurse failed to document in the nurse’s progress note that patient sign a DNR consent, on 3-11 shift, and 11-7 shift, d. On 08/15/2024 the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on the three shift (7-3, 3-11, 11-7). e. On 08/16/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on the 7-3 shift, 3-11 and 11-7 shift. f. On 08/17/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on three shift (7-3, 3-11, 11-7). g. On 08/18/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on the 3-11 and 11-7 shift. h. On 08/19/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on the 7-3 shift, 3-11 and 11-7 shift. i. On 08/20/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR/DNI on the 7-3 shift, 3-11 and 11-7 shift. 2. R.R #41 is a 92-year-old female who was admitted on 08/04/2024 with a diagnosis of Enterocolitis. On 08/21/2024 at 11:30 AM the record was reviewed with the Infection Control Coordinator (employee #20). It was found that the patient’s representative signed a DNI consent on 08/06/2024 at 6:54 AM. Evidence was found of the physician’s written DNI order on 08/13/2024 at 11:05 AM. There is 3 days of difference from the DNR consent and the DNR order. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 11:30 AM and the following was found: a. The nurse failed to document the activation of the plan of care for DNR. b. On 08/10/2024, the nurse failed to document in the nurse’s progress note and in the flow sheet that patient sign a DNR consent, on 7-3 shift, 3-11 shift, and 11-7 shift, c. On 08/11/2024, the nurse failed to document in the nurse’s progress note and in the flow sheet that patient continues with a DNR order on 11-7 shift. d. On 08/12/2024, the nurse failed to document in the nurse’s progress note and in the flow sheet that patient continues with a DNR order on 11-7 shift. e. On 08/13/2024, the nurse failed to document in the nurse’s progress note and in the flow sheet that patient continues with a DNR order on 3-11 shift. f. On 08/14/2024, the nurse failed to document in the nurse’s progress note and in the flow sheet that patient continues with DNR order 7-3 shift, 3-11 shift, and 11-7 shift, g. On 08/15/2024 the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on 11-7 shift. h. On 08/16/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on 3-11 and 11-7 shift. i. On 08/17/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on 3-11 shift. j. On 08/18/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on the 11-7 shift. k. On 08/19/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on the 7-3 shift, 3-11 and 11-7 shift. l. On 08/20/2024, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR order on the 7-3 shift, 3-11 and 11-7 shift.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 20423 Based on records reviewed (R.R) and review of restrain protocol and policies and procedure with the nurse supervisor (employee #15) and Infection Control Officer (employee #20), it was determined that the facility failed to ensure that restraint be used when less restrictive interventions be ineffective to protect the patient from harm for 1 out of 1patient in restraint. (R.R. #45). Findings include: The facility ’ s policy and procedure related to Protocol of Patient in Restriction or Seclusion reviewed on 08/21/2024 at 2:00 PM in the part VI state: Preventive techniques for non-violent or non-self-destructive behavior: Estimate and attempt to correct possible causes of agitation or confusion. Conditions such as hypoxia, hypoglycemia, acute alcohol or drug intoxication, or brain trauma may present as confusion, combativeness, or agitation. Promote rest, make adjustments to the temperature, noise, or light in the room. Provide a calm environment. Use simple instructions. Speak in a soothing tone of voice. Avoid using body language. Review medications for possible adverse effects. Place patient near the nursing station. Meet patient needs such as pain, comfort, hydration, or hygiene. Involve family members. If after implementing the preventive measures mentioned above, there is no positive response, proceed to initiate the restriction protocol based on the behavior presented by the patient: Agitated, hostile, aggressive behavior that endangers the safety of the patient or others. Confused or disoriented patient whose level of agitation or mobility exposes him to harm himself, other people, or property. Attempt to interrupt or discontinue medical treatment. Management of the patient with non-violent behavior: Initiation of restraint: There must be a written or telephone order, which must be countersigned by the physician within the next 24 hours. When the physician in charge of the patient is not available at the time the need for restraint is determined, the nursing staff in charge initiates the intervention and obtains the order within the first hour. The patient evaluation is performed face to face by the physician in charge of the patient, resident physician, and intern physician. The nursing professional is responsible for educating the family member and documenting it in the medical record. Monitoring: The nursing professional is responsible for monitoring the restrained patient every two hours. From the beginning of the restraints, evaluations are performed on each shift to identify changes in the patient’s behavior that allow the discontinuation of the restraints. Care plans are activated. Documentation: The beginning of the restraint is documented in the record by the physician in charge or delegate. The medical order has a duration of 24 hours. The medical record includes the following: Alternative methods used before reaching the restriction. Specific description of the behavior or condition that justifies the restriction. Signs or symptoms and diagnosis of the patient upon admission. Results obtained from the security measures applied to the patient with the purpose of maintaining his health, his personal well-being and respecting his dignity. Notification of the use of restriction or seclusion from the physician in charge of the patient. Date and time of the beginning of the restriction. Review of the Care Plan. Results of attempts to discontinue the restriction. Renewal of the restriction protocol: The renewal of the restriction is documented in the record by the responsible physician or his delegate as well as the inmates. The medical order has a duration of 24 hours. If it is necessary to continue with the restrictions, a new order for the same is issued every 24 hours. 1.R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. According to the record review performed on 08/21/2024 at 1:43 PM with nurse supervisor (employee #15), it was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/14/2024 at 17:01 PM the physician ordered Restraint Monitoring every 2 hour. On 08/15/2024 at 9:38 PM the physician ordered Restraint Monitoring every 2 hour. On 08/18/2024 at 20:10 PM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/19/2024 at 14:26 PM, the physician ordered Restraint Monitoring every 2 hour. On 08/20/2024 at 5:07AM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/21/2024 at 7:29 AM the physician ordered Restraint Initial now, every 8-hour, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. Evidence was found that the registered Nurse initiate the restraint monitoring on 08/14/2024 at 20:00 PM and continue monitoring every 2 hours, except on 08/16/2024 at 8:55 AM that was performed 2 hour 55 minutes, on 08/17/2024 at 6:00 AM that was performed 3 hours, On 08/18/2024 that was not performed since 2:00 AM until 8:00 AM, on 08/19/2024 since 10:00 AM until 14:00 PM. The registered nurse (RN) failed to document the sign and symptom or patient behavior before restraint, failed to document the less restrictive interventions or alternative measure before restraint. The RN progress note lacks documentation that patient was restraint, the reason for restraint, the patient behavior for restraint, physician notification before restraint, mechanism for restrain. No evidence was found related to physician evaluation face to face before restraint. No evidence was found related to less restrict measure to be performed before restraint the patient. a.The facility failed to meet their restraint policy and procedure. b. The RN failed to document the sign and symptom or patient behavior before restraint. c. The RN failed to document the less restrictive interventions or alternative measure before restraint. d. The RN failed to document that physician was notified and evaluate patient before restraint. e. The RN failed to activate the restraint plan of care. f. The RN failed to document in the nursing Progress Note and in the nursing flow sheet that patient was in restraint and the patient behavior justification for continue restraint and the constant observation and intervention to the patient in the nursing progress note in each 7-3, 3-11 and 11-7 shift. g. The RN failed to document in the restraint monitoring sheet the patient assessment on 08/18/2024 at 4:00 AM and at 6:00PM, on 08/19/2024 at 12:00 PM. h. The RN failed to document the patient, or their relative orientation related to the restraint when started. i. The RN continue restraint patient without a physician order on 08/15/2024, on 08/16/2024, on 08/17/2024, and on 08/19/2024. j. The physician on charge of patient failed to perform a comprehensive face to face assessment that justified the use of restraint in the patient. k. The physician failed to write a new physician order every 24 hours for the continue or renew the restraint order. l. The Physician failed to document in the progress note the daily justification for continue the restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 20423 Based on records reviewed (R.R) and review of restrain protocol and policies and procedure with the nurse supervisor (employee #15) and Infection Control Officer (employee #20), it was determined that the facility failed to ensure that restraint plan of care was activated and reviewed in each nurse shift for 1 out of 1 patient in restraint. (R.R. #45). Findings include: The facility’ s policy and procedure related to Protocol of Patient in Restriction or Seclusion reviewed on 08/21/2024 at 2:00 PM in the part VI state: Preventive techniques for non-violent or non-self-destructive behavior: Estimate and attempt to correct possible causes of agitation or confusion. Conditions such as hypoxia, hypoglycemia, acute alcohol or drug intoxication, or brain trauma may present as confusion, combativeness, or agitation. Promote rest, make adjustments to the temperature, noise, or light in the room. Provide a calm environment. Use simple instructions. Speak in a soothing tone of voice. Avoid using body language. Review medications for possible adverse effects. Place patient near the nursing station. Meet patient needs such as pain, comfort, hydration, or hygiene. Involve family members. If after implementing the preventive measures mentioned above, there is no positive response, proceed to initiate the restriction protocol based on the behavior presented by the patient: Agitated, hostile, aggressive behavior that endangers the safety of the patient or others. Confused or disoriented patient whose level of agitation or mobility exposes him to harm himself, other people, or property. Attempt to interrupt or discontinue medical treatment. Management of the patient with non-violent behavior: Initiation of restraint: There must be a written or telephone order, which must be countersigned by the physician within the next 24 hours. When the physician in charge of the patient is not available at the time the need for restraint is determined, the nursing staff in charge initiates the intervention and obtains the order within the first hour. The patient evaluation is performed face to face by the physician in charge of the patient, resident physician, and intern physician. The nursing professional is responsible for educating the family member and documenting it in the medical record. Monitoring: The nursing professional is responsible for monitoring the restrained patient every two hours. From the beginning of the restraints, evaluations are performed on each shift to identify changes in the patient’s behavior that allow the discontinuation of the restraints. Care plans are activated. Documentation: The beginning of the restraint is documented in the record by the physician in charge or delegate. The medical order has a duration of 24 hours. The medical record includes the following: Alternative methods used before reaching the restriction. Specific description of the behavior or condition that justifies the restriction. Signs or symptoms and diagnosis of the patient upon admission. Results obtained from the security measures applied to the patient with the purpose of maintaining his health, his personal well-being and respecting his dignity. Notification of the use of restriction or seclusion from the physician in charge of the patient. Date and time of the beginning of the restriction. Review of the Care Plan. Results of attempts to discontinue the restriction. Renewal of the restriction protocol: The renewal of the restriction is documented in the record by the responsible physician or his delegate as well as the inmates. The medical order has a duration of 24 hours. If it is necessary to continue with the restrictions, a new order for the same is issued every 24 hours. 1.R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. According to the record review performed on 08/21/2024 at 1:43 PM with nurse supervisor (employee #15), it was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/14/2024 at 17:01 PM the physician ordered Restraint Monitoring every 2 hour. On 08/15/2024 at 9:38 PM the physician ordered Restraint Monitoring every 2 hour. On 08/18/2024 at 20:10 PM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/19/2024 at 14:26 PM, the physician ordered Restraint Monitoring every 2 hour. On 08/20/2024 at 5:07 AM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/21/2024 at 7:29 AM the physician ordered Restraint Initial now, every 8-hour, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. Evidence was found that the registered Nurse initiate the restraint monitoring on 08/14/2024 at 20:00 PM and continue monitoring every 2 hours, except on 08/16/2024 at 8:55 PM that was performed 2 hour 55 minutes, on 08/17/2024 at 6:00 AM that was performed 3 hours, On 08/18/2024 that was not performed since 2:00 AM until 8:00 AM, on 08/19/2024 since 10:00 AM until 14:00 PM. The registered nurse (RN) failed to document the sign and symptom or patient behavior before restraint, failed to document the less restrictive interventions or alternative measure before restraint. The RN progress note lacks documentation that patient was restraint, the reason for restraint, the patient behavior for restraint, physician notification before restraint, mechanism for restrain. No evidence was found related to physician evaluation face to face before restraint. No evidence was found related to less restrict measure to be performed before restraint the patient. a. The facility failed to meet their restraint policy and procedure. b. The RN failed to document the sign and symptom or patient behavior before restraint. c. The RN failed to document the less restrictive interventions or alternative measure before restraint. d. The RN failed to document that physician was notified and evaluate patient before restraint. e. The RN failed to activate the restraint plan of care. f. The RN failed to document in the nursing Progress Note and in the nursing flow sheet that patient was in restraint and the patient behavior justification for continue restraint and the constant observation and intervention to the patient in the nursing progress note in each 7-3, 3-11 and 11-7 shift. g. The RN failed to document in the restraint monitoring sheet the patient assessment on 08/18/2024 at 4:00 AM and at 6:00 AM, on 08/19/2024 at 12:00 PM. h. The RN failed to document the patient, or their relative orientation related to the restraint when started. i. The RN continue restraint patient without a physician order on 08/15/2024, on 08/16/2024, on 08/17/2024, and on 08/19/2024. j. The physician on charge of patient failed to perform a comprehensive face to face assessment that justified the use of restraint in the patient. k. The physician failed to write a new physician order every 24 hours for the continue or renew the restraint order. l. The Physician failed to document in the progress note the daily justification to continue the restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 20423 Based on records reviewed (R.R) and review of restrain protocol and policies and procedure with the nurse supervisor (employee #15) and Infection Control Officer (employee #20), it was determined that the facility failed to ensure that restraint be used in accordance with a physician order for 1 out of 1 patient in restraint. (R.R. #45). Findings include: 1.R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. According to the record review performed on 08/21/2024 at 1:43 PM with nurse supervisor (employee #15), it was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/14/2024 at 17:01 PM the physician ordered Restraint Monitoring every 2 hour. On 08/15/2024 at 9:38 PM the physician ordered Restraint Monitoring every 2 hour. On 08/18/2024 at 20:10 PM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/19/2024 at 14:26 PM, the physician ordered Restraint Monitoring every 2 hour. On 08/20/2024 at 5:07 AM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/21/2024 at 7:29 AM the physician ordered Restraint Initial now, every 8-hour, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. Evidence was found that the registered Nurse initiate the restraint monitoring on 08/14/2024 at 20:00 PM and continue monitoring every 2 hours, except on 08/16/2024 at 8:55 AM that was performed 2 hour 55 minutes, on 08/17/2024 at 6:00 AM that was performed 3 hours, on 08/18/2024 that was not performed since 2:00 AM until 8:00 AM, on 08/19/2024 since 10:00 AM until 14:00 PM. The registered nurse (RN) failed to document the sign and symptom or patient behavior before restraint, failed to document the less restrictive interventions or alternative measure before restraint. The RN progress note lacks documentation that patient was restraint, the reason for restraint, the patient behavior for restraint, physician notification before restraint, mechanism for restrain. No evidence was found related to physician evaluation face to face before restraint. No evidence was found related to less restrict measure to be performed before restraint the patient. a. The facility failed to meet their restraint policy and procedure. b. The RN failed to document the sign and symptom or patient behavior before restraint. c. The RN failed to document the less restrictive interventions or alternative measure before restraint. d. The RN failed to document that physician was notified and evaluate patient before restraint. e. The RN failed to activate the restraint plan of care. f. The RN failed to document in the nursing Progress Note and in the nursing flow sheet that patient was in restraint and the patient behavior justification for continue restraint and the constant observation and intervention to the patient in the nursing progress note in each 7-3, 3-11 and 11-7 shift. g. The RN failed to document in the restraint monitoring sheet the patient assessment on 08/18/2024 at 4:00 AM and at 6:00 AM, on 08/19/2024 at 12:00 PM. h. The RN failed to document the patient, or their relative orientation related to the restraint when started. i. The RN continue restraint patient without a physician order on 08/15/2024, on 08/16/2024, on 08/17/2024, and on 08/19/2024. j. The physician on charge of patient failed to perform a comprehensive face to face assessment that justified the use of restraint in the patient. k. The physician failed to write a new physician order every 24 hours for the continue or renew the restraint order. l. The Physician failed to document in the progress note the daily justification for continue the restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 20423 Based on records reviewed (R.R) and review of restrain protocol and policies and procedure with the nurse supervisor (employee #15) and Infection Control Officer (employee #20), it was determined that the facility failed to ensure that restraint order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy for 1 out of 1 patient in restraint. (R.R. #45). Findings include: The facility ’ s policy and procedure related to Protocol of Patient in Restriction or Seclusion reviewed on 08/21/2024 at 2:00 PM in the part VI state: Preventive techniques for non-violent or non-self-destructive behavior: Estimate and attempt to correct possible causes of agitation or confusion. Conditions such as hypoxia, hypoglycemia, acute alcohol or drug intoxication, or brain trauma may present as confusion, combativeness, or agitation. Promote rest, make adjustments to the temperature, noise, or light in the room. Provide a calm environment. Use simple instructions. Speak in a soothing tone of voice. Avoid using body language. Review medications for possible adverse effects. Place patient near the nursing station. Meet patient needs such as pain, comfort, hydration, or hygiene. Involve family members. If after implementing the preventive measures mentioned above, there is no positive response, proceed to initiate the restriction protocol based on the behavior presented by the patient: Agitated, hostile, aggressive behavior that endangers the safety of the patient or others. Confused or disoriented patient whose level of agitation or mobility exposes him to harm himself, other people, or property. Attempt to interrupt or discontinue medical treatment. Management of the patient with non-violent behavior: Initiation of restraint: There must be a written or telephone order, which must be countersigned by the physician within the next 24 hours. When the physician in charge of the patient is not available at the time the need for restraint is determined, the nursing staff in charge initiates the intervention and obtains the order within the first hour. The patient evaluation is performed face to face by the physician in charge of the patient, resident physician, and intern physician. The nursing professional is responsible for educating the family member and documenting it in the medical record. Monitoring: The nursing professional is responsible for monitoring the restrained patient every two hours. From the beginning of the restraints, evaluations are performed on each shift to identify changes in the patient’s behavior that allow the discontinuation of the restraints. Care plans are activated. Documentation: The beginning of the restraint is documented in the record by the physician in charge or delegate. The medical order has a duration of 24 hours. The medical record includes the following: Alternative methods used before reaching the restriction. Specific description of the behavior or condition that justifies the restriction. Signs or symptoms and diagnosis of the patient upon admission. Results obtained from the security measures applied to the patient with the purpose of maintaining his health, his personal well-being and respecting his dignity. Notification of the use of restriction or seclusion from the physician in charge of the patient. Date and time of the beginning of the restriction. Review of the Care Plan. Results of attempts to discontinue the restriction. Renewal of the restriction protocol: The renewal of the restriction is documented in the record by the responsible physician or his delegate as well as the inmates. The medical order has a duration of 24 hours. If it is necessary to continue with the restrictions, a new order for the same is issued every 24 hours. 1.R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. According to the record review performed on 08/21/2024 at 1:43 PM with nurse supervisor (employee #15), it was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/14/2024 at 17:01 PM the physician ordered Restraint Monitoring every 2 hour. On 08/15/2024 at 9:38 PM the physician ordered Restraint Monitoring every 2 hour. On 08/18/2024 at 20:10 PM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/19/2024 at 14:26 PM, the physician ordered Restraint Monitoring every 2 hour. On 08/20/2024 at 5:07 AM the physician ordered Restraint Initial now, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. On 08/21/2024 at 7:29 AM the physician ordered Restraint Initial now, every 8-hour, Behavior Requirement: Disoriented, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. Evidence was found that the registered Nurse initiate the restraint monitoring on 08/14/2024 at 20:00 PM and continue monitoring every 2 hours, except on 08/16/2024 at 8:55 AM that was performed 2 hour 55 minutes, on 08/17/2024 at 6:00 AM that was performed 3 hours, on 08/18/2024 that was not performed since 2:00 AM until 8:00 AM, on 08/19/2024 since 10:00 AM until 14:00 PM. The registered nurse (RN) failed to document the sign and symptom or patient behavior before restraint, failed to document the less restrictive interventions or alternative measure before restraint. The RN progress note lacks documentation that patient was restraint, the reason for restraint, the patient behavior for restraint, physician notification before restraint, mechanism for restrain. No evidence was found related to physician evaluation face to face before restraint. No evidence was found related to less restrict measure to be performed before restraint the patient. a. The facility failed to meet their restraint policy and procedure. b. The RN failed to document the sign and symptom or patient behavior before restraint. c. The RN failed to document the less restrictive interventions or alternative measure before restraint. d. The RN failed to document that physician was notified and evaluate patient before restraint. e. The RN failed to activate the restraint plan of care. f. The RN failed to document in the nursing Progress Note and in the nursing flow sheet that patient was in restraint and the patient behavior justification for continue restraint and the constant observation and intervention to the patient in the nursing progress note in each 7-3, 3-11 and 11-7 shift. g. The RN failed to document in the restraint monitoring sheet the patient assessment on 08/18/2024 at 4:00 AM and at 6:00 AM, on 08/19/2024 at 12:00 PM. h. The RN failed to document the patient, or their relative orientation related to the restraint when started. i. The RN continue restraint patient without a physician order on 08/15/2024, on 08/16/2024, on 08/17/2024, and on 08/19/2024. j. The physician on charge of patient failed to perform a comprehensive face to face assessment that justified the use of restraint in the patient. k. The physician failed to write a new physician order every 24 hours for the continue or renew the restraint order. l. The Physician failed to document in the progress note the daily justification for continue the restraint.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 20423 Based on thirteen medical record review for Isolation, DNR and restraint with the Infection Control Officer (employee #20), Nurse supervisor (employee #13, #14, #15), it was determined that the facility failed to ensure that the nursing staff develops, and keeps current, nursing care plans for each patient for 13 out of 13 medical records review with respect to the nursing plan of care component for isolation, restraint and DNR. (RR #33, RR #34, #35. #36, #37. #38. #39, #40, #41, #42, #443, #44, and #45). Findings include: 1. R.R #33 is an 82-year-old male who was admitted on 08/16/2024 with a diagnosis of Congestive Heart Failure (CHF) and High Blood Pressure (HBP). On 08/20/2024 at 11:30 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered on 08/19/2024 at 14:03 PM Isolation Precaution for Klebsiella in urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. 2. R.R #34 is a 74-year-old female who was admitted on 08/15/2024 with a diagnosis of Pneumonia, and Urine Tract Infection (UTI). On 08/20/2024 at 11:35 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered Contact Isolation on 08/19/2024 at 8:30 AM for Klebsiella Pneumonia and Schizophrenia Coli in gastrostomy and in urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient’s representative signed a Do Not Resuscitate (DNR) consent on 08/16/2024 at 12:41 AM. Evidence was found of the physician’s written DNR order on 08/16/2024 at 12:45 AM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan. 3. R.R #35 is a 61-year-old female who was admitted on 08/09/2024 with a diagnosis of Lung Cancer with Metastasis. On 08/20/2024 at 1:30 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered on 08/09/2024 at 2:43 PM Protective Isolation due to Immunocompromise status of the patient. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. 4. R.R #36 is a 92-year-old female who was admitted on 08/04/2024 with a diagnosis of Enterocolitis. On 08/20/2024 at 2:47 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 08/04/2024 at 12:23 PM Contact Isolation due to Clostridium Difficile. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient’s representative signed a Do Not Intubate (DNI) consent on 08/16/2024 at 10:20 AM. Evidence was found of the physician’s written DNI order on 08/16/2024 at 8:19 AM. However, no evidence was found that the Registered Nurse (RN) activate the DNI Care Plan. 5. R.R #37 is a 65-year-old male who was admitted on 07/26/2024 with a diagnosis of Sepsis. On 08/202024 at 3:00 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 07/29/2024 at 12:03 PM Isolation due to Klebsiella Pneumonia, Pseudomonas Aeruginosa in ulcer culture. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient’s representative signed a DNR consent on 08/08/2024. Evidence was found of the physician’s written DNR order on 08/08/2024 at 15:21 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR Care Plan. 6. R.R #38 is a 35-year-old female who was admitted on 08/09/2024 with a diagnosis of Matrix Cancer. On 08/20/2024 at 3:30 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 08/09/2024 at 1:00 PM Protective Isolation. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. 7. R.R #39 is a 79-year-old male who was admitted on 07/11/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). On 08/21/2024 at 8:44 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered on 07/19/2024 at 14:05 PM Isolation due to Pseudomonas Aeruginosa and Candida Albica in Urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. 8. R.R #40 is a 75-year-old male who was admitted on 08/04/2024 with a diagnosis of Left Lare Pleural Effusion. On 08/21/2024 at 9:47 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the patient’s representative signed a DNR consent on 08/14/2024 at 13:47 PM. Evidence was found of the physician’s written DNR order on 08/14/2024 at 17:50 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan. 9. R.R #41 is a 92-year-old female who was admitted on 08/04/2024 with a diagnosis of Enterocolitis. On 08/21/2024 at 11:30 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the patient’s representative signed a Do Not Intubate (DNI) consent on 08/06/2024 at 6:54 AM. Evidence was found of the physician’s written DNI order on 08/13/2024 at 11:05 AM. However, no evidence was found that the Registered Nurse (RN) activate the DNI Care Plan. 10. R.R #42 is a 44-year-old female who was admitted on 08/13/2024 with a diagnosis of Covid 19. On 08/21/2024 at 10:44 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 08/13/2024 at 20:47 PM Droplet Isolation due to Covid. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. 11. R.R #43 is a 72-year-old male who was admitted on 06/27/2024 with a diagnosis of Pleural Effusion and CHF. On 08/21/2024 at 10:09 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the patient’s representative signed a DNR consent on 06/28/2024 at 2:34 PM. Evidence was found of the physician’s written DNR order on 06/28/2024 at 14:38 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan. 12. R.R #44 is a 90-year-old male who was admitted on 08/17/2024 with a diagnosis of Altered Mental Status. On 08/217/2024 at 3:12 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #13. It was found that the patient’s representative signed a DNR consent on 08/17/2024 at 12:52 PM. Evidence was found of the physician’s written DNR order on 08/17/2024 at 12:05 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan. 13. R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. On 08/21/2024 at 1:43 PM the record was reviewed with the Infection Control Coordinator (employee #20) and with nurse supervisor (employee #13). It was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. The RN initiate the restraint monitoring on 08/14/2024 at 20:00 PM. However, no evidence was found that the Registered Nurse (RN) activate the Restrain Care Plan.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 20423 Based on thirteen medical records reviewed (R.R) for Isolation, DNR and restraint with the Infection Control Officer (employee #20), Nurse supervisor (employee #13, #14, #15), it was determined that the facility failed to ensure medical record be complete, dated, in writing or electronic form by the person responsible for service provided for 13 out of 13 records reviewed. (RR#33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44 and #45) Findings include: 1. R.R #33 is an 82-year-old male who was admitted on 08/16/2024 with a diagnosis of Congestive Heart Failure (CHF) and High Blood Pressure (HBP). On 08/20/2024 at 11:30 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered on 08/19/2024 at 14:03 PM Isolation Precaution for Klebsiella in urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:30 AM and the following was found: a. The nurse failed to document the activation of the isolation Care Plan. b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution c. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with Isolation. 2. R.R #34 is a 74-year-old female who was admitted on 08/15/2024 with a diagnosis of Pneumonia, and Urine Tract Infection (UTI). On 08/20/2024 at 11:35 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered Contact Isolation on 08/19/2024 at 8:30 AM for Klebsiella Pneumonia and Schizophrenia Coli in gastrostomy and in urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient’s representative signed a Do Not Resuscitate (DNR) consent on 08/16/2024 at 12:41 AM. Evidence was found of the physician’s written DNR order on 08/16/2024 at 12:45 AM. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:35 AM and the following was found: a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan. b. The nurse failed to document the activation of the isolation Care Plan. c. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution d. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR. e. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR. f. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order and Isolation. 3. R.R #35 is a 61-year-old female who was admitted on 08/09/2024 with a diagnosis of Lung Cancer with Metastasis. On 08/20/2024 at 1:30 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the physician ordered on 08/09/2024 at 2:43 PM., Protective Isolation due to Immunocompromise status of the patient. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 1:30 PM and the following was found: a. The nurse failed to document the activation of the isolation Care Plan. b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution c. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with Isolation. 4. R.R #36 is a 92-year-old female who was admitted on 08/04/2024 with a diagnosis of Enterocolitis. On 08/20/2024 at 2:47 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor (employee #15). It was found that the physician ordered on 08/04/2024 at 12:23 PM Contact Isolation due to Clostridium Difficile. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient’s representative signed a Do Not Intubate (DNI) consent on 08/16/2024 at 10:20 AM. Evidence was found of the physician’s written DNI order on 08/16/2024 at 8:19 AM. However, no evidence was found that the Registered Nurse (RN) activate the DNI Care Plan. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:35 AM and the following was found: a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan. b. The nurse failed to document the activation of the isolation Care Plan. c. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution d. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR. e. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR. f. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order and Isolation 5. R.R #37 is a 65-year-old male who was admitted on 07/26/2024 with a diagnosis of Sepsis. On 08/202024 at 3:00 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 07/29/2024 at 12:03 PM Isolation due to Klebsiella Pneumonia, Pseudomonas Aeruginosa in ulcer culture. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. It was found that the patient’s representative signed a DNR consent on 08/08/2024. Evidence was found of the physician’s written DNR order on 08/08/2024 at 15:21 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR Care Plan. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:35 AM and the following was found: a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan. b. The nurse failed to document the activation of the isolation Care Plan. c. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution. d. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR. e. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR. f. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order and Isolation 6. R.R #38 is a 35-year-old female who was admitted on 08/09/2024 with a diagnosis of Matrix Cancer. On 08/20/2024 at 3:30 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 08/09/2024 at 1:00 PM, Protective Isolation. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:35 AM and the following was found: a. The nurse failed to document the activation of the isolation Care Plan. b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution. c. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with Isolation. 7. R.R #39 is a 79-year-old male who was admitted on 07/11/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). On 08/21/2024 at 8:44 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee (#14). It was found that the physician ordered on 07/19/2024 at 14:05 PM Isolation due to Pseudomonas Aeruginosa and Candida Albica in Urine. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:35 AM and the following was found: a. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution. b. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with Isolation 8. R.R #40 is a 75-year-old male who was admitted on 08/04/2024 with a diagnosis of Left Lare Pleural Effusion. On 08/21/2024 at 9:47AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the patient’s representative signed a DNR consent on 08/14/2024 at 13:47 PM. Evidence was found of the physician’s written DNR order on 08/14/2024 at 17:50 PM. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 AM and the following was found: a. The nurse failed to identify the patient treatment Kardex that patient have a DNR/DNI order. b. The nurse failed to document the activation of the DNR (Dead Process) Care Plan. c. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR. d. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR. f. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order. 9. R.R #41 is a 92-year-old female who was admitted on 08/04/2024 with a diagnosis of Enterocolitis. On 08/21/2024 at 11:30 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the patient’s representative signed a Do Not Intubate (DNI) consent on 08/06/2024 at 6:54 AM. Evidence was found of the physician’s written DNI order on 08/13/2024 at 11:05 AM. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 Am and the following was found: a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan. b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR. c. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR. d. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order. 10. R.R #42 is a 44-year-old female who was admitted on 08/13/2024 with a diagnosis of Covid 19. On 08/21/2024 at 10:449 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #15. It was found that the physician ordered on 08/13/2024 at 20:47 PM, Droplet Isolation due to Covid. However, no evidence was found that the Registered Nurse (RN) activate the Isolation Care Plan. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/20/2024 at 11:30 AM and the following was found: a. The nurse failed to document the activation of the isolation Care Plan. b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the isolation precaution. c. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with Isolation. 11. R.R #43 is a 72-year-old male who was admitted on 06/27/2024 with a diagnosis of Pleural Effusion and CHF. On 08/21/2024 at 10:09 AM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #14. It was found that the patient’s representative signed a DNR consent on 06/28/2024 at 2:34 PM. Evidence was found of the physician’s written DNR order on 06/28/2024 at 14:38 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 AM and the following was found: a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan. b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR. c. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR. d. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order. 12. R.R #44 is a 90-year-old male who was admitted on 08/17/2024 with a diagnosis of Altered Mental Status. On 08/217/2024 at 3:12 PM the record was reviewed with the Infection Control Coordinator (employee #20) and Nurse supervisor employee #13. It was found that the patient’s representative signed a DNR consent on 08/17/2024 at 12:52 PM. Evidence was found of the physician’s written DNR order on 08/17/2024 at 12:05 PM. However, no evidence was found that the Registered Nurse (RN) activate the DNR (Dead Process) Care Plan. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 AM and the following was found: a. The nurse failed to document the activation of the DNR (Dead Process) Care Plan. b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the DNR. c. No evidence was found documented in the physician progress the orientation of the patient and patient relative related to the DNR. d. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with DNR order. 13. R.R. #45 is an 85-year-old male who was admitted on 08/11/2024 with a diagnosis of Pneumonia. On 08/21/2024 at 1:43 PM the record was reviewed with the Infection Control Coordinator (employee #20) and with nurse supervisor (employee #13). It was found that on 08/14/2024 at 17:01 PM the physician ordered Restraint Initial now, Behavior Requirement: Harm to self, Restraint Type: Foam/ Soft Limb, Restraint Location: Bilateral Upper extremity. The RN initiate the restraint monitoring on 08/14/2024 at 20:00 PM. However, no evidence was found that the Registered Nurse (RN) activate the Restrain Care Plan. Nurses progress note, Nurses flow sheet and Plan of care was reviewed on 08/21/2024 at 9:47 AM and the following was found: a. The nurse failed to document the activation of the Restraint Care Plan. b. No evidence was found documented in the RN progress note the orientation of the patient and patient relative related to the Restraint. c. No evidence was found documented in the physician progress the face-to-face comprehensive assessment that justify the restraint order d. No evidence was found documented in the nurse progress note and in the flow sheet that patient continues with restraint order.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 20423 Base on observation tour with the Infection Contro Officer employee #20, it was determined that the facility failed failed to ensure that all drug and biological be kept in a secure area and locked. Finding include: During the initial tour with the Infection Contro Officer employee #20 in the 8th floor, 7th floor, 6th floor and 5th floor on 08/20/2024 and 08/21/2024 from 9:00 AM till 3:00 PM, it was observed the following 1. The medication room door was unlocked in the 8th floor, 7th floor, 6th floor and 5th floor. 2. Over the crash cart of the 8th floor, 7th floor, 6th floor and 5th floor was observed a tray of crash cart drower with medication used if two patient was in arrest without security.”

“SAFETY POLICY AND PROCEDURES CFR(s): 482.26(b) [§482.26 Condition of Participation: Radiologic Services §. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.] §482.26(b) Standard: Safety for Patients and Personnel The radiologic services, particularly ionizing radiology procedures, must be free from hazards for patients and personnel. This Standard is not met as evidenced by: 15884 Based on observational tour and interview with the Radiology Supervisor (employee #4) and Director of Nursing (DON) (employee #1), it was identified that facility failed to ensure the area is equipped with all required emergency ancillary equipment required in the event of an emergency. Findings include: 1. During observational tour at the radiology department on 08/21/2024 at 2:00 PM it was informed by the Radiology Supervisor (employee #4) that they perform diagnostic procedures to pediatric patients. Radiology Supervisor (employee #4) stated that the department perform approximately 13 cases every month. 2. When asked to the Radiology Supervisor (employee #4) on 8/21/2024 at 2:20 PM if they had a pediatric emergency crash cart at this area, she said that they do not have a pediatric emergency crash cart in the area because when pediatric cases went to the area hospital pediatric healthcare personnel who transport the patient accompanied and stay at bedside with the patient and they bring an emergency case where there is all the equipment that they were going to need in an event of an emergency. 3. Radiology Supervisor (employee #4) and DON (employee #1) on 8/21/2024 at 2:50 PM stated that they understand that it is necessary to have available a pediatric emergency crash cart stocked with emergency medical equipment, supplies and drugs needed in the event of an emergency. DON (employee #1) stated on interview on 8/21/2024 at 3:15 PM that having their own pediatric emergency crash cart on this area, this allows facility to be responsible for this crash cart content and equipment. DON also stated on interview on 8/21/2024 at 3:25 PM that nursing department had a nurse assigned to radiology department that is going to be the person in charge of this responsibility along by the pharmacy personnel department.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 15884 Based on the observational tour of the facility’s kitchen that prepares the patient’s meals, review of menus, policies/procedures and interview, it was determined that the facility failed to maintain entry and exit doors in good condition, stainless steel tables in good condition, meat walking freezer and refrigerator in good condition, chemicals and disinfectants used labeled indicating contents and percent of dilution, ceiling tiles free of humidity, appliances in good condition, walls and floors clean and in good condition, bathroom ceilings areas free of humidity and housekeeping areas in good condition. Findings include: 1. The following was found during the observational tour of the kitchen service with and administrative dietitian (employee #3) of the hospital on 08/20/2024 from 9:30 AM till 11:50 AM: a. Two doors located at the diet department (one for the staff entrance and the other where tray carts and provisions and merchandise is received) were observed with peeling paint in need of cleaning and maintenance. b. At the room assigned for meat handling and storage two stainless steel tables used to cut meat products and defrosts meat were observed deteriorated with corrosion rust and stains. c. A food processor was observed store on one of the tables located at the room assigned for meat handling, this appliance is observed corroded. It was asked to the administrative dietitian (employee #3) on 08/20/2024 from 9:35 AM if this appliance is in use, and she stated that this appliance is not use and can be taken out the area. Facility failed to ensure that kitchen environment is free of unnecessary items. d. Walking freezer and refrigerator used to storage meat was observed with rust on the floor and on areas at the entrance door and on the areas where this appliance is embedded. e. A chemical store in a bottle with spray dispenser without a label who indicate the content, percent of dilution and the date when it was prepared was observed located in a table at the room assigned for meat handling and storage. Administrative dietitian (employee #3) stated on interview on 08/20/2024 from 9:55 AM that the chemical that this bottle contains is Arrex a chemical use for sanitizing and disinfect. f. A bottle dispenser with a pink solution inside without a label who indicate the content, percent of dilution and the date when it was prepared was observed located in a table at the room assigned for meat handling and storage. Administrative dietitian (employee #3) stated on interview on 08/20/2024 from 9:59 AM that the liquid that this bottle contains is soap. g. At the room assigned for vegetable handling and storage it was observed black mold on two ceiling tiles located at the entrance of the walking refrigerator where vegetables are store. h. An ice machine was observed located on the kitchen production area; the legs of the ice machine were observed corroded with rust. i. A corner of a wall in the hallway used to transport food tray carts and receive provisions and merchandise, were observed broken with pieces of ceramic tiles hanging, a metal cover was located on this corner to protect the ceramic tiles that was observed dented and loose. j. The floor of the hallway area located in the area of the door where the kitchen staff enter to the kitchen is observed in need of cleaning. k. Ceiling tiles located in the toilet cubicle of the kitchen women bathroom were observed with damp appearance and full of black mold. Two additional ceiling tiles located in the kitchen women bathroom were observed with damp appearance and brown spots. l. In the kitchen housekeeping room was observed a hole on the ceiling where the acoustic tile was located. It was informed by the administrative dietitian (employee #3) on 08/20/2024 from 10:59 AM that she notifies environmental maintenance department that there is a leak in this area on 07/10/2024. She said that environmental maintenance department inform her that there is a broken pipe that cause the leak and that they need to fix first the broken pipe and then proceed to replace the ceiling tile. m. A floor cleaning bucket located in the kitchen housekeeping room was observed with a lot of rust on the handle, springs and other metal components of the bucket. In this area a floor mop is storage with the head up instead of on a down position. Keep floor mop with the head up when not in use, promotes that waste that could be accumulated on the head of the mop pass to the mop pole and be contact with housekeeping personnel hands and gloves. 47384 n. During the visual inspection of the kitchen on 08/20/2024 to from 9:00 AM through 9:45 AM and staff interview it was noticed that 3 compartment sink was not prepared as sanitation regulations require. It was observed that the staff working the sink did not have knowledge of the temperatures required in the different sinks’ compartments. In turn, it was requested that the concentration of sanitizer be taken on the third compartment and the concentration measurement read 600 ppm and the requirement is 200 ppm. Overuse of the sanitizing agent could be harmful. The facility does not have written policies regarding the use of the three-compartment sink.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47384 Based on tests to equipment, interviews and observations made during the survey for Life Safety from fire with a facility Engineering Director (employee #24), 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 08/20/2024 through 08/22/2024 from 8:00 AM till 4:00 PM with the facility Engineer (employee #24); for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form (K0223, K0291, K0293, K0324, K0345, K0363, K0751, K0791, K911 and K0923).”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 47632 Based on observations made during the physical environment survey with the Operating Room Manager (employee #6) and Associate Director of Nursing (employee #26), it was determined that the structure of this facility was not maintained to protect and safeguard supplies and equipment to ensure safety. Findings include: 1. During the tour made in the holding area on 08/20/2024 at 9:20 AM through 4:00 PM, the following was found: a. On 08/20/2024 at 9:33 AM, six expired #6 suction catheters were observed in the surgical cabinet 06/15/2024. 2. During the tour made in recovery area on 08/20/2024 at 9:20 AM through 4:00 PM, the following was found: a. On 08/20/2024 at 9:41 AM, a metal table with stains was observed in cubicle #1. b. On 08/20/2024 at 9:50 AM, a lack of paint on the walls was observed in the isolation room. c. On 08/20/2024 at 10:10 AM, a stained acoustics, broken window operator, chipped door frame area, stained window frame area and lack of paint were observed in cubicle #10. d. On 08/20/2024 at 10:25 AM, a chipped door frame area, stained acoustics, and stained metal table were observed in cubicle #11 and #12. e. On 08/20/2024 at 10:35 AM, a broken window operator and stained window frame area were observed in cubicle #13 and #14. 3. During the tour made in recovery phase II area on 08/20/2024 at 9:20 AM through 4:00 PM, the following was found: a. On 08/20/2024 at 10:51 AM, a stained acoustic was observed. 4. During the tour made in the crash cart located in the hallway between the waiting and recovery area on 08/20/2024 from 9:20 AM to 4:00 PM the following was found: a. On 08/20/2024 at 11:02 AM, one #16 nasogastric tube and two #10 suction tubes were noted to expire on 10/10/2023. b. On 08/20/2024 at 11:03 AM, seven expired #6 suction probes were observed 06/15/2024. 5. During the tour made operating room area on 08/20/2024 from 9:20 AM to 4:00 PM the following was found: a. On 08/20/2024 at 11:04 AM, the air duct was observed in room #1 with dust and fourteen 2-0 Prolene sutures (18” 45cm) that expired on 06/30/2024. b. On 08/20/2024 at 1:49 PM, a surgical cabinet without a handle on the door was observed in room #7. c. On 08/20/2024 at 2:56 PM, two ceiling lights were observed, one with no metal with dust and the other detached with dust, crack was also found in the ceiling of room #3. d. On 08/20/2024 at 3:24 PM, surgical sink with stains was observed between rooms #3 and #4. 6. During the tour made at the instrument washing room area on 08/20/2024 from 9:20 AM to 4:00 PM the following was found: a. On 08/20/2024 at 11:14 AM, an air duct with dust, a stained floor and malfunctions were observed when opening and closing the door. b. On 08/20/2024 at 11:27 AM, two 0.45% sodium chloride 1000 ml and six 1.5% glycine irrigation ups 3000 ml were observed expired 06/2024. 7. During the tour made at the emergency room area on 08/21/2024 from 9:20 AM to 4:00 PM the following was found: a. On 08/21/2024 at 9:45 AM, the temperature and relative humidity record was observed in the altered medicine room from January to July 2024. i. Appropriate temperature value 70°F - 75°F January 51.0- 68.2 February 66.0- 67.8 March 64.9- 69.1 April 65.0- 69.1 May 67.0- 69.6 June 66.2- 69.4 July 67.1- 69.8 ii. Appropriate humidity value 30% - 60% January 61.0%-69.1% February 72%-61.1% March 74%-63% April 74%-64% May 73%-61% June 69%-61% July 72-61% b. On 08/21/2024 at 1:38 PM, it is observed that the nursing staff they did not carry out the high and low control levels, cleaning of the glucometer and staff signature. iii. Cleaning and disinfection not carried out in the following days: January 31, 2024 March 22, 2024 March 23, 2024 iv. Control solution tests every 12 hours daily at 7:00AM and 7:00PM Triage: July 9, 2024- signature missing July 11, 2024- signature missing July 14, 2024- 7:00PM missing July 25, 2024- 7:00PM missing August 7, 2024- 7:00PM missing August 16, 2024- 7:00PM mssing August 18, 2024- 7:00 PM missing Emergency Room: July 14, 2024- 7:00PM missing July 15, 2024- signature missing July 17, 2024- signature missing July 20, 2024- signature missing July 23, 2024- 7:00PM missing August 10, 2024- 7:00PM missing Anexo 3: July 18, 2024- 7:00AM and 7:00PM missing July 24, 2024- 7:00PM missing July 26, 2024- 7:00PM missing”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47632 Based on the observational tour with the operating room supervisor (employee #6), associate director of nursing (employee # 26) and emergency room supervisor (employee#7) interview, it was determined that the facility failed to provide standards for infection control related to adequate infection control standards at the surgery ward, ambulatory ward and emergency ward. Findings include: 1. During the observational tour with the operation room supervisor (employee #6) on 08/20/2024 through 08/22/2024 at 9:00AM to 4:00PM, to the medicine ward, and ambulatory ward the following was found: a. On 08/20/2024 at 9:27AM, observed unlabeled primary and secondary lines in holding area in cubicles #1, #2, #3, #4. b. On 08/20/2024 at 3:20PM, a nurse anesthetist (employee #12) in room #4 was observed putting on gloves on two occasions without washing her hands. c. On 08/21/2024 at 2:16PM, it was observed in outpatient surgery room #3 that a nurse anesthetist (employee #11) was administering intravenous medication without wearing gloves. d. On 08/22/2024 at 8:44AM, an unidentified open vial of Valium 50 mg/10 ml was observed. e. On 08/22/2024 at 8:52AM, nursing staff of emergency room (employee #8), (employee #9) and (employee #10) observed gel nails in accordance with policies/procedures and administrative order #284.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 15884 Based on observational tour, at the radiology and nuclear medicine department, the 8th floor, 7th floor, 6th floor and 5th floor on 08/20/2024 throught 08/21/2024 from 9:50 PM through 4:00 PM, it was determined that the facility fail to include methods for preventing and control the transmission of infections, including maintaining clean and sanitary environment within those hospital areas. Findings include: 1. During observational tour at the ambulatory radiology and nuclear medicine area the following was observed: a. Eight wooden chairs located at the waiting room inside the department were observed with the fabric upholstery torn and worn. b. The mattress of a stretcher located in the area where nuclear medicine procedures were performed is observed torn, worn and broken. c. A wooden counter located near the area where sonographic procedures were performed is observed overawed with items to be used during procedures, with broken Formica, uneven out of square with open doors. 2. During observational tour at the hospital ambulatory radiology area the following was observed: a. The floor of the room where the CT scanner is located was observed worn out, with dark spots, scratches, with scuffs in areas where there is most traffic. b. Housekeeping room located inside of the hospital ambulatory radiology area was observed with a lot of rust on the Cross Tee of the ceiling tiles. In this area 2 floor mops were storage with the head up instead of on a down position. Keep floor mops with the head up when not in use, promote that waste that could be accumulated on the head of the mop pass to the mop pole and be contact with housekeeping personnel hands and gloves. 47632 3. During the tour made in the holding area with the Operating Room Manager (employee #6) and associate director of nursing (employee #26) on 08/20/2024 at 9:20 AM through 4:00 PM, the following was found: a. On 08/20/2024 at 9:33AM, four prepared 9nss sodium chloride serums were observed next to a sharp container. 4. During the tour made in recovery area on 08/20/2024 at 9:20 AM through 4:00 PM, the following was found: a. On 08/20/2024 at 9:40AM, in the isolation room, a compression stocking machine was observed placed on the floor and a humidifier (Vyaire) empty in the sink. b. On 08/20/2024 at 10:10AM, window operator observed with dust in cubicle #10. c. On 08/20/2024 at 10:35AM, observed an empty humidifier (Vyaire) in the sink. 5. During the tour made to the emergency room area on 08/20/2024 through 08/21/2024 from 9:20 AM to 4:00 PM the following was found: a. On 08/20/2024 at 3:10PM, cables from electrocardiograph machines were observed on the floor of the triage area. 6. During the tour made operating room area on 08/20/2024 from 9:20 AM to 4:00 PM the following was found: a. On 08/20/2024 at 11:04 AM, the air duct was observed in room #1 with dust. b. On 08/20/2024 at 2:56 PM, two ceiling lamps were observed, one without metal with dust and the other detached with dust in room #3. 20423 7. During observation tour on the 8th floor, it was observed the following: a. Nasal canula catheter was observed place in the oxygen meter, room 801 A. b. The corrugate air hose of the Bi pap was observed unlabeled room 803A. c. The bed rail was observed with peeling paint room 803A, 808B. d. The bathroom was observed with broken tile in the shower, room 803. e. The room walls was observed with waste the double-sided tape room 803, 806. f. The room walls near the sharp container was observed with hole room and peeling paint 804 g. The room walls was observed with peeling paint, room 804, 806, 807, 808, 809, 810, 811, 812. h. Nasal canula catheter was observed tied to the bed rail, room 805. i. Urinal was observed direct in the floor, room 805. j. Nightstand was observed with broken Formica, room 806. k. Bedside light cord tied with a piece of blue cloth room 806. l. The rooms door was observed with peeling paint room 806, 811. m. The bathroom door was observed with peeling paint room 807. n. Acoustic with humidity room 807. o. Broken plug in the wall of room 810. p. Cleaning cart, with cleaning products in front of the housekeeping room in the hallway and housekeeping room was with the door unlocked. 8. During observation tour on the 7th floor, it was observed the following: a. The patient bed linen was observed dirty room 700. b. The non rebreathing mas was observed in the floor, room 701B. c. The corrugate air hose of the Bi pap was observed unlabeled room 701B d. Urinal was observed direct in the floor, room 703A, 712A. e. Oxygen mask attached to the oxygen meter room 703A. f. Nonsterile glove was observed over the bedroom 703B. g. Bed linen was observed over the regular trash can room 710, 712. h. Floor was observed very dirty, room 715. 9. During observation tour on the 6th floor, it was observed the following: a. Bed linen was observed with blood spot room 600B. b. The corrugate air hose of the Bi pap was observed unlabeled, and the mask was place over the Bi pap room 600B. c. Broken toilet paper dispenser room 603.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 15884 Based on review of clinical records, policies/procedures and interview with the supervisor of Social Workers (employee #2), it was found that the facility failed to establish timeframe at an early stage of hospitalization to perform the initial assessment of patients who are likely to suffer adverse health consequences upon discharge in absence of discharge planning as well as for other patients upon the request of the patient representative’s. This deficient affect 4 out of 15 patients evaluated for discharge planning (RR#32, #46, #47 and #51). Findings include: Upon review of the facility’s policy control number: DTS-0821-0019 last update on 05/19/2024, on 08/22/2024 at 9:00 AM. Policy stated on the procedures that an interview by social worker or discharge planning personnel must be performed to guarantee necessary interventions for patients to ensure appropriate transition from hospital to private home. It was identified that facility’s policy control number: DTS-0821-0019 include provisions to address cases with psychosocial situations in addition to cases who may need discharge planning process when is identified that may need Home Health Agency, Hospice agency Skilled Nursing SNF’s or require post -hospital services (intravenous antibiotic therapy or specialized medical equipment). 1. The surveyor asked to the supervisor of Social Worker (employee #2), on 08/22/24 at 10:15 AM if facility had establish a time frame to perform the initial assessment of patients who are likely to suffer adverse health consequences upon discharge in absence of discharge planning as well as for other patients upon the request of the patient representative’s and she stated that for cases who are received by a consult of a physician they establish a 24 hours as the time frame to evaluate the case and begin the discharge planning process. She stated that other cases referred by member of health care personnel or patient’s representatives are evaluated but facility had not established a time frame or criteria for establish priorities on those cases. She also stated during interview that discharge planning department screen other cases that based on the diagnosis, they know that must need discharge planning process but that for those cases they had not establish the time frame. 2. RR#32 is a 57-year-old male patient admitted on 07/11/2024 with a diagnosis of Acute Respiratory Failure and Mechanical Ventilation. During the review of the case with supervisor of Social Worker (employee #2), on 08/22/2024 at 11:49 AM it was identified that this patient had a sacral ulcer and a gastrostomy. She stated that since he had been diagnosed with sacral ulcer and was dependent of mechanical ventilator he must need coordination for home care services, ambulance, medical equipment, mechanical ventilation, enteral feeding machine and enteral supplements and nursing services at home. A case who needs all those services must be consulted accordingly with facility policy DTS-0821-0019 and evaluated at 24 hours. Case was evaluated on 07/26/2024. 3.RR#46 is a 41-year-old female patient admitted on 08/18/2024 with a diagnosis of Diabetes Ketoacidosis Di Novo. During the review of the case with supervisor of Social Worker (employee #2), on 08/22/2024 at 10:00 AM it was identified that this patient had not been evaluated by discharge planning. It was asked to the supervisor of Social Worker (employee #2), on 08/22/24 at 10:10 AM if this case require evaluation by discharge planning. She stated that since she had been diagnosed with Diabetes Di Novo need coordination for glucometer, assessment post discharge by an endocrinologist and education at home to ensure that acquire knowledge to manage her condition and prevent adverse health consequences occur upon discharge. She also stated that this case it should have been consulted to discharge planning or referred by a health care professional that was participated in her care. However, this consult or referral it was not carried out. Patient was evaluated on 08/22/2024 at 12:10 PM. 4. RR#47 is a 67-year-old female patient admitted on 08/17/2024 with a diagnosis of Infected Ulcers on both Heels. During the review of the case with supervisor of Social Worker (employee #2), on 08/22/2024 at 10:30 AM it was identified that this patient had not been evaluated by discharge planning. It was asked to the supervisor of Social Worker (employee #2), on 08/22/24 at 10:40 AM if this case require evaluation by discharge planning. She stated that since she had been diagnosed with ulcers, she must need home care services, ambulance and nursing services at home. She also stated that this case it should have been consulted to discharge planning or referred by a health care professional that was participated in her care. However, this consult or referral it was not carried out. Patient was evaluated on 08/22/2024 at 12:16 PM. 5. RR#51 is a 67-year-old female patient admitted on 08/10/2024 with a diagnosis of Infected Sacral Ulcer. During the review of the case with supervisor of Social Worker (employee #2), on 08/22/2024 at 11:00 AM it was identified that this patient had not been evaluated by discharge planning. It was asked to the supervisor of Social Worker (employee #2), on 08/22/24 at 11:05 AM if this case require evaluation by discharge planning. She stated that since she had been diagnosed with sacral ulcer, she must need home care services, ambulance and nursing services at home. Case was evaluated on 08/21/2024.”

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 15884 Based on review of clinical records, policies/procedures and interview with the supervisor of Social Worker (employee #2), it was found that the facility failed to ensure review of the discharge plan, of those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This deficient affect 1 out of 15 cases evaluated for discharge planning (RR#9) Findings include: Upon review of the facility’s policy control number: DTS-0821-0019 last update on 05/19/2024, on 08/22/2024 at 9:00 AM. Policy stated on the procedures that an interview by social worker or discharge planning personnel must be performed in order to guarantee necessary interventions for patients to ensure appropriate transition from hospital to private home. It was identified that facility’s policy control number: DTS-0821-0019 include provisions to address cases with psychosocial situations in addition to cases who may need discharge planning process when is identified that may need Home Health Agency, Hospice and Skilled Nursing- SNF’s or require post -hospital services (intravenous antibiotic therapy or specialized medical equipment). 1. RR#9 is an 82-year-old male patient admitted on 08/09/2024 with a diagnosis of Acute Respiratory Failure and Sepsis. During the review of the case with supervisor of Social Worker (employee #2), on 08/22/2024 at 10:50 AM it was identified that this patient had been hospitalized on 07/31/2024 and was discharged on 08/08/2024 and that discharge planning program evaluate the patient during the previous admission and coordinate ambulance and medical equipment to the patient when was discharge on 08/08/2024. The patient returns to the hospital on 08/09/2024 with a diagnosis of Sepsis and Melena. 2. It was request to the supervisor of Social Worker (employee #2),on 08/22/2024 at 11:20 AM discharge planning process for this case who was readmitted in a very short period after being discharge from the facility in order to identify if they identify if there any situation related with patient post-discharge needs that could impact and provoke patient readmission to the hospital in a very short period after being discharge and this information is not provided. 3. It was asked to the supervisor of Social Worker (employee #2), on 08/22/2024 at 11:45 AM if facility had a mechanism to ensure that in every case that patient was readmitted, and discharge planning program had previously intervened to delineate a discharge planning process and plan were evaluate in order to ensure that the plans are responsive to the patient post-discharge needs. Supervisor of Social Workers (employee #2), stated on 08/22/2024 at 11:55 AM that discharge planning re-evaluate cases readmitted to the facility, but this criterion was not included in their policies and procedures as a determinant to intervene.”

“POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 47632 Based on the review of seven records reviewed (R.R), review of policies and procedures and interview with the operating room supervisor (employee #5), it was determined that the facility failed to ensure that outpatients are evaluated and called after 24 hours after the surgery was performed to ensure acceptable standards of practice for 9 out of 16 records reviewed (R.R #16, #17, #18, #19, #21, #23, #26, #27, #28). Findings include: Policy and procedures: Seguimiento a paciente ambulatorio reviewed on 08/21/2024 at 2:20PM indicate that the call will be made between twenty-four and forty-eight hours after the patient has been discharged. 1. During the review of nine record (R.R #16, #17, #18, #19, #21, #23, #26, #27, #28) on 08/21/2024 at 9:20 AM through 11:30AM, it was evident that no calls were made more than 24 to 48 hours after the surgeries. 2. The facility did not ensure that nursing staff made follow-up calls to outpatients within 24 to 48 hours.”

“EQUIPMENT AND SUPPLIES CFR(s): 482.53(c), (c)(1), (c)(2) §482.53(c) Standard: Facilities Equipment and supplies must be appropriate for the types of nuclear medicine services offered and must be maintained for safe and efficient performance. The equipment must be-- (1) Maintained in safe operating condition; and (2) Inspected, tested and calibrated at least annually by qualified personnel. This Standard is not met as evidenced by: 15884 Based on observational tour and interview with the Nuclear Medicine Supervisor (employee #4) and Director of Nursing (employee #1), it was identified that facility failed to ensure the area is equipped with all required emergency ancillary equipment required in the event of an emergency. Findings include: 1. During observational tour at the radiologic department on 08/21/2024 at 3:00 PM it was informed by the Nuclear Medicine Supervisor (employee #4) that they perform nuclear medicine diagnostic procedures to pediatric patients. Nuclear Medicine Supervisor (employee #4) stated that the department perform approximately 3 cases every month. 2. When asked to the Nuclear Medicine Supervisor (employee #4) on 8/21/2024 at 3:20 PM if they had a pediatric emergency crash cart at this area, she said that thy do not have a pediatric emergency crash cart in the area because when pediatric cases went to the area hospital pediatric healthcare personnel who transport the patient accompanied and stay at bedside with the patient and they bring an emergency case where there is all the equipment that they were going to need in an event of an emergency. 3. Radiologic Supervisor (employee #4) and Director of Nursing (employee #1) on 8/21/2024 at 3:30 PM stated that they understand that it is necessary to had available a pediatric emergency crash cart stocked with emergency medical equipment, supplies and drugs needed in the event of an emergency. Director of Nursing (employee #1) stated on interview on 8/21/2024 at 3:50 PM that having their own pediatric emergency crash cart on this area, this allows facility to be responsible for this crash cart content and equipment. Director of Nursing (employee #1) also stated on interview on 8/21/2024 at 3:25 PM that nursing department had a nurse assigned to radiologic department that is going to be the person in charge of this responsibility along by the pharmacy personnel department.”

“ORDERS FOR RESPIRATORY SERVICES CFR(s): 482.57(b)(3) Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws. This Standard is not met as evidenced by: 20423 Based on the review of six medical records, policies/procedures, it was determined that the facility failed to ensure that services are provided in accordance with the physician’s orders related to how many hours was given, assessment and re-assessment post therapy, physician’s lack of written respiratory therapy reorder in accordance to standards of practice, medical orders not according of policies and procedures for 4 out of 6 clinical records reviewed (RR #72, #73, #74 and #75). Findings include: Five medical records were reviewed on 08/22/2024 from 8:30 till 12:00 PM of patients who received respiratory therapy with the respiratory therapy assistant employee # 16 and the Infection Control Officer (employee #20) and provided evidence of the following: 1. R.R #72 is an 80-year-old female admitted on 08/09/2024 with a diagnosis of Infected Sacral Ulcer. The record was review on 08/22/2024 at 11:15 AM and was found the following: a. On 08/14/2024 at 12:41 PM the physician ordered Ipratropium 0.5 milligram (mg) by power nebulizer (PN) every 8 hour. b. It was found that the physician edits in the electronic record (audit log renovation) the initial physician order on 08/17/2024 at 13:38 PM, on 08/19/2024 at 14:44 PM, and on 08/21/2024 at 14:51 PM. c. The physician failed to write a new order for the Ipratropium 0.5 mg by PN every 8 hour on 08/17/2024 at 13:38 PM, on 08/19/2024 at 14:44 PM, and on 08/21/2024 at 14:51PM instead of edit. d. On 08/14/2024, no evidence was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 mg by PN every 8 hour at 15:00 PM. e. It was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 mg by PN every 8 hour in the electronic flow sheet template, however no evidence was found the documentation of patient lung auscultation pre and post treatment. f. The electronic template for the documentation of the respiratory therapy treatment provide to the respiratory therapist documented the full assessment of the patient and documented the patient lung auscultation previous the treatment and post treatment. e. The respiratory therapist failed to document the patient lung auscultation previous the treatment and post treatment. 2. R.R #73 is a 91-year-old female admitted on 08/20/2024 with a diagnosis of Leucopenia. The record was review on 08/22/2024 at 10:05 AM and was found the following: a. On 08/20/2024 at 10:32 Am the physician ordered Ipratropium 0.5 milligram (mg)by power nebulizer (PN) every 2 hour. At 14:25 PM ordered Nasal Cannula at 3 litter per minute (Lt/min) b. On 08/19/2024, no evidence was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 milligram by power nebulizer (PN) every 4 hour at 15:00 PM and 19:00 PM. c. It was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 mg by PN every 2 hour in the electronic flow sheet template, however no evidence was found the documentation of patient lung auscultation pre and post treatment and the use of oxygen by canula nasal at 3lt/min. d. The electronic template for the documentation of the respiratory therapy treatment provide to the respiratory therapist documented the full assessment of the patient and documented the patient lung auscultation previous the treatment and post treatment. e. The respiratory therapist failed to document the patient lung auscultation previous the treatment and post treatment. f. On 08/20/2024 at 19:10 PM the respiratory therapist documented only the post treatment vital sign, failed to document the level of consciousness pretreatment vital sign, oxygen delivery method, the auscultation pre and post treatment. 3. R.R #74 is a 69-year-old female admitted on 08/17/2024 with a diagnosis of Bronchopneumonia (BKP) and Congestive Heart Failure (CHF). The record was review on 08/22/2024 at 9:30 AM and was found the following: a. On 08/17/2024at 13:03 pm the physician ordered Bilevel positive airway pressure (Bipap) continue with Inspiratory Positive Airway Pressure (Ipap):14, Expiratory Positive Airway Pressure (Epap): 8, Respiratory Rate (RR):14, Fraction of Inspired Oxygen (FiO2): 60%. It was found that the physician edits the initial physician order on 08/18/2024 at 11:51 AM, Ipap: 12-14, Epap: 6-8, RR: 12-14, FiO2: 100-80%. On 08/21/2024 at 17:26 PM, Ipap: 12-14, Epap: 6-8, RR: 20-14, FiO2: 80-60%. b. The physician failed to write a new order for the Bipap parameter on 08/18/2024 at 11:51 am and on 08/21/2024 at 17:26 PM instead of edit c. On 08/17/2024 at 8:46 AM the physician ordered Ipratropium Bromide 0.5 mg by power nebulizer (PN) every 4 hour. d. On 08/19/2024, no evidence was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 milligram by power nebulizer (PN) every 4 hour at 15:00 PM and 19:00 PM. e. It was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 milligram by power nebulizer (PN) every 4 hour in the electronic flow sheet of the Bipap treatment, this electronic template does not provide to the respiratory therapist to document the re-assessment Vital Sign and auscultation post treatment. f. The respiratory therapist failed to document the respiratory treatment in an electronic flow sheet (Intervention Respiratory Nebulizer treatment) the patient auscultation of the lung in each treatment provided to the patient. g. The electronic template for the documentation of the respiratory therapy treatment provide to the respiratory therapist documented the full assessment of the patient and documented the patient lung auscultation previous the treatment and post treatment. h. The respiratory therapist failed to document the patient lung auscultation previous the treatment and post treatment. 4. R.R #75 is a 64-year-old male admitted on 08/19/2024 with a diagnosis of Chest Pain. The record was review on 08/22/2024 at 11:30 AM and was found the following: a. On 08/20/2024 at 22:58 PM the physician ordered Ventury Mask at 50% and at 12:29 PM the physician performed a telephonic ordered Ipratropium 0.5 mg by PN every 4 hour. At 14:25 PM. b. The physician failed to counter sign the telephonic order. b. On 08/21/2024, no evidence was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 mg by PN every 4 hour at 11:00 AM and 15:00 PM. On 08/22/2024 at 3:00 AM. c. It was found that the respiratory therapist documented the administration of the treatment Ipratropium 0.5 mg by PN every 4 hour in the electronic flow sheet template, however no evidence was found the documentation of patient lung auscultation pre and post treatment. d. The electronic template for the documentation of the respiratory therapy treatment provide to the respiratory therapist documented the full assessment of the patient and documented the patient lung auscultation previous the treatment and post treatment. e. The respiratory therapist failed to document the patient lung auscultation previous the treatment and post treatment. f. No evidence was found in the electronic flow sheet the documentation of patient use of oxygen by Ventury mask at 50% on 08/21/2024 at 19:00 PM, at 23:00 PM and on 08/22/2024 at 3:00 AM.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/08/2024 from 1:30 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to track the location of on-duty staff and sheltered patients in the hospitals facility’s care during an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #) on 08/08/2024 at 1:30 PM it was noted that the EP failed to have written procedures to document the specific name and location of the receiving facility or other location.”

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/08/2024 from 1:30 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide means to shelter in place for patients, staff and volunteers who remain in the facility. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #) on 08/08/2024 from 1:30 PM through 3:30 PM it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the Hospital during and after an emergency.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/08/2024 at 1:30 PM to 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #) on 08/08/2024 it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §482.15(b)(6).”

“Based on tests to equipment, interviews and observations made during the survey for Life Safety from fire with a facility Engineering Director (employee #24), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101. Based on a recertification survey, observation with the Engineering Director (employee #24) and Safety Ofiicer (employee #22), on 08/22/2024 at 11:45 AM it was determined that the facility failed to prevent patients from harm. This constitute an Immediate Jeopardy to 71 out of 154 patients admitted at the facility.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #22) and Engineering Sub-director from 9:00 AM to 4:00 PM, it was determined that the smoke barrier doors on the fourth and fifth floor failed to close flush when released as required by the 2012 edition of the Life Safety Code of the NFPA Section 7.2.1.8.2. Findings include: 1. The smoke barrier doors on the fourth and fifth floor were observed on 08/22/2024 approximately al 10:30 AM did not close flush to its frame, this can permit smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #22) and Engineering Sub-director( employee #23) and Engineering Director (employee #24) from 9:00 AM to 4:00 PM, it was determined that the facility failed to have emergency lighting in accordance with 7.9. Findings include: 1. Emergency light on Operation Room #3 was found inoperable. 2. No emergency light to iluminate the exit pathway on the outside of ambulance entrance on first floor.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #22) and Engineering Sub-director( employee #23) and Engineering Director (employee #24) from 9:00 AM to 4:00 PM, it was determined that the facility failed to provide exit and directional signs displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 Findings include: 1. On the Pharmacy Department it was noted that no exit sign directed from entry through the hospital to working area and exteirior of the buiilding. 2. On some floors it was noticed that exit signs were missing directing to all available exits on the floor”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 47384 Based on a recertification survey, observations made during the life safety from fire, it was determined that the facility failed to ensure that cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Findings include: During observational tour for Life Safety from Fire on 08/20/2024 at approximately 9:05 AM with the facilty’s Engineering Director (employee #24) and the Safety Officer (employee #22) the following was noticed in the Diet Department. 1. Grease Baffles not properly installed leaving approximately 2” gap into the exhaust hood system. 2. Rubber Blow Off Caps Fire Suppression Nozzles were missing on 8 of the ANSUL nozzles of the system.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #22) and Engineering Sub-director (employee #23) and Engineering Director from 9:00 AM to 4:00 PM, it was determined that the facility failed to efectively maintain initiation of the fire alarm system by manual means and by detection device, or detection system as required in (NFPA101) 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5. This deficiency could affect 71 patients out of 154 patient census. Findings include: At approximately 11:45 AM on 08/22/2024, the activation of the manual activation device (pull station) located at the emergency exit was requested. The Safety Officer proceeded to activate the device and it did not turn on the emergency alarm. We then proceeded to the second device available on the floor located in the second emergency exit and proceeded to activate it and the emergency alarm did not activate either. Upon further investigation it was indicated that the deficiency in the manual alarm ignition system replicated on the fifth, fourth, third, second, first and ground floors. In addition, it was reported that the deficiency in the system also affected the operation of the smoke detectors in the same areas.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #22) and Engineering Sub-director from 9:00 AM to 4:00 PM, it was determined that the facility failed to have a fire alarm system that is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Findings include: 1) Fire alarm annunciator reported 223 trouble signals that were not restored to normal within 200 seconds. Trouble detected on screen: NO ANSWER BMC 3RD FLR FARMACIA COUNTER”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire with the facility’s Safety Officer (Employee #22) and Engineering sub-director (employee #23), it was determined that the facility failed to protect corridors at clinical floors ( doors do not latch) as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.3.6.3. Findings include: During the tour for life safety from fire on 08/21/2024 through 08/22/2024 from 8:30 AM through 4:00 PM, patient’s sleeping room doors were tested it was found that patient’s sleeping rooms #503, #505, #516, #518 do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request.”

“Draperies, Curtains, and Loosely Hanging Fabr CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire with the facility’s Safety Officer (Employee #22) and Engineering sub-director (employee #23), it was determined that the facility failed to certify that window curtains and room dividing curtains are up to standard with NFPA 701 in accordance with 10.3.1. Findings include: During observational tour on faclity’s eighth, seventh, fifth and fourth floors were verified, as well as the emergency room area. No tag with flame retardant or fire resistant in accordance with an equivalent standard to NFPA 701 was observed on curtains.”

“Construction, Repair, and Improvement Operati CFR(s): NFPA 101 Construction, Repair, and Improvement Operations Construction, repair, and improvement operations shall comply with 4.6.10. Any means of egress in any area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency and compliance with NFPA 241. 18.7.9, 19.7.9, 4.6.10, 7.1.10.1 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #22) and Engineering Sub-director( employee #23) and Engineering Director (employee #24) from 9:00 AM to 4:00 PM, it was determined that the facility failed inspect daily to ensure its ability to be used instantly in case of emergency and compliance with NFPA 241. 8.7.9, 19.7.9, 4.6.10, 7.1.10.1 Findings include: During observational tour on faclity’s third floor construction site it was noticed that: 1. One (1) out of three (3) fire extinguisher was with expired inspection 2. One (1) out of three (3) fire extinguisher did not have monthly inspection since April 2024”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #22) and Engineering Sub-director from 9:00 AM to 4:00 PM, it was determined that the facility failed to observe that electrical system complies with NFPA 99 Chapter 6. Findings include: 1. On 08/20/2024 approximately at 9:00 AM the Electrical Panel SF-B01 located in the Diet Department area was observed unlocked not guarding of electrical live parts. 2. On 08/20/2024 approximately at 9:00 AM the Electrical Panel KP-2 and KP located in the Diet Department was observed unlocked not guarding of electrical live parts. 3.On 08/21/2024 approximately at 11:00 AM the Electrical Electrical Panel located in the patient care area was observed unlocked not guarding of electrical live parts in the Imaging area. 4. On 08/20/2024 approximately at 11:30 AM the Electrical Electrical Room was found unlocked on the fifth floor”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/20/2024 through 08/21/2024 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #22) and Engineering Sub-director from 9:00 AM to 4:00 PM, it was determined that the facility failed to handle cylinders with precautions as specified in (NFPA 99) 11.7.3. Findings include: 1. On 08/20/2024 approximately at 9:45 AM a type H oxygen tank was observed on LDR 1 room. 2. On 08/21/2024 approximately at 8:35 AM a type CL helium tank was observed on top of a equipment cart not secured. 3. On 08/21/2024 approximately at 8:35 AM three type H oxygen tanks were observed without protection cap on tank bank cage. 4. On 08/22/2024 approximately at 2:00 PM a type H oxygen tank was observed on the in-patient waiting area of the Imaging Center. 5. On 08/22/2024 approximately at 2:15 PM a type E oxygen tank was observed un secured on the machine room of the MRI area.”