cms_PR
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731 rows sorted by deficiency_tag
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag ▼ | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 282 | 282 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 151 | F | 0 | 1 | 1VLO11 | Based on observations and interview with Nurse Supervisor (employee #4) during the recertification survey, it was determined that the facility failed to ensure that residents who receive care at the facility have autonomy related to choices about their care, establish a specific rules for provisions they can bring to the facility during the resident stay which affects 14 out of 14 admitted residents (Sample selection residents #1 through #8 and Random sample residents #1 through #6). Findings include: 1.During observational tours performed on 5/11 at 8:30 am, the surveyor watched posted on every residents bulletin board a sign indicating Attention family and residents. It is not allowed to bring fruits, food, flowers or over the counter medicines (medicines you buy without a prescription) . Interview perform to (employee #4) on 5/11 at 9:35 am reveals that the facility puts this sign to prevent residents do not ate foods can affect her or his treatment and recovery and the flowers for infection control. 2. The facility failed to develop a mechanism to ensure that residents can receive with their consent, provisions or gives from family members and other relatives at the facility, without any restrictions. | 2018-09-01 |
| 481 | 481 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2012-02-29 | 151 | D | 0 | 1 | G0N711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of eight medical records and interview with the medication pass Registered Nurse (RN) (employee #12), it was determined that the facility failed to ensure that residents have autonomy and choice, to the maximum extent possible regarding pain medications used during their stay at the facility for one out eight sample selection residents (resident #6). Findings include: Resident #6 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the medication pass on 2/28/12 at 10:25 am the resident referred pain to the medication pass Registered Nurse (RN) (employee #12) of seven (7) on a scale of 1 through 10. The RN told the resident that she was ordered [MEDICATION NAME] 1 tablet every 3 hours for pain. The resident asked the nurse if the facility had Tylenol with [MEDICATION NAME] for pain, because she has used this medication before and it works better for her than [MEDICATION NAME]. The RN told the resident that she needed to ask the physician to re-evaluate her pain medications. The RN told the resident that she could gave her the [MEDICATION NAME] now while she waits for the physician's evaluation. The resident told the RN that she would take the [MEDICATION NAME] and the RN administered the medication to the resident on 2/28/12 at 10:35 am. No evidence was found that facility personnel notified the physician to re-evaluate the resident's medication orders. The facility failed to ensure that the resident's perceptions of pain is fully considered during the pain assessment by nursing personnel (employee #12) and during the evaluation by the physician. | 2015-06-01 |
| 547 | 547 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2012-04-20 | 151 | F | S02O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined that the facility failed to promote the right of each resident to know and distinguish personnel in charge of their direct care which could affect twenty-eight out of twenty-eight admitted residents (residents #1 through #9 and random sample residents #1 through #19). Findings include: 1. Observations made during of the initial tour on 4/18/12 from 8:35 am through 11:55 am provided evidence of the following: a. Facility employees #17 and #18 were observed giving direct care (changing bed sheets and providing resident care) to residents. These employees did not have identification or name tags in order to be identified by the residents, visitors, resident's relatives and other persons at the facility. b. Facility employee #16 was observed escorting residents to the physical therapy area. He did not have an identification or name tag in order to be identified by the residents, visitors, resident's relatives and other persons at the facility. c. Facility employee #20 was observed visiting resident's rooms, she did not have an identification or name tag in order to be identified by the residents, visitors, resident's relatives and other persons at the facility. She was interviewed on 4/18/12 at 9:10 am and she stated that she is a Licensed Practice Nurse and was preparing items to give baths to residents. d. Facility employee #5 (Registered Nurse) was observed preparing intravenous antibiotics for residents, in front of resident's room [ROOM NUMBER], she did not have an identification or name tag in order to be identified by the residents, visitors, resident's relatives and other persons at the facility. She was interviewed on 4/18/12 at 9:34 am and she stated that she is a Registered Nurse. e. The relative of resident #7 was interviewed on 4/18/12 at 11:50 am and she stated that she did not know who were the registered nurses, licensed practical nurses or therapists because they do not have… | 2014-04-01 | ||
| 636 | 636 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2011-02-17 | 151 | C | 5V0111 | Based on observations and interviews, it was determined that the facility failed to promote the right of residents to know and distinguish personnel in charge of their direct care which could affect thirty-five out of thirty-five admitted residents (residents #1 through #9 and random sample residents #1 through #26). Findings include: 1. Observations made during of the initial tour on 2/15/11 from 7:25 am through 10:00 am provided evidence of the following: a. Facility employees #3, #12 and #13 were observed dressed in light violet scrub uniforms giving direct care (changing bed sheets and providing resident care) to residents. These employees did not have identification or name tags in order to be identified by the residents, visitors, resident's relatives and other persons at the facility. The facility's Director of Nursing (D.O.N) (employee #2) stated during an interview on 2/16/11 at 2:23 pm that these personnel were licensed practical nurses (LPNs). b. Facility employee #4 was observed dressed in a pink scrub uniform giving direct care (changing bed sheets and providing resident care) to residents. This employee did not have identification or name tag in order to be identified by the residents, visitors, resident's relatives and other persons at the facility. The facility's Director of Nursing (D.O.N) (employee #2) stated during an interview on 2/16/11 at 2:27 pm that this person is a new licensed practical nurse (LPN), who does not have a light violet scrub uniform that are used by the LPNs at this facility. 2. Observations made during the observational tour on 2/16/11 from 8:12 am through 10:00 am provided evidence of the following: a. A facility registered nurse (RN) (employee #11) was observed preparing the medication cart in order to begin the medication pass. She was observed dress in a white nurse's uniform without a name tag or identification. The facility's nursing supervisor (employee #2) stated during an interview on 2/16/11 at 8:15 am that she is a registered nurse. b. Facility employee #10 was o… | 2014-03-01 | ||
| 695 | 695 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2010-02-19 | 151 | F | OWRV11 | Based on observations and interviews, it was determined that the facility failed to promote the right of each resident to know and distinguish personnel in charge of their direct care which affects twenty-five out of twenty-five admitted residents (residents #1 through #9 and random sample residents #1 through #16). Findings include: 1. Observations made during of the initial tour on 2/17/10 from 8:45 am through 10:45 am provided evidence of the following: a. Facility employees #15 and #16 were observed giving direct care (changing bed sheets and providing resident care) to residents. These employees did not have identification or name tags in order to be identified by the residents, visitors, resident's relatives and other persons at the facility. b. Facility employee #27 was observed escorting residents to the physical therapy area. He did not have an identification or name tag in order to be identified by the residents, visitors, resident's relatives and other persons at the facility. c. Facility employee #29 was observed visiting resident's rooms, she did not have an identification or name tag in order to be identified by the residents, visitors, resident's relatives and other persons at the facility. She was interviewed on 2/17/10 at 10:00 am and she stated that she is the recreational coordinator. d. Facility employee #2 (registered nurse) was observed interacting with residents on various occasions but did not have an identification or name tag in order to be identified by the residents, visitors, resident's relatives and other persons at the facility. 2. The relative of resident #1 was interviewed on 2/18/10 at 2:00 pm and she stated that she did not know who were the registered nurses, licensed practical nurses or therapists because they do not have identification or name tags and they are dressed in a lot of different colors. 3. Resident #5 was interviewed on 2/17/10 at 1:56 pm and she stated that she did not know who were the registered nurses, the licensed practical nurses or the therapists because th… | 2014-02-01 | ||
| 342 | 342 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2014-09-12 | 154 | E | 0 | 1 | 2S3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on ten resident's records reviewed, observations and interview, it was determined that the facility failed to ensure that 2 out of 10 residents or their legal representatives are fully informed of their health status (Residents #2 did not know clearly his diagnostic. Resident #8 family member are not informed about her health status). Findings include: 1. Resident #2 is a [AGE] years old male. admitted on [DATE] with diagnostics of Left Diabetic Foot, Diabetes type II, Hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 8/25/14 at 2:35pm resident was interview and stated; I am not clear about my diagnostic. In this facility they said that I have [DIAGNOSES REDACTED] but in the hospital an orthopedist and a podiatrist said that I have arthritis. I have a pending consult with the rheumatologist since last week but the consult is not answer yet . On record review 8/26/2014 at 10:45 am consultations were found without answer. Rheumatology consult dated on 8/24/2014 at 11:00 am, Podiatric consult dated on 8/15/2014 at 7:50 am and orthopedic consult dated on 8/25/2014 with no hours. The facility policy for consult was reviewed on 8/26/14 at 10:55 am and stated that consultant physician has 72 hours to answer the consult. Podiatric consult do not comply with facility policy. 2. Resident #8 is a [AGE] years old female. admitted on [DATE] with a diagnostic of Left [MEDICAL CONDITION]. On an interview with residents ' family member on 8/27/2014 at 10:00 am family member states: I do not know why my mother has a Foley. She always urine without problems. She supposed to go home today but they stop the discharge process because I did not have the necessary equipment yet . No documentation was found in the residents ' record related to the resident or her daughter orientation regarding resident condition and treatments. | 2017-06-01 |
| 721 | 721 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2010-06-08 | 154 | D | GXXQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on eight clinical records reviewed and resident interview, it was determined that the facility failed to ensure that one out of eight residents is fully informed of their total health status and it is transmitted to the resident appropriately related to the residents' refusal to take prescribed medications (Resident #3). Findings include: 1. Resident #3 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was interviewed on 6/8/10 at 9:00 am due to her refusal to take prescribed medications and she said that she has had bad reactions with certain medications such as Cipro, [MEDICATION NAME] and [MEDICATION NAME] Forte. She stated that these medications give her diarrhea and makes her dizzy if she has this she can not perform her physical therapy exercises. She also stated that she is not opposed to taken other medications, just as long as they do not give her these side affects because her main goal is to receive all of the programed therapy sessions possible before she is discharged . The facility failed to provide evidence of the following: a. No evidence was found that the facility informed health consequences related to the refusal of the prescribed medications or inquired about other medications previously used by the resident that were tolerated by her. b. No evidence was found of on-going efforts on the part of facility to keep the resident informed about different medication options after she refused the medications and documenting and acting upon the resident's expressed concerns. | 2014-01-01 | ||
| 192 | 192 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2016-03-04 | 155 | D | 0 | 1 | TSLL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of eight medical records and interviews performed during recertification survey from 3/1/16 thru 3/4/16, it was determined that the facility failed to promote the right of residents to formulate advance directive for 1 out of 8 sample selection resident (Resident #8 ). Findings include: 1. Resident #8 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED].#8 was performed on 3/3/16 at 10:55 am and provided evidence that facility informs and provide written information to the resident concerning the right to accept or refuse medical or surgical treatment, however the area were resident or relative establish or formulate advance directives was left in blank. Facility failed to determine whether the resident wish to executed an advance directive or has given other instructions to indicate what care he or she desires in case of subsequent incapacity. | 2019-05-01 |
| 217 | 217 | MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE INC | 405030 | CALLE COSME REPARTO SAN LUCAS ENTRADA SECTOR CANEJ | RIO PIEDRAS | PR | 926 | 2016-02-12 | 155 | E | 0 | 1 | NNQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of eight medical records and interviews performed during extended survey from 2/8/16 thru 2/12/16 it was determined that the facility failed to promote the right of residents to formulate advance directive for 3 out of 8 sample selection resident (Resident #1, # 2 and #3 ) Findings include: 1. Resident #2 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review was performed on 2/8/16 at 2:30 pm and provided evidence that during admission process the facility informs and provide written information to residents concerning the right to accept or refuse medical or surgical treatment. In the area were resident or relative establish or formulate advance directives resident select Do Not Intubate. However the physician did not sign the order to promote resident wishes Advance Directive to do not intubate in the event of an emergency. 2. Resident #3 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review was performed on 2/9/16 at 9:00 am and provided evidence that during admission process the facility informs and provide written information to residents concerning the right to accept or refuse medical or surgical treatment. In the area were resident or relative establish or formulate advance directives resident select Do Not Resucitate. However the physician did not sign the order to promote resident wishes Advance Directive to do not resucitate in the event of an emergency. 3. Resident #1 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review was performed on 2/8/16 at 1:49 pm and provided evidence that during admission process the facility informs and provide written information to residents concerning the right to accept or refuse medical or surgical treatment. In the area were resident or relative establish or formulate advance directives resident have 3 choices: Do Not Resuscitate (DNR), D… | 2019-04-01 |
| 234 | 234 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2015-07-06 | 155 | D | 0 | 1 | 5IF611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of ten medical records and interviews performed during recertification survey from 6/30/15 thru 7/6/15 it was determined that the facility failed to promote the right of residents to formulate advance directive for 1 out of 10 sample selection resident (Resident # 5) Findings include: 1. Resident #5 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review was performed on 6/30/15 at 3:30 pm and provided evidence that during admission process the facility informs and provide written information to residents concerning the right to accept or refuse medical or surgical treatment, however the area were resident or relative establish or formulate advance directives was left in blank. Accordance with Minimum Data Set (MDS) Resident Assessment and Care Screening Instrument date of reference 6/28/15 resident ability to understand verbal content was impaired and he was coded as rarely/never understands and his ability to express ideas and wants was also coded as rarely/never understood. The facility failed to determine whether the resident wish to executed an advance directive or has given other instructions to indicate what care he desires in case of subsequent incapacity. | 2018-11-01 |
| 283 | 283 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 155 | F | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of eight medical records and interviews performed during recertification survey from 5/11 thru 5/14/15, it was determined that the facility failed to promote the right of residents to formulate advance directive for 4 out of 8 sample selection resident (Resident #1, #3, #4 and #5). Findings include: 1. Resident #4 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review of resident #4 was performed on 5/11/15 at 2:53 pm and provided evidence that facility informs and provide written information to the resident concerning the right to accept or refuse medical or surgical treatment, however the area were resident or relative establish or formulate advance directives was left in blank. Facility failed to determine whether the resident wish to executed an advance directive or has given other instructions to indicate what care he or she desires in case of subsequent incapacity. 2. Resident #5 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review of resident #5 was performed on 5/12/15 at 9:25 am and provided evidence that facility informs and provide written information to the resident concerning the right to accept or refuse medical or surgical treatment, however the area were resident or relative establish or formulate advance directives was left in blank. Facility failed to determine whether the resident wish to executed an advance directive or has given other instructions to indicate what care he or she desires in case of subsequent incapacity. 3. Resident #3 was admitted on [DATE] due to Left Total Knee Replacement. The resident was accompanied by her sister during the admission process. The Advanced Directives was signed by resident's sister. During interview with resident performed on 5/11/15 at 10:00 am she referred that she left her sister to sign the admission's papers because she was tired and in pain. When the surveyor asked ab… | 2018-09-01 |
| 453 | 453 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2012-07-20 | 155 | E | 0 | 1 | 93CN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #8 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. This resident have impaired cognitive skills for daily decision making and does not have the ability to understand others. The record review was performed on 7/20/12 at 10:00 am and provided evidence that the document which contains the resident's information related to advanced directives in order to acquire information for the establishment of advanced directives was not signed by the resident or the person in charge of the resident. The facility failed to ensure that the resident signed appropriate self determination documents during her stay at the facility which includes advanced directives. Based on the review of ten medical records, it was determined that the facility failed to promote the right of residents to formulate advance directive for two out of ten sample selection residents (Residents #6 and #8). Findings include: 1. Resident #6 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. This resident does not have impaired cognitive skills for daily decision making and has the ability to understand others. The record review was performed on 7/19/12 at 10:00 am and provided evidence that the document which contains the resident's information related to advanced directives in order to acquire information for the establishment of advanced directives was not signed by the resident or the person in charge of the resident. The area on the "Right for Self Determination" form where the resident is supposed to sign, had a note from the facility personnel who filled out the form and it stated "unable to sign" and was dated 6/24/12. The facility failed to ensure that the resident signed appropriate self determination documents during her stay at the facility which includes advanced directives. | 2015-07-01 |
| 511 | 511 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2011-07-22 | 155 | D | 0 | 1 | EPDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of five resident's records, policies/procedures and interview, it was determined that the facility failed to promote the right of residents to formulate advance directive for one out of five sample selection residents (resident #5). Findings include: 1. Resident #5 (closed record) is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the review of the medical record on 7/21/11 at 10:55 am, it was identified that the advance directives documents who included the information of the mechanism to formulate advance directives by residents at the facility was signed by her husband during the admission process on 7/7/11. However the area where the form indicates if the resident had advance directives was left in blank. No information was found in the medical record related to the reason why it was left in blank, the area where the document indicates if the resident wishes to formulate advance directives. The facility failed to ensure that appropriate procedures related with the formulation of advance directives by residents are followed. a. The nursing supervisor (employee #1) stated during an interview on 7/22/11 at 1:55 pm that the person who signed the advance directive formulary was acting on behalf on the resident and assumes responsibility for the provision of health care when the resident can not formulate advance directives. It is not acceptable that the person who signs the formulary does not indicate if the resident formulates or wishes to formulate advance directives. | 2014-10-01 |
| 525 | 525 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2011-03-18 | 155 | D | R1BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident's records reviewed, policies/procedures, interview and observations, it was determined that the facility failed to promote the right of residents to formulate advance directive for one out of ten sample selection residents (resident #2) related with Do Not Resuscitate (DNR) orders. Findings include: Resident #2 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was observed bedridden, has a gastrostomy and [MEDICAL CONDITION] connected to a mechanical ventilator on 3/16/11 at 9:30 am. The resident's husband stated during an interview on 3/17/11 at 10:38 am that he signed a "Do Not Resuscitate" order for the resident during admission on 2/28/11. Review of the medical record on 3/17/11 at 9:00 am provided evidence that during admission the husband signed a DNR consent but no evidence was found of the physician's signature on the consent or the progress notes that included the reasons for the DNR. The DNR form did not have the physician's name and the physician's signature. The facility's policies and procedures were reviewed on 3/17/11 at 2:00 pm and it states that the physician who places the order for Do Not Resuscitate must also document the current progress notes related to the resident's condition. No documentation was found in the resident's record related to the residents' or her legal representatives' orientation regarding the DNR. No evidence was found that the DNR was current and binding. The facility failed to ensure that the physician implements appropriate procedures related with the DNR. | 2014-04-01 | ||
| 548 | 548 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2012-04-20 | 155 | E | S02O12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of seven medical records and interview during the follow-up visit, it was determined that the facility failed to promote the right of residents to formulate advance directive for four out of seven sample selection residents (Residents #1, #2, #3 and #7). Deficiencies not corrected Findings include: 1. Resident #1 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review of resident #1 was performed on 7/5/12 at 1:03 pm and provided evidence that the advanced directive document in order to acquire information for the establishment of advanced directives was signed by the person in charge of the resident. However, the date when the advanced directive was signed was not included on the document. The facility failed to promote complete documentation which includes the date when the advanced directive was signed by the resident's relatives. 2. Resident #3 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The nursing supervisor (employee #4) stated during an interview on 7/6/12 at 11:13 am that this resident has moderately impaired cognitive skills for daily decision making and she could not sign the advanced directive document. However, the facility did not contact a person in charge of the resident in order to complete the advanced directive document given to the resident at admission. 3. Resident #7 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review of resident #7 was performed on 7/6/12 at 1:50 pm and provided evidence that the advanced directive document in order to acquire information for the establishment of advanced directives was signed by the resident's daughter, however the area where the resident's relative indicates if she refuses any treatment or procedure was left in blank. The facility failed to maintain complete documentation of the advanced directives performed by the resident's daught… | 2014-04-01 | ||
| 625 | 625 | SAN JUAN AGING CENTER | 405021 | 65 INF AVE K3 H4 | RIO PIEDRAS | PR | 924 | 2012-04-24 | 155 | F | E6TK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of ten medical record and interview, it was determined that the facility failed to promote the right of residents to formulate advance directive for two out of three sample selection resident (Resident #1 and #2). Findings include: 1. Resident #1 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review of resident #1 was performed on 4/23/12 at 10:53 am and provided evidence that the advance directive document in order to acquire information for the establishment of advance directives was left in blank. The nursing supervisor (employee #1) stated during an interview on 4/23/12 at 3:23 pm that this resident was severely impaired related to cognitive skills for decision making and the resident's daughter was the person in charge of the resident. The facility could not contact the relative in order to complete the advance directives and they were waiting for the relative to visit the resident to acquire information. 2. Resident #2 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 4/23/12 at 1:30 pm and provided evidence that the advance directives documents which includes information to formulate advance directives by residents at the facility was signed by the resident during the admission process on 4/17/12. However, the area where the form indicates if the resident wishes to formulate advance directives has a check mark and does not have the resident's initials as required by the document. The resident was observed on 4/23/12 at 8:30 am oriented and requires limited/extensive assistance for bed mobility, transferring, personal hygiene and bathing. The facility failed to ensure that appropriate procedures related with the formulation of advance directives by residents are followed. | 2014-03-01 | ||
| 696 | 696 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2010-02-19 | 155 | D | OWRV11 | Based on the review of ten medical record and interview, it was determined that the facility failed to promote the right of residents to formulate advance directive for one out of ten sample selection resident (Resident #3). Findings include: The record review of resident #3 was performed on 2/17/10 at 1:23 pm and provided evidence that the advance directive document in order to acquire information for the establishment of advance directives was left in blank. The nursing supervisor (employee #51) stated during an interview on 2/18/10 at 8:43 am that this resident was moderately impaired related to cognitive skills for decision making and the resident's son was the person in charge of the resident. The facility could not contact the relative in order to complete the advance directives and they were waiting for the relative to visit the resident to acquire information. | 2014-02-01 | ||
| 313 | 313 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 156 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with the Social Worker (employee #15), resident's family members, the Administrator (employee # 13), the Owner and President of the Governing Body (employee # 1), administrative documents, policies and procedures (P&P's) and record reviews performed on the recertification survey on 5/19 thru 5/22/15, it was determined that the facility failed to provide services according to residents needs for 2 out of 8 sample residents (RR #1 and #6). Findings include: 1. The facility is requiring prior to admission, that resident to be admitted and who are disoriented must be accompanied by a family member to observe and to prevent resident ' s falls. During the admission process, the residents must bring with them all maintenance medications that are taking at home, (Cross reference TAG 323). a. According to interview with the Social Worker (employee # 15) performed on 5/21/15 at 11:45 am, she stated: There are two coordinators that goes to the hospitals to interview residents that are going to be admitted to our facility. During the interview, the coordinators give them a form named What to bring? , where it mention the personal items, clothes that they have to bring to our facility during the admission process and includes to bring their maintenance medications that they take at home. Also, the coordinator give orientation to family members that residents who are disoriented needs company during his/her stay at the facility, to give assistance and to watch them to prevent falls. b. During the review of the admission packet performed on 5/21/15 at 1:30 pm, it was found the form named What to bring? On step #4 of this form, establishes that maintenance medications must be brought to the facility in their bottles, not on pill boxes. This form is given to family members during the pre screening process that the coordinator performs prior to admission. c. According to interview with the Administrator (employee # 13) performed on 5/22/15 … | 2018-09-01 |
| 482 | 482 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2012-02-29 | 156 | F | 0 | 1 | G0N711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of eight medical record and interview with the social worker (employee #10), it was determined that the facility failed to provide medicare recipients the important message from medicare about rights and information related to the resident's rights during the stay at the facility as well as the medicare appeal rights related to facility discharge, the deficient practice was identified for five out of eight residents of the sample selection (sample selection residents #1, #2, #4, #5 and #7). Findings include: 1. The following was identified during review of eight medical records with the facility's social worker (employee #10) on 2/28/12 from 1:23 pm till 2:15 pm: a. Resident #5 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. This resident's relative was informed on 2/28/12 of the important message from medicare about rights and information related to the resident's rights during the facility stay as well as the medicare appeal rights related to facility discharge, the facility's plan is to discharge the patient on 3/1/12. However, no evidence was found that the resident's relative was informed upon admission of the important message from medicare about these rights and information related to the resident's rights during the facility stay as well as the medicare appeal right related to the facility's discharge. This information must be provided to resident's relatives upon admission and then two days prior to discharge from the facility according with information given by the facility's social worker (employee #5) on 2/28/12 at 1:48 pm and policies reviewed on 2/28/12 at 2:15 pm. The facility failed to promote the right of each resident to be informed upon admission of the rights as a medicare resident and the discharge appeal rights. b. Resident #2 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. during the facility stay as well as the medicare appeal rig… | 2015-06-01 |
| 649 | 649 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2012-03-15 | 156 | C | OK6U11 | Based on the review of ten medical records with the MDS coordinator (employee #3) and social worker (employee #7) and interview, it was determined that the facility failed to provide medicare recipients the important message from medicare about rights and information related to resident's rights during the stay at the facility as well as the medicare appeal right related to the facility's discharge, this deficient practice was identified for ten out of ten residents of the sample selection (residents #1 through #10). Findings include: 1. The following was identified during the review of ten medical records with the facility's MDS coordinator (employee #3) from 3/13/12 through 3/15/12 from 8:00 am till 3:00 pm: a. The facility has not implemented a mechanism to ensure that the important message from medicare about rights and information related to the resident's rights during the facility stay as well as the medicare appeal right related to the facility's discharge was provided to each medicare resident admitted to the facility to receive services. The Social Worker (employee #7) stated during interview on 3/13/12 at 3:00 pm that this important message from medicare was not provided to residents or relatives during admission. The facility failed to promote the right of each resident to be informed upon admission of their right as a medicare resident and the discharge appeal right. | 2014-03-01 | ||
| 260 | 260 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 162 | F | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation tour, interviews with resident and professional personnel performed from 6/16/15 thru 6/18/15 during the recertification survey, it was determined that the facility failed to supply brief and urinal disposable kit to the residents during the admission at the facility, for 1 out of 10 residents (R) in the sample selection (R #9 ). Findings include: 1.R #9, is a [AGE] years old male , admitted to SNF on 6/15/15 due to Intramedulary Nail Left Hip, oriented in time, place and person, he is bedridden, because of the [MEDICAL CONDITION] and the Below Knee Amputation on his left leg. Secondary Diagnoses: [REDACTED]. As observed, during the initial tour from 6/16/15 at 9:30 am, the resident room has a strong odor of humidity and urine. Resident bed was observed and reveals that the linen has old blood stains, gauze with blood on his bed and the resident has a dirty shirt on. The register nurse employee #1 indicates that the social worker call yesterday the relatives because the patient need clothes and brief. 2. On 6/17/15 at 9:00 am resident #9 was found in his bed and he asks if some can bring him the bottle because he wants to urine in the collector and not in the brief. During interview with the resident #9 on 6/17/15 at 9:00 am it was found that the resident before the accident he did not use brief. He started using brief at the hospital after surgery. The resident stated my wife came yesterday and brought some brief because someone from here called her and told her that I need brief. I prefer the urinal before the brief . 3. During RR on 6/17/15 at 11:00 am it was found that the social worker (employee #13) did not performed an interview to the resident the same day of the admission to assess and to identify resident's needs. She assesses the resident's needs on 6/16/15 at 2:00 pm and did not ask the patient if he needed something to feel comfortable. The social worker sated that on 6/16/15 at 9:00 am the nursing personnel … | 2018-10-01 |
| 483 | 483 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2012-02-29 | 162 | F | 0 | 1 | G0N711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the initial tour with the Nursing Supervisor (employee #1) and interviews with family members, it was determined that the facility failed to provide "incontinence care and supplies" for nine out of nine admitted residents who use adult disposable brief (sample selection residents #1, #2, #4, #5, #6, #7 and random sample residents #2, #3 and #8). Findings include: During the initial observational tour of resident's rooms on 2/28/12 from 8:45 am till 10:30 am, the resident's daughters in room [ROOM NUMBER]A (sample selection resident #6) and #310B (random sample resident #2) were interviewed and they stated on 2/28/12 at 9:20 am that they were transferred from the ninth floor to the Hospital's SNF on the third floor. When they arrived at the third floor (SNF), nursing personnel informed them for the first time that they needed to buy disposable briefs for their mothers because they do not supply them at the SNF. Interview with sample selection residents #1, #2, #4, #5, #7 and random sample residents #3 and #8 on 2/28/12 from 1:00 pm till 2:00 pm provided evidence that they were asked to bring their own adult disposable briefs. The facility failed to ensure that items such as those used for "incontinence care and supplies" are provided by the facility to ensure that care and services are provided as regulations dictate. | 2015-06-01 |
| 1 | 1 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2017-05-04 | 164 | D | 0 | 1 | ZOYB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification extended survey, observations during medication pass with the Registered Nurse (RN) (Employee #1) performed from 5/2/17 thru 5/4/17, it was determine that the facility failed to ensure that residents are treated with respect and dignity during delivery of nursing care, for 1 out of 28 residents (Suplemental Sample Resident #11). Findings include: 1. During de medication pass on 5/3/17 at 9:37 am with the RN (Employee #1) on room [ROOM NUMBER]A it was observed that the RN was administering medication and explaining the medications to the resident and the physician (MD) (Employee #2) entered to the residents room without knocking the door and requesting permission to enter, and immediately started talking to the RN (Employee#1) ignoring the presence of the resident. 2. The MD (Employee #2) gave to the RN (Employee #1) information about the medication that had just ordered to the resident of room [ROOM NUMBER][NAME] During Interview with Administrator (Employee #3) on 5/3/17 at 3:12 pm, she stated: I already talked to the physician about the incident on room [ROOM NUMBER]A and he told me that he did not mention the name of the resident just the room number and the medication. But we are going to keep working on that. | 2020-09-01 |
| 129 | 129 | HIMA SAN PABLO CUPEY SNF | 405031 | CARR 844 KM 0 5 CUPEY BAJO | RIO PIEDRAS | PR | 928 | 2017-03-16 | 164 | D | 0 | 1 | LEID11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an initial certification survey, observations during medication administration pass with a Registered Nurse (RN) (employee #1) performed from 3/14/17 thru 3/16/17, it was determine that the facility failed to promote residents' right for personal privacy during administration of subcutaneous injections for 1 out of 3 Residents ( R ) (R #1). Findings include: The RN employee #1 was observed on 3/14/17 at 9:05 am performing a medication administration of [MEDICATION NAME] 30 mgs subcutaneous to Resident #1, the RN #1 exposed the residents' abdominal area and did not close completely the curtain to provide privacy during the medication administrations, while the room's door was open. The facility failed to ensure that nursing staff promote residents' right for personal privacy, respect and dignity. | 2020-09-01 |
| 193 | 193 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2016-03-04 | 164 | F | 0 | 1 | TSLL11 | Based on observational tour performed from 3/1/16 thru 3/4/16 during survey and interview to nursing supervisor, it was determined that the facility failed to promote resident ' s rights concerning to privacy and confidentiality due to personal information exposed in a corridor, This deficient practice had the potential to affect 17 out of 17 residents admitted at the facility (R#1to #9) and sample selection cases ( RR# 1 to #7). Findings include: 1. During initial observational tour on 3/1/16 at 9:00 am it was observed on one of the corridors in front of the wheelchair scale that personnel posted on the wall a list to be use to document resident's name, room number and weight obtained. 2. Nursing supervisor (employee #1) stated on interview on 3/1/16 at 10:02 am that the list is to be use to document resident's name, room number and weight obtained and should not be posted on the wall, because on this document the personnel documents resident's information. 3. During the medication pass on 03/02/2016 at 8:57am it was observed that the Register Nurse (employee # 3) who was performing the medication pass left the Medication Administration Record [REDACTED]. The facility failed to promote resident ' s rights concerning to privacy and confidentiality due to personal information exposed in a corridor. | 2019-05-01 |
| 210 | 210 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2016-02-25 | 164 | F | 0 | 1 | EI0Q11 | Based on observations and interview it was identified that facility failed to promote confidentiality of information contained in the resident's clinical records. This deficient practice had the potential to affect for 5 out of 5 residents (R) in the sample selection (RR #1, through # 5) and 4 out of 4 residents in the random sample selection (RR #1, through #4). Findings include: 1. A mechanism to ensure that obligations regarding privacy and confidentiality of resident's clinical record information and policies and procedures established by the facility to comply with Health Insurance Portability and Accountability Act ( HIPAA) law were not followed not promoted. The following findings were identified during survey procedures on 2/23/16 through 2/25/16: a.An activity and recreative therapy student was observed intervening with residents during recreative activity sessions ( on 2/23/16 through 2/25/16) It was identify that this activity and recreative therapy student may have access to resident's information contained on the medical record in order to execute recreative activities and related procedures. b. Evidence that this student was informed related with obligations regarding privacy and confidentiality of resident's clinical record information were not provided during survey. c. Evidence that this student was informed about policies and procedures established in the facility to comply with HIPAA law regulation were not provided during survey. The facility 's Recreative therapyst specialisyst (employee #2) stated on interview on 2/25/16 at 10:00 am that this activity and recreative therapy student began to practice since several weeks ago. She stated that facility administration services told her that she must coordinate with the student days of practice and activities to be performed and that this student was assigned to be under her supervision. She stated that no information related with privacy and confidentiality of resident's clinical record information or about policies and procedures established in … | 2019-05-01 |
| 284 | 284 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 164 | F | 0 | 1 | 1VLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during physical environment tour and interview performed to Safety Offficer (employee #6), it was determined that the facility failed to promote residents' right for personal privacy from the outside of their rooms for 4 out of 14 (resident #3,#4,#5 and #7). 1. A mechanism to ensure that residents' have the right for personal privacy is promoted was not performed, nor followed according with the following findings: a. During the physical environment tour performed on 5/14/15 from 8:30 am until 1:00 pm, it was identified that curtains that cover the outside windows located in rooms #307, #308, #309, #310, #314, #315, #316 and #317 are wide open and the windows do not have dyes. These windows are located on the side of the facility's roof, subcontractors and personnel working in this area or who pass near the windows can see the residents in their room from the outside. b. It was observed at 9:30 am on 5/14/15 resident of room [ROOM NUMBER]A it was taking a bath in bed and the licensed practitical (employee #21) did not close the windows curtain completely. Interview performs to employee #6 reveals that anyone from the outside can see right through the windows because they do not have dyes. Surveyor asked to employee #6 if physical plant department has a list or daily register for the subcontractors who perform works around the facility and he indicates they do not have a daily register for subcontractors who perform daily jobs and repairs around the facility. c. The facility failed to ensure the staff promote resident ' s personal privacy and safety during stay in the facility. | 2018-09-01 |
| 314 | 314 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 164 | F | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview it was identified that facility failed to promote the right of each resident to personal privacy and confidentiality of his or her personal and clinical records which could affect all residents admitted at the facility. Findings include: 1. A mechanism to ensure that the right of personal privacy and confidentiality of resident clinical conditions are maintained is not followed accordingly with the following findings: a. During the flash tour observation performed on 5/19/15 at 9:00 am thru 11:00 am it was observed a red sign indicating Resident con historial de alergias Resident with allergic history also it was observed a red band on residents wrists indicating the information of what kind of medication is allergic too. b. According with information provided by Physical Therapist supervisor (employee #12) on 5/19/15 at 9:45 am We use this sign and the wrist band to identify the residents with medication allergies [REDACTED]. c. The facility failed to promote resident ' s privacy and confidentiality of information. | 2018-09-01 |
| 391 | 391 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2014-09-10 | 164 | F | 0 | 1 | SRWL11 | Based on observations and interview it was identified that facility failed to promote the right of each resident to personal privacy and confidentiality of his or her personal and clinical records which could affect all residents admitted at the facility. Findings include: 1. A mechanism to ensure that the right of personal privacy and confidentiality of resident clinical records record are maintained is not followed accordingly with the following findings: a. According with information provided by facility pharmacist (employee #10) on 8/22/14 at 10:05, Walgreens pharmacy was visiting SNF area to inform residents about a program that they had in place where they offer to deliver medications prescribed on discharge. She stated that as part of the program Walgreens visit residents who are going to be discharge and offer the services. If the resident agrees to receive the services, Walgreens ' personnel picks up the medication discharge prescription and goes to Walgreens pharmacy to prepare the prescription, then returns to the SNF and deliver the medications at bedside . b. According with information provided by facility pharmacist (employee #10) on 8/22/14 at 10:15: If a resident agree to participate on Walgreens program; information about medication prescription are provided to the Walgreens personnel (by fax or personal). Walgreens ' personnel prepare the prescription, then return to the SNF and deliver the medications at bedside . c. Information about the person identity who came from Walgreens to pick up the prescription and then return to the SNF to deliver the medications at bedside, were not documented by the facility. d. A consent or document signed by the resident who agrees to participate in Walgreens program to authorize the facility to provide/release discharge medication prescription and other required information requested by the pharmacy were not completed at the facility. e. A mechanisms to ensure that residents authorize the facility to provide/release information related with health care plan to … | 2017-06-01 |
| 454 | 454 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2012-07-20 | 164 | E | 0 | 1 | 93CN11 | 2. A mechanism to ensure that residents' have the right for personal privacy is promoted was not performed, nor followed according with the following findings: a.During the initial observational tour on 7/18/12 from 8:43 am till 11:00 am with the head nurse (employee #3), it was identified that curtains that cover the outside windows located in rooms #118 and #119 (random sample residents #11 and #13) are too short and do not cover the entire window area. These windows are located on the side of the facility's parking lot, personnel and visitors who pass through the sidewalk near the parking lot can see the residents in their room from the outside. Based on observations made during the drug pass and initial observational tour, it was determined that the facility failed to promote residents' right for personal privacy during the medication administration and from the outside of their rooms for three out of thirty-four admitted residents (resident #8, random sample residents #11 and #13). Findings include: 1. During the medication pass in the room of resident #8 on 7/19/12 at 10:30 am, the Registered Nurse (RN) (employee #8) was observed giving the resident medications by gastrostomy tube. The RN (employee #8) did not close the curtain (this bed is closest to the front door) and a physical plant employee (employee #5) and a family member of another resident entered the room and the resident was exposed because the curtain was not drawn. The facility failed to provide privacy for this resident to ensure that the resident was treated with respect and was provided privacy when the RN administered medications by gastrostomy tube. | 2015-07-01 |
| 512 | 512 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2011-07-22 | 164 | F | 0 | 1 | EPDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the medication drug pass with a Registered Nurse (RN) (employee #2), it was determined that the facility failed to promote residents' right for personal privacy for three out of three residents during administration of subcutaneous injections (random sample residents #1, #2 and #3). Findings include: During the medication drug pass on 7/22/11 from 8:20 am till 10:10 am, it was observed that when the RN (employee #2) went to administer the [MEDICATION NAME] 40 mgs subcutaneously, to residents in rooms #1A, #2A and #3A (random sample residents #1, #2 and #3), she exposed the residents' abdominal area and did not close the curtain to provide privacy during the medication administrations. | 2014-10-01 |
| 549 | 549 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2012-04-20 | 164 | E | S02O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the drug pass and femoral catheter care and observational tour, it was determined that the facility failed to promote residents' right for personal privacy during medication administration, femoral catheter care and when transferring from the bed to the wheel chair while in their rooms for three out of twenty-eight admitted residents (resident #1, #6 and random sample resident #12). Findings include: 1. Resident #1 is a [AGE] years old female who was observed on 4/19/12 at 8:50 am, during the drug pass for medication administration by femoral catheter, the Registered nurse (employee #5) failed to run the curtain completely around the resident's bed to provide privacy for this resident from staff and other persons who entered in the resident's room during the procedure. The resident's bed is near the front door which does not ensure residents' privacy during medication administration. 2. During the medication pass in the room of resident #6 on 4/19/12 at 9:15 am, the Registered Nurse (RN) (employee #21) was observed giving the resident medications by gastrostomy tube. The RN (employee #21) did not close the curtain and the room door was open while maintenance personnel (employee #26) were cleaning the room (sweeping and mopping). The facility failed to provide privacy for this resident to ensure that the resident was treated with respect and is provided privacy when the RN administers medications by gastrostomy tube. 3. During the medication pass in the room of random sample resident #12 (male resident) on 4/19/12 at 9:30 am, a hospital employee (resident escort) (employee #15) was observed moving resident #12 from the bed to the wheelchair to take the resident to the physical therapy department, however the resident only had on a pair of disposable briefs and the curtain was not drawn which exposed the resident to other persons entering the room. The resident's bed is near the front door which does not ensure… | 2014-04-01 | ||
| 637 | 637 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2011-02-17 | 164 | F | 5V0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the medication drug pass on 2/16/11 from 8:45 am till 10:23 am, it was found that the RN (employee #11) was preparing medications for the resident in room [ROOM NUMBER]A (random sample resident #1). When the RN went to administer the [MEDICATION NAME] 30 mgs subcutaneously, she exposed the resident's abdominal area and closed the curtain but left a side of the bed uncovered by the curtain leaving the resident exposed while she administered the medication. 3. During the medication drug pass on 2/16/11 from 8:45 am till 10:23 am, it was found that the RN (employee #11) was preparing medications for the resident in room [ROOM NUMBER]A (sample selection resident #7). When the RN went to administer the [MEDICATION NAME] 30 mgs subcutaneously, she exposed the resident's abdominal area and closed the curtain but left a side of the bed uncovered by the curtain leaving the resident exposed while she administered the medication. Based on observations made during the initial tour with a Registered Nurse (RN) (employee #1), it was determined that the facility failed to promote residents' right for personal privacy before entering resident's rooms to ensure that they were willing to receive visitors which was observed at eighteen out of eighteen resident's rooms which could affect thirty-five out of thirty-five admitted residents (sample selection residents #1 through #9 and random sample residents #1 through #26) and failed to draw the curtains in resident's rooms #2A and #3A during [MEDICATION NAME] injection administrations for sample selection resident #7 and random sample resident #1. Findings include: 1. During the initial tour observational tour of resident's rooms on 2/15/11 from 7:10 am through 10:00 am the registered nurse (RN) (employee #1) failed to knock on resident's doors before entering. When the RN failed to knock before entering resident's rooms, she could not verify if the residents were willing to receiving a visit or if they… | 2014-03-01 | ||
| 650 | 650 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2012-03-15 | 164 | E | OK6U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the initial tour, it was determined that the facility failed to promote the residents' right for personal privacy during bathing procedures for two out of twenty-nine admitted residents (resident #2 and random sample resident #6). Findings include: 1. Resident #2 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the initial tour on 3/13/12 at 10:00 am, it was observed that the resident was sitting on a wheelchair with disposable briefs on top of an underpad before nursing personnel (employee #10) took the resident into the shower. The resident's room door was in the closed position, however the resident was left exposed to persons entering and leaving the room while the nurse prepared the shower for the resident. The facility failed to provide privacy for this resident from staff and other persons who entered the room while he was waiting to be showered. 2. During the tour of the room of random sample resident #6 (female resident) on 3/13/12 at 10:30 am, nursing personnel were giving her a bed bath. The Licensed Practical Nurse (LPN) (employee #9) closed the door to provide privacy for this resident, however the curtains did not close completely and the resident's back side could be seen from one of the sides of the curtain when staff entered the resident's room. The facility failed to to ensure that the patient was treated with respect and is provided privacy during the bed bath. The resident's bed is near the front door which does not ensure the residents' privacy during the bathing process if the curtain is not drawn properly. | 2014-03-01 | ||
| 697 | 697 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2010-02-19 | 164 | F | OWRV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the drug pass and ulcer care and observational tour, it was determined that the facility failed to promote residents' right for personal privacy during medication administration, ulcer care and while in their rooms for three out of twenty-five admitted residents (resident #3, #8 and random sample resident #9). Findings include: 1. Resident Sample #8 is a [AGE] years old male who was observed on 2/18/10 at 8:50 am during the drug pass for medication administration by gastrostomy tube. Registered nurse #8 failed to run the curtain completely around the resident's beds to provide privacy for this resident from staff and other persons who entered in the resident's room during the procedure. The resident's bed is near the front door which does not ensure residents' privacy during medication administration. Also, when registered nurse #8 finished the medication administration procedure he left the room while the resident was uncovered. 2. Random sample resident #9 is an [AGE] years old female who was observed on 2/19/10 at 12:10 pm during ulcer care. Registered nurse #11 failed to run the curtain completely around the resident's bed to provide privacy for this resident from staff and other persons who were entering in the resident's room during the ulcer care procedure. 3. During an observational round of resident's rooms on 2/19/10 at 9:15 am with the physical plant manager (employee #52) resident #3 was visited in room [ROOM NUMBER]. The resident was observed lying in bed covered with a blanket up to her waist and a yellow gown covering her chest area. Yellow gowns are usually worn by maintenance personnel or staff during ulcer care, but the resident did not like what she was wearing and she requested the yellow gown from the facility. The yellow gown is see through and the resident did not have anything on under the yellow gown, exposing her breasts to persons who entered her room such as the physical plant mana… | 2014-02-01 | ||
| 315 | 315 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 165 | F | 0 | 1 | 1WB711 | Based on eight sample records review and residents group interview performed during recertification survey from 5/19 thru 5/22/15, it was determined that the facility failed to ensure that 5 out of 5 residents know the grievances process. Findings include: 1. The group interview was performed on 5/19/15 at 2:50 pm with a participation of 5 residents. It was found that 5 out of 5 residents did not show knowledge of the facility's policies and procedures related to the grievances processes. a. Only one resident could mention that in case of any situation that cause anger and discomfort, will talk with the nursing supervisor for advice. | 2018-09-01 |
| 343 | 343 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2014-09-12 | 165 | F | 0 | 1 | 2S3211 | Based on review of admission package, it was determined that the facility failed to promote residents' right to receive information about phone numbers and entities whom to contact to file a grievance. This deficient practice could affect 10 out of 10 residents (sample selection residents #1 through #10). Findings include: 1. During review of grievance policies and procedures on 8/25/14 at 11:40 am with the risk manager director (employee #15) the following was identified: a. Information about phone numbers and entities other than the facility on whom to contact to file a grievance were not provided to residents when admitted to receive services at the facility. b. State agency complaint and Medicare hot line phone numbers were included incorrect in the admission package information provided to residents during admission to the facility. | 2017-06-01 |
| 379 | 379 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2014-05-15 | 165 | F | 0 | 1 | NPM711 | Based on review of admission package with risk management officer (employee # 7) it was determined that the facility failed to promote residents' right to receive information about phone numbers and entities whom to contact to file a grievance. This deficient practice could affect 8 out of 8 residents (sample selection residents #1 through #4 and random sample residents #1 through #4). Findings include: 1. During review of grievance policies and procedures on 5/14/14 at 11:39 am with the risk manager director (employee # 7) the following was identified: a. Information about phone numbers and entities other than the facility on whom to contact to file a grievance were not provided to residents when admitted to receive services at the facility. b State agency complaint and medicare hot line phone numbers were not included in the admission package information provided to residents during admission to the facility. | 2017-06-01 |
| 392 | 392 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2014-09-10 | 165 | F | 0 | 1 | SRWL11 | Based on review of admission package with risk management officer (employee #3) it was determined that the facility failed to promote residents' right to receive information about phone numbers and entities whom to contact to file a grievance. This deficient practice could affect 8 out of 8 residents (sample selection residents #1 through #8). Findings include: 1. During review of grievance policies and procedures on 8/20/14 at 11:40 am with the risk manager director (employee #3) the following was identified: a. Information about phone numbers and entities other than the facility whom to contact to file a grievance were provided wrong to residents when admitted to receive services at the facility. b State agency complaint and Medicare hot line phone numbers were included incorrect on the admission package information provided to residents during admission to the facility. | 2017-06-01 |
| 2 | 2 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2017-05-04 | 166 | D | 0 | 1 | ZOYB11 | Based on a recertification extended survey, review of the admission package it was determined that the facility failed to provide the correct telephone numbers for grievance process. This deficient practice could affect 28 out of 28 admitted residents. Findings include: On 05/02/17 at 10:30 am during the review of the admission package it was identified that the facility admission packet booklet did not have the correct numbers to file a grievance to the Puerto Rico Health Department (Instituciones de Salud Ley 101) and Medicare Hot Line. The facility fail to maintain an updated telephone numbers for the patient's grievance process. | 2020-09-01 |
| 130 | 130 | HIMA SAN PABLO CUPEY SNF | 405031 | CARR 844 KM 0 5 CUPEY BAJO | RIO PIEDRAS | PR | 928 | 2017-03-16 | 167 | F | 0 | 1 | LEID11 | Based on an initial certification survey, observational tour of the facility, it was determined that the facility failed to ensure that the results of the most recent survey of the facility conducted by the State Licensing Division with its plan of correction is available for residents to review. This deficient practice had the potential to affect 3 out of 3 (Resident #1, #2, # and #3).admitted residents from which the right to examine the results of the most recent survey and the plan of correction in effect was not promoted. Findings include: During the initial observational tour of the facility on 3/14/17 at 6:55 am, no evidence for the initial state survey performed on (YEAR) and the plan of correction for the deficiencies. The facility must make the results available with all the deficiencies and with its approved plan of correction for residents' examination. | 2020-09-01 |
| 261 | 261 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 167 | C | 0 | 1 | 1RD011 | Based on the observational tour of the facility, it was determined that the facility failed to ensure that the results of the most recent survey of the facility conducted by the State Agency with its plan of correction is available for residents to review. Findings include: During the initial observational tour of the facility on 6/16/15 at 8:30 am, it was found that in the main entrance of the resident ' s dining room there is a tray with a folder which identifies it as the survey results from the last Medicare survey. However, no evidence was found that this folder contained the K-tags deficiencies from the last survey performed on 2014 and the plan of correction for the deficiencies. The facility must make the results available with all the deficiencies and with its approved plan of correction for residentes examination . | 2018-10-01 |
| 344 | 344 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2014-09-12 | 167 | C | 0 | 1 | 2S3211 | Based on the observational tour of the facility, it was determined that the facility failed to ensure that the results of the most recent survey of the facility conducted by the State Agency with its plan of correction is available for residents to review. Findings include: During the initial observational tour of the facility on 8/25/14 at 9:55 am, it was found that in front of the nursing station there is a box with a folder which identifies it as the survey results from the last Medicare survey. However, the folder only contain facility plan of correction and exhibits, there is no evidence of the Statement of Deficiencies (CMS-2567). | 2017-06-01 |
| 495 | 495 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4 L 10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2012-08-10 | 167 | C | 0 | 1 | H7DD11 | Based on the observational tour of the facility, it was determined that the facility failed to ensure that the results of the most recent survey of the facility conducted by the State Agency is available for residents to review. Findings include: During the initial observational tour of the facility on 8/9/12 at 9:20 am, it was found that in front of the nursing station there is a folder which identifies it as the survey results from the last Medicare survey. However, the last survey results found was dated 5/12/10, but no evidence was found that this folder contained the updated survey results of the year 2011. The last survey conducted was on 5/17/11 and 5/18/11 and the facility was found in compliance with skilled nursing facility regulations, but no evidence was found of the compliance letter sent to them for residents to view. | 2015-06-01 |
| 550 | 550 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2012-04-20 | 167 | C | S02O11 | Based on the observational tour of the facility, it was determined that the facility failed to ensure that the results of the most recent survey of the facility conducted by the State Agency with its plan of correction is available for residents to review. Findings include: During the initial observational tour of the facility on 4/18/12 at 8:00 am, it was found that next to the nursing station there is a box with a folder which identifies it as the survey results from the last Medicare survey. However, no evidence was found that this folder contained the plan of correction for the deficiencies found in this folder. The facility must make the results available for examination with its approved plan of correction. | 2014-04-01 | ||
| 631 | 631 | SAN JUAN AGING CENTER | 405021 | 65 INF AVE K3 H4 | RIO PIEDRAS | PR | 924 | 2013-08-23 | 167 | D | ROUJ11 | Based on observation and interview, survey results from the previous recertificastion survey was not visible and available so that residents could view them. Findings are: On 8/21/2013, the Director of Infection Control and the Director of Quality Assurance were asked where the past urvey results were posted. They could not find them, but made phone calls to find out where the results were. On 8/22/2013, the Medical Director of Utilization Review was asked where the survey results were posted. She showed the surveyor a holder on the wall for the results. The forms were not in order. She stated the plans of correction were supposed to be placed right after the deficiency, but were placed at random in the folder. She agreed, therefore, that since the forms were in such disarray, an observer would be unable to read and review the survey results. | 2014-03-01 | ||
| 651 | 651 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2012-03-15 | 167 | C | OK6U11 | Based on observations during the initial tour of the facility and interview with the administrator (employee #1), it was determined that the facility failed to ensure that residents have the most recent Medicare survey results available which could affect twenty-nine out of twenty-nine admitted residents (residents #1 through #9 and random sample residents #1 through #20). Findings include: Results of the most recent Medicare inspection performed at the facility was not observed available for residents to review on 3/13/12 at 7:30 am. The administrator (employee #1) stated during an interview on 3/13/12 at 7:55 am that the last inspection report was located in a drawer in front of the counter of the nurse's station, however the drawer was found empty. | 2014-03-01 | ||
| 235 | 235 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2015-07-06 | 172 | F | 0 | 1 | 5IF611 | Based on residents group interview and Nursing Supervisor (employee #1) interview, it was determine that the facility failed to have unrestricted visiting hours at the SNF, for 8 out of 8 residents in the group interview (RR#2, RR#8, RR#9) and (Random Sample #1, #2, #3, #4 and #5). Findings include: 1. During group interview to residents on 7/1/2015 at 10:00am eight out of eight (RR#2, RR#8, RR#9) and (Random Sample #1, #2, #3, #4 and #5) residents state that the visiting hours on the facility are from 8:00 am to 8:00 pm. Also the residents state that at 8:00 pm facility security officer pass to all rooms ant tell the visitors that the visiting hours are over. a. During interview with the Nursing Supervisor on 7/1/15 at 11:00 am, she stated: If the visitor talks to us we can make arrangement for visiting out the visiting scheduled. b. The facility fails to have unrestricted visiting hours . | 2018-11-01 |
| 262 | 262 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 172 | F | 0 | 1 | 1RD011 | Based on facility policies and procedures and residents group interviews, performed during recertification survey 6/16/15, from 1:30pm to 1:45pm, it was determine that the facility failed to ensure the access of family members and other relatives to visit the residents at the SNF which can affect all residents (R) admitted at the facility. (R #1 to R#21) Findings include: 1. During the group interview performed on 6/16/15, from 1:30pm to 1:45pm with 10 out of 21 residents. The surveyor discussed the facility rules on the group interview, and the 10 residents told the surveyor that the visiting hours were from 8:00 am to 8:00 pm. Review of the facility's policy on 6/16/15 at 3:00 pm on page 6 states that the facility has a general visiting hour from 8:30 am to 8:00 pm. a. The facility failed to develop a mechanism to ensure that residents can receive with their consent, visits from family members and other relatives any time at the facility, without visiting hour's restrictions. | 2018-10-01 |
| 285 | 285 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2015-05-18 | 172 | F | 0 | 1 | 1VLO11 | Based on individual and group interviews to residents, interviews with the nursing staff, Physician (employee #1), Physical Therapy Supervisor (employee #3), Director of Nursing (employee #2) Skilled Nursing Facility (SNF) Nursing Supervisor (Employee #4) and the review of administrative documents performed during recertification survey on 5/11 thru 5/14/15 from 8:00 am thru 5:00 pm, it was determine that the facility failed to ensure the access of family members and other relatives to visit the residents at the SNF, for 2 out of 8 residents (RR #1 and #3). Findings include: 1. During observational tours performed on 5/11 and 5/12/15 at 8:30 am, the surveyors watched posted on the bulletin boards located on each resident's room and treatment areas a letter for residents, family members and visitors establishing visiting hours from 3:30 p.m. until 8:30 pm. According to this letter and quote: the purpose for the resident's admission to this unit is to participate in a rehabilitation program that requires your participation in all senses, so visits during therapy activities interrupt your concentration, interventions and to perform the activities on the time frame that has been established by the professionals that work with you. The Hospital has established the visiting hours from 3:30 pm until 8:30 pm so you can receive your visitors and at the same time you can comply with your therapies. We appreciate your cooperation in a manner that you can take advantage on your therapies and complete the rehabilitation program established by each professional that works with you. a. During individual interview to resident #3, performed on 5/11/15 at 9:00 am she stated the following: During the admission process, a personnel member told me that visits has to be perform from 3:30 in the afternoon. Yesterday my sister came to visit me before 12:00 noon, but some of the staff did not allow her to enter the unit. She can not come in the morning hours because she takes care of our brother during the afternoon hours because he is b… | 2018-09-01 |
| 316 | 316 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 172 | F | 0 | 1 | 1WB711 | 2. The group interview was performed on 5/19/15 at 2:50 pm with a participation of 5 residents. When facility's rules were discussed the concern of three residents were related to the visiting hours, that has to be finished at 8:00 p.m. and if a family member wants to stay additional time they can not. Some of the residents said that there are family members that can not go to the facility early in the morning hours due to work and that they can visit during evening or night hours. However, if they arrive after 6:00 pm they know that soon they have to leave the facility because at 8:00 pm the security guard passes thru the rooms and announces that visiting hour has finished. 3. The facility failed to develop a mechanism to ensure that residents can receive with their consent, visits from family members and other relatives any time at the facility, without visiting hour' s restrictions. Based on observations, eight sample records review and interviews to Owner (employee #1), Administrator (employee #13) and during residents group interviews, performed during recertification survey from 5/19 thru 5/22/15, from 9:00 am thru 6:00 pm, it was determine that the facility failed to ensure the access of family members and other relatives to visit the residents at the SNF which can affect all residents admitted at the facility. Findings include: 1. During observational tours performed on 5/19/15 at 9:00 am, the surveyor watched posted on the bulletin board located on the hallway a sign indicating visiting hours from 8:00 a.m. until 8:00 pm. a. During record review performed on 5/22/15 at 2:00 pm it was found a report performed by the security guard of the facility dated 3/27/15 at 8:01 pm indicating he was under threat by the resident daughter because when he went to announce that the visiting hours was finished; when he open the door the resident was behind it and receive a wallop with the door. The residents' daughter performed a complaint about this situation. Interview with the Administrator (employee #13) and Facility… | 2018-09-01 |
| 698 | 698 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2010-02-19 | 174 | F | OWRV11 | Based on the group interview, interviews with personnel, review of policies/procedures and observations, it was determined that the facility failed to provide telephone services with reasonable accessibility where calls can be made and received without being overheard for twenty-five out of twenty-five admitted residents (sample selection #1 through #9 and random sample selection #1 through #16). Findings include: During observations of the nursing station on 2/17/10 at 8:40 am, it was found that the facility does not have a cordless telephone. The Physical Plant Manager (employee #52) was interviewed on 2/17/10 at 8:40 am related to procedures when residents request phone use or they receive calls at the nursing station and he stated that residents have to come to the nursing counter and they use the phone next to the nursing counter. He was asked if the facility had another area where patients could talk in private without being over heard and he stated that the designated area was next to the nursing station. He was also asked if the facility had a cordless phone and he stated that they did not. The Director of Nursing (employee #50) was interviewed on 2/17/10 at 12:15 pm and he was asked about phone use when residents are bedridden or those who require substantial time to get out of bed to go to the nursing counter and he had no reply. During the group interview on 2/17/10 at 2:00 pm two out of four residents (sample selection resident #4 and random sample resident #8) (the other two residents (random sample residents #1 and #2) did not participate verbally during the group interview) stated that they were not aware that they could receive or make phone calls from the facility. Facility policies/procedures reviewed on 2/17/10 at 3:20 pm provided evidence that residents can use the nursing counter phone if they do not have a phone, however no documentation was found that residents are made aware that they can receive and make calls without paying for them. No evidence was found that the policies and procedures… | 2014-02-01 | ||
| 194 | 194 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2016-03-04 | 176 | D | 0 | 1 | TSLL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the medication pass, medication reconciliation and interviews it was determine that the facility failed to demonstrate that the interdisciplinary group determine it safe for resident to self-administration of drugs for 1 out of 1 random sample (RS) (RS#1) Findings include: a. On 03/02/2016 at 10:00 am during the medication reconciliation after the medication pass it was identified that the RS #1 was prescribe [MEDICATION NAME] to be apply to affected area no evidence of the interdisciplinary group was found for the discussion of the self-administration of drugs . On interview on 03/02/16 at 10:05 am RS #1 stated that she is applying the medication herself. On 03/02/16 10:10 am during interview with Nursing Supervisor (employee # 1) stated that the RS #1 self-administration drug case has not been discuses during the interdisciplinary group. b. The facility failed to demonstrate that the interdisciplinary group determines it safe for resident to self-administration of drugs. | 2019-05-01 |
| 263 | 263 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 176 | F | 0 | 1 | 1RD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the initial observational tour and ten resident's medical records review with Nursing personnel (employee #1), Director of Nursing (employee #5), Pharmacist(employee # 7) and interview, it was determined that the facility failed to ensure that the right to 2 out of 21 admitted residents (R) the right to self administer drugs are promoted. (R #4 and #5). Findings include: 1. A mechanism to ensure that facility promote the right of each resident to be responsible for the self administration and storage of drugs that they may self-administer in a safe manner was not followed ,not performed accordingly with the following findings identified during survey procedures on 6/16/5 through 6/18/15: a. Sample selection R# 4 was observed during the initial tour requesting the nurse to provide a [MEDICATION NAME] inhaler device that the resident had in her purse. She stated that she use this device on an ongoing basis. However review of medical record documentation on 6/16/15 at 8:15 am did not evidence that this resident had available and self-administer the medication. Information of who will be responsible (the resident or the nursing staff) for storage and documentation of the administration of drugs, as well as the location of the drug administration (e.g., resident's room, nurses' station, or activities room) were not found documented. b. Resident #5 was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the record review performed on 6/16/15 at 11:00 am it was found that the physician ordered by telephone on 6/8/15 at 7:00 pm [MEDICATION NAME] 160 microgram (mcg)/ 4.5 mcg 2 pump Bid with an abbreviate of (PS). Interview with the nurse (employee #1) on 6/18/15 at 1:00 pm related to the abbreviation (PS) she stated that PS mean Patient Suminister. During interview with resident #5 on 6/16/15 at 4:05 pm he state that he has the medication with him and he administered the [MEDICATION NAME] 2 puff at bed time. On 6/17/15 at 9:00 am during in… | 2018-10-01 |
| 455 | 455 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2012-07-20 | 176 | F | 0 | 1 | 93CN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the initial observational tour and the review of ten resident's medical records with the head nurse (employee #3) and interview, it was determined that the facility failed to ensure that five out of thirty-four admitted residents who self administer drugs are evaluated for the need of these drugs and authorized by the interdisciplinary group for the use of these drugs (random sample residents #1, #2 and #4 and residents #2 and #3). Findings include: 1. Random sample resident #1 was observed during the initial tour with one bottle of [MEDICATION NAME] lotion on the night table on 7/18/12 at 10:15 am. The resident stated during an interview on 7/19/12 at 9:15 am that he use the lotion to relieve itchy skin on upper arms and legs. No evidence was found in the resident's record on 7/19/12 at 11:55 am during the medication reconciliation of the interdisciplinary groups' authorization of the use of this drug or that they knew the resident was using it. 2. Random sample resident #2 was observed during the initial tour with a tube of [MEDICATION NAME] topical medication and a small container of "vicks [MEDICATION NAME]" topical ointment on the night table on 7/18/12 at 8:43 am. The resident stated during an interview on 7/19/12 at 8:00 am that he uses the lotion to relieve itchy skin on his upper arms and for nasal congestion. No evidence was found in the resident's record on 7/19/12 at 8:51 am of the interdisciplinary groups' authorization of the use of these drugs or that they knew the resident was using it. 3. Resident #3 was observed on 7/19/12 at 8:49 am with a bottle of 250 ml of [MEDICATION NAME] alcohol 70% on the night table. The resident stated during an interview on 7/19/12 at 8:50 am that he use the alcohol to relieve itchy skin and a rash on the upper arms. No evidence was found in the resident's record on 7/19/12 at 8:51 am of the interdisciplinary groups' authorization of the use of this drug or that they knew the resident was… | 2015-07-01 |
| 484 | 484 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2012-02-29 | 176 | D | 0 | 1 | G0N711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of eight resident's medical records and observations, it was determined that the facility failed to ensure that one out of seven residents who self administer drugs are evaluated for the need of these drugs and authorized by the interdisciplinary group for the use of these drugs (resident #6). Findings include: 1. During the observational tour on 2/28/12 at 9:50 am, a bottle of [MEDICATION NAME] spray was found on the top of the resident's night table in resident's room [ROOM NUMBER]A (sample selection resident #6). No evidence was found in the resident's record on 2/29/12 at 10:25 am of the following: a. physician's orders [REDACTED]. b. Evaluation by the interdisciplinary team for the use of this drug. c. A plan of care for the use of this drug. | 2015-06-01 |
| 551 | 551 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2012-04-20 | 176 | E | S02O11 | Based on the initial observational tour and ten resident's medical records reviewed with nursing personnel (employee #6) and interviews, it was determined that the facility failed to ensure that three out of twenty-eight admitted residents who self administer drugs are evaluated for the need of these drugs and authorized by the interdisciplinary group for the use of these drugs (resident #8 and random sample residents #2 and #17). Findings include: 1. The following was observed during the initial tour on 4/18/12 from 8:30 am through 11:00 am: a. Resident #8 was observed with a bottle of Latanoprost ophthalmic drops 0.005% over the vents of the air conditioner unit. Nursing personnel (employee #7) stated during an interview on 4/19/12 at 7:40 am that the resident uses these eye drops that are administered to the right eye every evening. No evidence was found in the resident's record on 4/19/12 at 1:00 pm during the medication reconciliation of the interdisciplinary groups' authorization of the use of this drug or that they knew the resident was using it. b. Random sample resident #2 was observed during the initial tour with a small container of "Manteca de Ubre La Vaquita" ointment on her night table. The resident stated during an interview on 4/18/12 at 10:10 am that she uses the ointment on her left knee and the ankles to relieve pain. No evidence was found in the resident's record on 4/19/12 at 1:25 pm during the medication reconciliation of the interdisciplinary groups' authorization of the use of the drug or that they knew the resident was using it. c. Random sample resident #17 was observed during the initial tour with a container of Fiber Therapy on the night table. The resident stated during an interview on 4/18/12 at 10:00 am that she uses the fiber because occasionally she is constipated and it helps her go to the bathroom daily. She also stated that she uses Prunelax tablets occasionally to relieve constipation also. No evidence was found in the resident's record on 4/19/12 at 1:23 pm during the medicat… | 2014-04-01 | ||
| 652 | 652 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2012-03-15 | 176 | E | OK6U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the initial observational tour and ten resident's medical records review with the MDS Coordinator (employee #3) and Director of Nursing (employee #2) and interview, it was determined that the facility failed to ensure that four out of twenty-nine admitted residents who self administer drugs are evaluated for the need of these drugs and authorized by the interdisciplinary group for the use of these drugs (residents #2, #3 and random sample residents #1 and #4). Findings include: 1. Resident #2 was observed during the initial tour with one bottle of "Miel Rosada" on the night table on 3/13/12 at 9:15 am. Nursing personnel (employee #12) stated during an interview on 3/14/12 at 11:10 am that he uses the "Miel Rosada" on the resident after he provides oral care. No evidence was found in the resident's record on 3/15/12 at 11:00 am during the medication reconciliation of the interdisciplinary groups' authorization of the use of this drug or that they knew the resident was using it. 2. Resident #3 was observed during the initial tour with a small bottle of [MEDICATION NAME] Lubricant Eye Drops on the night table on 3/13/12 at 7:20 am. The resident stated during an interview on 3/13/12 at 7:25 am that she uses the eye drops to help the burning sensation in her eyes. No evidence was found in the resident's record on 3/15/12 at 11:10 am and medication reconciliation, of the interdisciplinary groups' authorization of the use of this drug or that they knew the resident was using it. 3. Random sample resident #1 was observed during the initial tour with a large container of Fiber Therapy on the night table on 3/13/12 at 7:15 am. The resident stated during an interview on 3/15/12 at 11:30 am that she uses the fiber because occasionally she is constipated and it helps her go to the bathroom daily. No evidence was found in the resident's record on 3/15/12 at 11:35 am and medication reconciliation, of the interdisciplinary groups' authorization of t… | 2014-03-01 | ||
| 115 | 115 | MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE INC | 405030 | CALLE COSME REPARTO SAN LUCAS ENTRADA SECTOR CANEJ | RIO PIEDRAS | PR | 926 | 2017-05-26 | 202 | D | 0 | 1 | PHOQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on ten records review (RR) during a recertification FOSS survey performed from 5/22 thru 5/26/17 from 8:30 am to 5:00 pm, it was determined that the facility failed to establish a mechanism that ensure accurate documentation from the physician and/or nursing staff when residents are transferred to other acute facilities to receive care, as observed in 1 out of 10 records review (RR#10). Findings include: 1. RR # 10 was performed on 5/24/17 at 2:00 pm and it belongs to a female resident of [AGE] years old who was admitted on [DATE] with a diagnose of Deconditioning due to a [MEDICAL CONDITIONS] with Left [MEDICAL CONDITION]. On 5/10/17 during the day shift which was at 8:36 am, this resident was transferred to an acute nearby hospital. The nursing progress note establishes that the resident has an oxygen saturation on 88%, pulse in 58/min and is hypoactive. The transfer form was reviewed and it only says the same information that was written in the nursing progress notes. It was not included that resident has a cardiac arrhythmia, as told by the physician, and the nurse failed to include that she was receiving antibiotic treatment for [REDACTED]. | 2020-09-01 |
| 576 | 576 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2013-09-13 | 203 | D | F6TZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notice of discharge for one (R9) of 17 residents in the sample. Findings include: Review of the clinical record revealed R9 was transferred to the emergency roiagnom on [DATE] at 1pm and was admitted to the hospital with [REDACTED]. Interview on 9/12/13 at 3:25pm with the Director of Nursing (DON) confirmed the facility did not complete a transfer form when a resident was transferred to the connected hospital and no written notification of transfer was provided to the resident or their family. | 2014-04-01 | ||
| 577 | 577 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2013-09-13 | 205 | D | F6TZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written information to the resident or the resident's legal representative that specified the duration of the facility's bed-hold policy for one (R9) of 17 residents in the sample. Findings include: Review of the clinical record revealed R9 was transferred to the emergency roiagnom on [DATE] at 1pm and was admitted to the hospital with [REDACTED]. Interview with the Director of Nursing (DON) on 9/12/13 at 3:25pm confirmed the facility would hold beds for 24 hours but had not provided written information to the resident or their family regarding their policy. | 2014-04-01 | ||
| 116 | 116 | MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE INC | 405030 | CALLE COSME REPARTO SAN LUCAS ENTRADA SECTOR CANEJ | RIO PIEDRAS | PR | 926 | 2017-05-26 | 206 | C | 0 | 1 | PHOQ11 | Based on a recertification FOSS survey, policies and procedures (P&P) review related to the be hold period while the resident is receiving services in other facility and interview with the Sub Administrator (employee # 4) performed on 5/26/17 at 9:45 am, it was determined that the facility failed to establish a mechanism if the resident exceeds the be-hold period. Findings include: 1. According to the P&P, the facility has established that each resident that has been transferred to other facility due to an emergency or other cause, will have 24 hrs. for his/her return to the skilled nursing facility(SNF), not considered as a new admission. During the be-hold period, all resident's goods and personal items will be at his/her room until the resident returns. However, the P&P does not mention what procedure the facility will implement if the resident remains more than 24 hours while receiving treatment in the other facility. According to interview with the Sub Administrator (employee #4) performed on 5/26/17 at 9:50 am, she stated: If a resident remains at other facility receiving treatment and he/she exceeded the be-hold period that will be considered a new admission. However, we keep their belongings in a locked place until the resident returns to our facility. If we have a list of residents requiring admission to the SNF, the resident that is in the be-hold period has the priority of the admission. The other facility has to present the case as if a new one to our admission staff. 2. During the survey process, the Administrative staff showed the surveyors a procedure where they established what they are going to do if resident exceeds the be-hold period. However, the Administration has to discuss it with the Governing Body for its approval and to offer orientation to all employees. | 2020-09-01 |
| 317 | 317 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2015-05-22 | 221 | G | 0 | 1 | 1WB711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, individual interview and group interview, and record review during the recertification survey on 5/19/15 to 5/22/15, it was determine that the facility failed to ensure that resident (R) is free from physical restraints, unless needed to treat a medical symptom for 1 out of 8 residents in the sample (R#6). Findings include: A resident indicates she was threatened to be restraint with four side rails up if she does not follow instructions. Fall Risk care plan has side rails for safety measures. 1. Resident #6 is [AGE] years old female who was admitted for care on 5/15/15 with a [DIAGNOSES REDACTED]. During the group interview performed on 5/19/15 patients indicates that a register nurse threatened her to raise all four side rails if she does not follows instruction. Interview the resident on 5/19/15 at 4:30 pm she indicates she feels worried because she lives alone and does not have anybody who can help her. She feels sad because two times during the nights the register nurse said if she does not follow instructions she is going to raise the four side rails. Resident indicates that she was sitting in the border of the bed because she feels uncomfortable and her neck hurts. She says the doctor gave her instruction to do that when she felt pain because is a method to relieve the pain. Reviewing the facility protocol for side rails and restrains the document reveals that the patient has to be evaluated and the resident and family has to give the consent to maintain the four side rails raises. (Cross Reference Tag F323). | 2018-09-01 |
| 456 | 456 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2012-07-20 | 221 | D | 0 | 1 | 93CN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on ten residents records reviewed, observations and interview, it was determined that the facility failed to ensure that the use of restraints were identified when a family member placed them on her mother and failed to provide a medication at the appropriate time which kept the resident sleeping instead of alert for one out of ten sample selection residents (resident #7). Findings include: Resident #7 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 7/19/12 at 2:00 pm and provided evidence that the resident did not have her five-day minimum data set (MDS) started. During the initial tour on 7/18/12 at 9:30 am the resident had her food tray on the food tray table and it was not eaten and her daughter stated during an interview on 7/18/12 at 9:35 am that her mother could not eat because she can not swallow since her hospitalization when they placed a nasogastric feeding tube and when she was sent to the SNF they removed it. The patient was observed disoriented and not cooperative, sleepy and bedridden. On 7/18/12 the physician evaluates the resident based on a request from nursing personnel because the resident was not eating and the physician orders [REDACTED]. On 7/19/12 at 8:30 am during the medication pass the resident was observed restrained from her upper extremities with soft restraints. The resident's daughter stated on 7/19/12 at 8:35 am that her other sister restrained her mother because she was trying to remove the nasogastric tube. The resident's daughter stated that the restraints her sister used were the ones that the mother had from her hospital stay. On 7/19/12 at 3:00 pm the physician orders [REDACTED].O trail. After the evaluation it was found that the resident tolerated swallowing and it was decided to continue with observations and oral feeding. On 7/20/12 at 8:30 am the resident's daughter stated that she could not feed her mother because she was … | 2015-07-01 |
| 526 | 526 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2011-03-18 | 221 | G | R1BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on residents records reviewed and observations, it was determined that the facility failed to ensure that the medical symptoms that warrant the use of restraints are documented in the resident's medical record along with ongoing assessments and failed to determine the presence of specific medical symptoms that would require the use of restraints for two out of ten sample selection residents (residents #1 and #2). Findings include: 1. Resident #2 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was observed bedridden, has a gastrostomy and [MEDICAL CONDITION] connected to a mechanical ventilator on 3/16/11 at 9:30 am. The resident was ordered to be on restrictions (by two points, the right and left arms) from 3/7/11 through 3/16/11. The reason for the restriction according with information found in the medical record reviewed on 3/16/11 at 3:54 pm was interruption of treatment. However identification of factors that are related to the resident's behavior and interruption of treatment were not documented on the decisional algorithm that must be completed by the physician who orders the restriction. Options to be considered before ordering the restriction were not documented on the decisional algorithm. The facility failed to maintain complete documentation of circumstances in which the resident has medical symptoms or behavior that warrants the use of restraints. 2. Resident #1 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 3/17/11 at 1:30 pm and provided evidence that the resident's cognitive pattern on the five-day minimum data set (MDS) performed on 3/12/11 describes a resident who is severely impaired for daily decision making, short/long memory problems and physical behavioral symptoms directed toward others refers "behavior not exhibited". The MDS also provided evidence that the resident requires total/extensive ass… | 2014-04-01 | ||
| 578 | 578 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2013-09-13 | 221 | K | F6TZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that each resident was free from physical restraints, unless needed to treat a medical symptom. Seven residents (R1, R2, R3, R8, R10, R16, and R17) of 17 in the standard and extended sample, were restrained to their beds through the use of limb restraints, which kept them tied to the bed. Fourteen (R1, R2, R3, R4, R5, R7, R8, R9, R10, R11, R12, R13, R16, and R17) of 15 current residents in the standard and extended sample were restrained in bed through the use of four side rails (one top and one bottom rail on each side of the bed). Residents were restrained for staff convenience (i.e. to provide supervision, to assure that residents did not get out of bed, and to relieve staff fears that residents would fall). Residents were restrained without consent. Restraints were used prior to an interdisciplinary assessment to evaluate resident behaviors. Less restrictive measures were not attempted prior to restraint use. Restraints were applied without physician orders. Care plans were not developed for the removal/reduction of restraints. At least three residents (R3, R16, and R17) sustained falls while restrained which required physician intervention. An additional resident (R8) was found wedged between the side rails, hanging from the wrist restraints during the standard and extended survey. The facility failed to conduct an assessment of the potential risks that these restraints created, even when they were aware that multiple residents had sustained accidents. The failure to assure that residents were free from physical restraints was identified as Immediate Jeopardy on 9/11/13, and was found to affect 42 of 64 residents in the facility. The facility did not allege abatement of the Immediate Jeopardy prior to surveyor exit from the facility on 9/13/13. Findings: 1. Observation during initial tour on 9/9/12 at 12:20 revealed R3 lying in bed. The resident had suture… | 2014-04-01 | ||
| 670 | 670 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2013-08-30 | 221 | E | ET9L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that each resident was free from physical restraints, unless needed to treat a medical symptom. Six of 10 sampled residents (R1, R3, R4, R5, R6 and R7) were restrained through the use of side rails for which there were no physician orders, assessments, care plans, or consent. Findings: 1. Observation of R5 during initial tour on 8/26/13 at 11:25am revealed the resident asleep in bed. Observation revealed the bed was equipped with four side rails (two ? rails per side) and three of the four rails (two top and one bottom) were in the up position. Observation of R5 on 8/26/13 at 2:20pm, 3:15pm, and 3:45pm; and 8/27/13 at 8:00am, and 3:15pm, also revealed that three of four side rails on the resident ' s bed were in the up position. Observation on 8/28/13 at 9:00am revealed R5 asleep in bed with all four side rails in the up position. An interview on 8/27/13 at 3:15pm with R5 revealed staff was raising the side rails because she had fallen at home. The resident, who was lying in bed with three of four side rails up, related that with the side rails raised, she could not get up and out of bed without help from staff. Review of the clinical record revealed R5 was admitted to the facility on [DATE] for rehabilitation therapy in response to fractures of the left femur and left humerus, which she sustained in a fall. Further review revealed the resident had additional [DIAGNOSES REDACTED]. According to the admission assessment, dated 8/23/13, R5 was alert and oriented to person, place, and time, and had no cognition issues. Review of admission orders [REDACTED]. There was no documented evidence the facility had assessed or provided a care plan for the use a restraint. Review of the " Protocolo de Residentes con Potencial a Caidas " (Protocol for Residents at Risk for Falls) in the clinical record revealed that it had been marked to indicate R5 was to have " uso de baran… | 2014-03-01 | ||
| 345 | 345 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2014-09-12 | 224 | I | 0 | 1 | 2S3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of records (RR) and policies/procedures (P&P) and interviews, it was determined that the facility failed to promote that resident (R) care and management follow best practices and standards of practice to prevent negligence in the management of residents who are receiving services at the facility for 2 out of 10 sample selection residents (R#1 and R#10 and random sample resident #8). Findings include: 1. During survey procedures throughout the first five days of survey from 8/25/14 to 8/29/14 the following was identified related with failure by the facility to care and provide medical care and attend properly cases admitted to the facility to receive rehabilitative, restorative, and ongoing skilled nursing care: Record sample selection # 10 ( closed record review ) is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted to the facility to provide rehabilitative, restorative, and ongoing skilled nursing care. During review of the case on 8/27/14 at 10:32 am it was identified a urine culture results of 3/21/14 that indicate microorganism isolated are [MEDICATION NAME] Faecalis and had the susceptibility panel for antibiotics. No evidence was found on the medical record of a physician orders [REDACTED]. During interview with the Infection control designated person (employee #3) stated on 8/28/14 at 1:00 pm that those cases must be informed to the hospital infection control officer to analyze, investigate and determine if resident had urinary tract infection. However evidence that this urine culture were reviewed was not provided. On 3/25/14 at 3:14 pm resident presents low blood pressure and weakness, nursing personnel call the physician in charge of the resident who orders to transfer to the emergency room ; in the emergency room they evaluate, treated and stabilize resident who was sent again to the SNF on 3/26/14 at 5:30 pm. No transfer physician orders… | 2017-06-01 |
| 527 | 527 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2011-03-18 | 224 | G | R1BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the complaint investigation (PR 432) and observations, review of medical records and incident and accident reports and interview, it was determined that the facility failed to maintain resident's free from neglect as evidenced by a lack of compliance with fall prevention for two out of ten sample selection residents (residents #7 and #10). Findings include: 1. A mechanism to ensure that the facility provides goods and services necessary to avoid physical harm were not promoted nor followed as evidence by the following: a. Resident #7 is a [AGE] years old female admitted on [DATE] at 11:00 pm with a [DIAGNOSES REDACTED]. The resident was admitted for rehabilitation and treatment with antibiotics for a urinary tract infection. The resident was evaluated for falls and was not found to be at risk for falls on 2/23/11. On 2/24/11 during the 7-3 and 3-11 shifts the resident received treatment and was evaluated by Physical Medicine Rehabilitation (PM&R) services. On 2/25/11 at 2:10 am according with information documented by the nurse in charge of the resident of the 11-7 shift, the resident fell down to the floor receiving trauma on the right side of the face and lower extremity. She was transferred to the emergency room of the same hospital at 2:20 am in order to be evaluated and receive treatment. Notification of the event to the resident's relatives of the accident was not found until 8:00 am. After the evaluation of the resident at the emergency room she was transferred to the acute care area of the hospital in order to receive treatment for [REDACTED]. Review of the incident report documented by the facility on 3/17/11 at 2:56 pm provided evidence that the investigation did not include information related with the circumstances where the accident occurred. Information from the employee directly involved and knowledgeable about the event, such as the nurse who discovered the resident on the floor was not included in the incident report… | 2014-04-01 | ||
| 638 | 638 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2011-02-17 | 224 | G | 5V0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the complaint investigation (PR 430), review of policies and procedures and review of ten resident's medical records with the Director of Nursing (D.O.N) (employee #2), it was determined that the facility failed to operationalize and implement policies and procedures to promote a safe environment for one out of ten residents who receive care at the facility in order to avoid physical harm (sample selection resident #10-closed record). Findings include: Resident #10 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. During the record review on 2/17/11 at 9:00 am, the functional status and activities of daily living (ADL) assistance on the 14 days Minimum Data Set (MDS) assessment was identified that the resident had improved since her admission to the facility, needs physical help in part of bathing activity and the ADL support must be provided by one person. On 1/30/11 at 11:00 am the resident was receiving a bath in the shower with the assistance of a Licensed Practical Nurse (LPN) when she fell down to the floor, after the fall the resident complained of a severe pain of the right leg. The resident was evaluated by the physician on 1/30/11 at 11:25 am and ordered [MEDICATION NAME] 30 mgs intramuscular and transfer to a hospital to receive an evaluation and treatment. A registered nurse (employee #20) in charge of documenting the incident report writes that the LPN was with the resident in the bathroom assisting during a shower, when the LPN left the room and left the resident alone and that the resident fell down while picking up a bar soap from the floor (but does not sign her name under this statement). The same report has written evidence that the LPN (employee #13) involved in the incident did not admit that she left the resident alone in the bathroom. The resident was transferred to another facility for evaluation and treatment on 1/30/11. According with information given by the ombudsman offi… | 2014-03-01 | ||
| 699 | 699 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2010-02-19 | 224 | G | OWRV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during observational tours and interviews, it was determined that the facility is not promoting care in a manner that enhances each residents' care for five out of twenty-five admitted residents (Residents #1, #5, #7 and random sample #6 and #11) related to uncomfortable and unsafe temperatures in resident's rooms and neglected resident #5 petition for a bed change and warmer room temperature which caused the resident mental anguish and distress. Findings include: 1. Resident #5 was observed during the initial observational tour on 2/17/10 at 10:30 am under three heavy blankets in room [ROOM NUMBER]. She was interviewed on 2/17/10 at 10:35 am related to the services provided at the facility and she stated that she was very cold. She stated that she was so cold that she could not sleep and that her feet were frozen because her bed is next to the air conditioner unit. The room temperatures was measured with a thermometer on 2/17/10 at 10:40 am and gave a reading of 62?F. The temperature finding in this resident's room and her concerns about the temperature were told to the nursing supervisor (employee #51) on 2/17/10 at 12:45 pm for action related to the residents' comfort and care. On 2/18/10 at 8:40 am accompanied by the physical plant manager (employee #52), the resident's room was visited again and the room temperature was measured with a "Tel Fast 2 laser" thermometer and gave a reading of 61?F and the resident was in the same bed next to the air conditioner unit. The resident was interviewed on 2/18/10 at 8:45 am and she was very upset and wanted to leave the facility. The physical plant manager notified the finding to the nursing supervisor and the Director of Nursing (employee #50) on 2/18/10 at 9:00 am to either lower the temperature or move the resident into a room where she can be further away from the air conditioner unit. On 2/19/10 at 9:00 am the resident's room was visited to verify the temperature and … | 2014-02-01 | ||
| 393 | 393 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2014-09-10 | 225 | F | 0 | 1 | SRWL11 | Based on review of abuse and neglect protocol and interview with the Quality Coordinator (employee #3), it was determinate that the facility failed to ensure that the results of abuse investigations must be reported to the administrator and to the State survey and certification agency within 5 working days of the incident. Finding included: 1. During the review of the Policy and procedure of abuse, neglect and sexual harassment prevention on 8//21/14 at 9:45 am it was found that: a. The policy establish in the section G, that the investigation of violation allegation was subtended are to be notified to the Human Resource Department. If the employee where removed the Directors Board notified the Examining Board or Tribunal Examining. However it does not establish a time frame to notify all pertinent agencies. The Quality Coordinator employee #9 was interview related to the time frame to report the abuse and neglect investigation and stated the result of the investigation is notified to the resident and the pertinent agency within 5 days of when compliance is reported . b. The facility failed to ensure that all compliance of abuse and neglect investigation be notified to the state survey within 5 working days of the incident. | 2017-06-01 |
| 414 | 414 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 225 | C | 0 | 1 | 1FFV11 | Based on review of abuse and neglect protocol and interview with the social worker (employee #9), it was determinate that the facility failed to ensure that the results of abuse investigations must be reported to the administrator and to the State survey and certification agency within 5 working days of the incident. Finding included: 1. During the review of the Policy and procedure of abuse, neglect and sexual harassment prevention on5/29/14 at 11:00 am it was found that: a. The policy establish in the section VII, that the investigation of violation allegation and other incident is to be reported to all pertinent agencies in a time frame of 15 days. The social worker (employee #9) was interview related to the time frame to report the abuse and neglect investigation and stated the result of the investigation is notified to the patient and the pertinent agency within 15 days of the compliance is reported . b. The facility failed to ensure that all compliance of abuse and neglect investigation be notified to the state survey within 5 working days of the incident. | 2017-06-01 |
| 579 | 579 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2013-09-13 | 225 | F | F6TZ11 | Based on interview and record review, the facility failed to assure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility failed to provide evidence that all alleged violations were thoroughly investigated, and failed to report the results of all investigations to the State survey and certification agency within 5 working days of the incident, and if the alleged violation. This failure had the potential to affect all residents of the facility and constituted Substandard Quality of Care. Findings: 1. Interview during the entrance conference revealed the facility's Risk Management Officer was also the facility's Abuse Coordinator. An interview with the Abuse Coordinator on 9/12/13 at 9:30am revealed she had assumed this position the previous month in August, 2013. She related that she was responsible for conducting investigations and involving other departments (such as the facility's Social Worker, Medical Director, or Human Resources) as needed. The Abuse Coordinator related that abuse/neglect could include measures such as not providing residents with food or medications as ordered. She stated that during her time in this position, she had investigated allegations that patients had not received their medications or treatments. However, she had not made a report of these allegations to any government agency. She stated that any reports to government agencies (such as the police, Department of Families (Adult Protective Services) or the Ombudsman were to be made by the facility Administrator. Interview with the Abuse Coordinator revealed she was unaware that Federal regulations required allegations of abuse in certified nursing facilities to be reported to the State Survey Agency (SSA). Further interview revealed she was also not aware of the Federal req… | 2014-04-01 | ||
| 48 | 48 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2017-05-25 | 226 | L | 1 | 1 | NJQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a standard and extended FOSS survey for recertification and a complaint investigation PR 598, review of the facility's grievance and complaint registry, policies and procedures (P&P's), and interviews performed on 5/22, 5/23, 5/24, and 5/25/17 it was determined that the facility failed to prevent patients from harm. This constitutes an Immediate Jeopardy to 13 out of 13 residents (R) admitted at the facility. (R#1 to R#13) Findings include: During the resident #6 complaint investigation performed on 5/24/17 at 10:30 am, the following was found: 1. Resident #6 is a [AGE] years old male admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident #6 was admitted for physical therapy, occupational therapy and wound care. The resident #6 was discharge home on 5/18/17 at 12:50 pm, having a length of stay of 51 days in the facility. The close record review was performed on 5/25/17 at 2:00 pm. 2. The Resident #6 complaint allegations of 4/6/17 were the following: a. The nursing staff talked to him and treated him in a rude way. b. The nursing staff ignored when he called the nursing station. c. The nursing staff did not come to the room to change him on bed positioning. d. The nursing staff did not assess and manage the pain that the sacral ulcer caused. e. The pain provokes constantly vomit episodes to the resident #6. f. The nursing staff did not come to the room to clean resident #6. 3. During close record review (RR) of Resident #6 on 5/25/17 at 2:00 pm was found the following: a. The Minimum Data Set (MDS) report of 4/4/17 on section G0110. Activities of Daily Living (ADL) Assistance on 5/25/17 at 3:12 pm provides evidence that the resident #6 is total dependent on bed mobility and that includes how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. The resident #6 needs full staff performance every time in bed mobility, one personal physical assist. b. The Min… | 2020-09-01 |
| 131 | 131 | HIMA SAN PABLO CUPEY SNF | 405031 | CARR 844 KM 0 5 CUPEY BAJO | RIO PIEDRAS | PR | 928 | 2017-03-16 | 226 | F | 0 | 1 | LEID11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an initial certification survey, review of abuse and neglect protocol, review of employee credential file with the human resource manager (employee #6) and interview with the skill nursing facility (SNF) manager (employee #4), it was determinate that the facility failed to maintain updated abuse and neglected protocol training for 3 out of 37 employee credential files (C.F.) reviewed. Failed to maintain the highest practicable mental and psychosocial well-being, off resident due to the facility lack of an hand in hand training for skill nursing home resident with dementia. (Nursing CF# 8, Physician C.F. #1, Food Services C.F. #5). Findings include: 1. During the review of 37 employees credential file on 3/15/17 from 1:00 pm till 4:00 pm an 3/16/17 from 10:0 am till 1:00 pm with the human resource manager (employee #6), it was found that 3 out of 37 employees credential file (C.F) did not have evidence of updated abuse and neglect training during (YEAR) and (YEAR). a) Nursing C.F #8, no evidence was found related to updated abuse and neglected protocol training, the last training was on 2/7/16, one years ago. b) Physician C.F. #1, no evidence was found related to abuse and neglected protocol training. c) Food Services C.F. #5, no evidence was found related to abuse and neglected protocol training. During interview performed on 3/15/17 at 11:00 am to the SNF Manager (employee #4) related to Dementia Training and Protocol she stated On (MONTH) (YEAR) information arrived related to the CMS condition of participation 483.95 (g2) Training Requirement that include Dementia training. The SNF manager with the social worker and the facility educator started to perform a draft related to Dementia Protocol to present to the governing body. I contact with a geriatric physician to orient the SNF nurses and personnel related to Dementia and [MEDICAL CONDITION]. Today at 3:00 pm the physician is going to start the orientation and going to perform an… | 2020-09-01 |
| 159 | 159 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2016-03-17 | 226 | E | 0 | 1 | UG6111 | Based on observations and review of facility abuse and neglect policies and procedure with Quality coordinator (employee # 2), it was determined that the facility failed to developed an abuse and neglect policy and procedure that include report to the state agency as Nurse registry or licensing authority in 5 days if in the investigative report are found guilty of abuse and neglect. Findings include: During the review of facility abuse and neglect police and procedure (P&P) on 3/15/16 at 10:00 a.m it was found that the P&P lack of a time frame to report to the state agency if found guilty of abuse and neglect. | 2019-06-01 |
| 178 | 178 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2016-03-10 | 226 | D | 0 | 1 | GFHV11 | Based on review of abuse and neglect protocol, review of new employee credential file and interview with the human resource manager (employee #8), interview with the Director of Nursing (employee #1), it was determinate that the facility failed to comply with the Affordable Care Act, Title VI, subtitle B Part III, Subtitle C, Section 6201 regarding the screening process to all potential direct access employees by a back ground check program. Findings include: 1. A mechanism to ensure that a program to conduct background checks on all prospective direct resident access employees of facility was not performed accordingly with findings identified during survey procedures on 3/7/16 through 3/10/16: a. Director of Nursing (employee #1), stated on interview on 3/9/16 at 11:05 am that facility had in place a mechanism to screen for criminal background to all potential direct access employees accordingly with Puerto Rico State requirements. They request to the potential employee Certificado de Buena Conducta and Law 300 of (MONTH) 2,1999 Verificacion De Historial Delictivo de Proveedores de Servicios de Cuidado a Ninos y Envejecientes de Puerto Rico. b. Accordingly with Director of Nursing (employee #1), on 3/9/16 at 11:50 am facility appoint a new nursing supervisor on (MONTH) (YEAR). However this employee does not had the Law 300 of (MONTH) 2,1999 Verificacion De Historial Delictivo de Proveedores de Servicios de Cuidado a Ninos y Envejecientes de Puerto Rico. certification. | 2019-06-01 |
| 195 | 195 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2016-03-04 | 226 | E | 0 | 1 | TSLL11 | Based on review of abuse and neglect protocol and interview with Clinical dietitian (employee #8), it was determinate that the facility failed to ensure to that all employees from kitchen and provide services at the SNF receives the annually training of protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. Findings include: 1. Review of the abuse and neglect training attendance from (YEAR), no evidence was found that the kitchen employees the training provided on (MONTH) (YEAR). During interview with the clinical dietitian employee # 8 on 3/4/16 at 9:30 am related to the kitchen employee, as ask by the surveyor if the facility provided the abuse and neglect training, she state that she was supposed to give the training to their employee because these was assigned from the human resources department last year; before it was the human resources department who was in charged to give the training. At this moment I did not have the time to give it . | 2019-05-01 |
| 236 | 236 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2015-07-06 | 226 | F | 0 | 1 | 5IF611 | Based on review of abuse and neglect protocol, review of new employee credential files and interview with the Human Resource employee (employee # 2 ) , interview with the Administrator (employee #3 ) and interview with the Medical Director (employee # 4) it was determined that the facility failed to comply with the Affordable Care Act, Title VI, subtitle B Part III, Subtitle C, Section 6201 regarding the establishment of screening process to all potential direct access employees by a back ground check program. Findings include: 1. A mechanism to ensure that a program to conduct background checks on all prospective direct resident access employees of facility was not performed accordingly with findings identified during survey procedures on 6/30/15 through 7/6/15: a. Human resource employee (employee # 2) , stated on interview on 7/1/15 at 10:55 am that as part of pre-employment process facility request to the potential direct access employees Certificado de Buena Conducta and Law 300 of (MONTH) 2, 1999 Verificacion De Historial Delictivo de Proveedores de Servicios de Cuidado a Ninos y Envejecientes de Puerto Rico . He stated that Law 300 was only requested to potential direct access candidates who apply to work on the SNF (Long Term Care Facility) since year 2014. He also stated that facility did not have in place a federal back ground check program to screen all potential direct access employees. b. Administrator (employee #3 ), stated on interview on 6/30/15 at 1:50 pm that facility had in place a mechanism to screen for criminal background to all potential direct access employees accordingly with Puerto Rico State requirements. They request to the potential employee Certificado de Buena Conducta and Law 300 of (MONTH) 2, 1999 Verificacion De Historial Delictivo de Proveedores de Servicios de Cuidado a Ninos y Envejecientes de Puerto Rico . However, the facility did not have in place a federal back ground check program to screen all potential direct access employees. c. Medical Director (employee # 4 ) , state… | 2018-11-01 |
| 264 | 264 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2015-06-18 | 226 | E | 0 | 1 | 1RD011 | Based on review of abuse and neglect protocol, review of new employee credential file and interview with the human resource manager (employee #8), interview with the Quality Coordinator (employee #2), it was determinate that the facility failed to comply with the Affordable Care Act, Title VI, subtitle B Part III, Subtitle C, Section 6201 regarding the establishment of screening process to all potential direct access employees by a back ground check program. Findings include: 1. A mechanism to ensure that a program to conduct background checks on all prospective direct resident access employees of facility was not performed accordingly with findings identified during survey procedures on 6/16/15 through 6/18/15: a. Quality Coordinator (employee #2), stated on interview on 6/18/15 at 10:55 am that facility had in place a mechanism to screen for criminal background to all potential direct access employees accordingly with Puerto Rico State requirements. They request to the potential employee Certificado de Buena Conducta and Law 300 of (MONTH) 2,1999 Verificacion De Historial Delictivo de Proveedores de Servicios de Cuidado a Ninos y Envejecientes de Puerto Rico However facility did not have in place a federal back ground check program to screen all potential direct access employees. b. Human resource manager (employee #8), stated on interview on 6/18/15 at 11:45 am that as part of pre-employment process facility only request to the potential direct access employees Certificado de Buena Conducta and Law 300 of (MONTH) 2,1999 Verificacion De Historial Delictivo de Proveedores de Servicios de Cuidado a Ninos y Envejecientes de Puerto Rico . | 2018-10-01 |
| 394 | 394 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2014-09-10 | 226 | F | 0 | 1 | SRWL11 | Based on review of abuse and neglect protocol, review of new employee credential file and interview with the human resource manager (employee #4), interview with the Personnel Development and education Coordinator (employee #5) and interview with the Quality Coordinator (employee #3), it was determinate that the facility failed to ensure that new employee is train related to abuse and neglected previously to start at the Skill Nursing Facility (SNF) unit and failed to develop an operational policy and procedure for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property for 11 out of 13 new employee credential files (C.F.) reviewed. (CF#1, #3, #4, #5, #6, #7, #8, #9, #10, #12 and #13). Failed to maintain updated abuse and neglected protocol training for 17 out of 20 credential file (C.F. #1, #2, #3, #4, #6, #7, #8, #10, #11, #12, #13, #15, #16, #17, #18, #19 and #20). Finding included: 1. During the review of 13 new employee credential file on 8/20/14 at 3:00 pm during 2013 and 2014 with the human resource manager (employee #4), it was found that 11 out of 13 new employee credential file (C.F did not have evidence of abuse and neglect training during 2013 and 2014. a) C.F #3 the social worker was appointment on 7/16/14, no evidence was found related to abuse and neglected protocol training. b) C.F. #4 Physical Therapy assistance was appointment on 12/19/13; no evidence was found related to abuse and neglected protocol training. c) C.F. #5 Housekeeping was appointment on 4/8/14; no evidence was found related to abuse and neglected protocol training. d) C.F. #6 Housekeeping was appointment on 7/14/14; no evidence was found related to abuse and neglected protocol training. e) C.F. #7 Housekeeping was appointment on 4/7/14; no evidence was found related to abuse and neglected protocol training. f) C.F. #8 Physical Therapy assistance was appointment on 6/24/13; no evidence was found … | 2017-06-01 |
| 415 | 415 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4-L-10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2014-05-29 | 226 | E | 0 | 1 | 1FFV11 | Based on review of abuse and neglect protocol and interview with the Nurse supervisor (employee #2), it was determinate that the facility failed to ensure to develop and operational policy and procedure for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property on 2 out of 5 employee credential files reviewed. (CF#4 & #5) Finding included: 1. During the review of credential file on 5/29/14 at 11:00 am of new employee employees during 2013 and 2014 it was found that contractor maintenance employee credential file did not have evidence of abuse and neglect training during 2013 and 2014. 2. During interview with the nurse supervisor employee # 2 on 5/29/14 at 11:30 am related to the contracted maintenance employee as ask by the surveyor if the facility provided the abuse and neglect training and she state that she is not sure. 3. Review of the abuse and neglect training attendance from 2013 and 2014, no evidence was found that the two employee of the contracted maintenance employee assisted the training provided on 8/22/13, 8/26/13, 4/21/14 and 5/20/14. | 2017-06-01 |
| 457 | 457 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2012-07-20 | 226 | C | 0 | 1 | 93CN11 | Based on the review of policies and procedures, facility in-service activities, personnel files, satisfaction survey and interview with the quality assurance officer (employee #2), it was determined that the facility failed to operationalize policies and procedures to train employees who provide care at the skilled nursing facility or make improvements based on the satisfaction survey. Findings include: 1. Review of policies and procedures related to Abuse and Neglect protocols and in-service mandatory training activities on 7/20/12 at 3:00 pm provided the following evidence: a. Abuse and Neglect in-service activities are offered to facility personnel using a learning module, where personnel read material and human resources certifies that they comply with the in-service training. However, review of learning materials used to train personnel provided evidence that the module does not include learning objectives, pre-test, post-test and case review or situations to promote that personnel who take the module improved their skills in the implementation of protocols and policies to prevent abuse and neglect at the facility. The facility failed to promote the use of learning materials that provide feedback of the knowledge that personnel obtain after performing the mandatory training. 2. A mechanism to ensure that approaches and practices that facilitate the detection and prevention of abuse and neglect are implemented to promote the improvement of care and treatment was not followed, nor performed according with the following findings: a. On the resident satisfaction survey performed during the first trimester of natural year 2011 (January/11 through March/11) residents and relatives give a higher percent to nursing, physician and housekeeping services in a range between excellent and good. However on the resident satisfaction survey performed during the first trimester of natural year 2012 (January/12 through March/12) residents and relatives give a considerable lower percent to nursing, physician and housekeeping s… | 2015-07-01 |
| 473 | 473 | CENTRO MEDICO WILMA N VAZQUEZ SNF | 405025 | ROAD 2 KM 39 5 BO ALGARROBO | VEGA BAJA | PR | 693 | 2012-08-08 | 226 | E | 0 | 1 | 9YT011 | Based on the review of policies and procedures, facility in-service activities, personnel credential file (employees #5, #9 and credentials files #1, #2 and #3), it was determined that the facility failed to operationalize policies and procedures for screening and training employees who provide care at the skilled nursing facility which could affect seven out of seven admitted residents (residents #1, #2, #3, #4 and random sample residents #1, #2, #3). Findings include: 1. Review of policies and procedures related to Abuse and Neglect protocols and resident interventions on 8/7/12 at 2:00 pm provided the following evidence: a. According with policies and procedures provided by the facility, all personnel who offer direct care at the facility must receive abuse and neglect in-service training. b. Evidence presented by the facility related to personnel who participated in the Abuse and Neglect in-service training did not include the facility's contracted Dietitians (employee #5 and #9). c. No evidence was found that the facility performed back ground screening of the nursing staff and contracted Dietitians (employee #5, #9 and credentials files #1, #2 and #3), this includes obtaining information from previous employers or current employers, the only question asked when persons are inquiring about employment was if they were convicted of any crime other than traffic violations. | 2015-07-01 |
| 496 | 496 | SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC | 405029 | CALLE 4 L 10 URB COLINAS DEL OESTE | HORMIGUEROS | PR | 660 | 2012-08-10 | 226 | C | 0 | 1 | H7DD11 | Based on the review of policies and procedures, facility in-service activities, personnel files and interview with the nursing supervisor (employee #1), it was determined that the facility failed to operationalize policies and procedures for screening and training employees who provide care at the skilled nursing facility. Findings include: 1. Review of policies and procedures related to Abuse and Neglect protocols and resident interventions on 8/10/12 at 1:00 pm provided the following evidence: a. Abuse and Neglect in-service activities offered at the facility for the year of 2012 does not include personnel who offer direct care to residents. b. According with policies and procedures provided by the facility, all personnel who offer direct care at the facility must receive abuse and neglect in-service training. c. Evidence presented by the facility of personnel who participated in the Abuse and Neglect in-service only included administrative personnel and clerk. | 2015-06-01 |
| 552 | 552 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2012-04-20 | 226 | D | S02O11 | 2. A mechanism to ensure that residents and resident's relatives may report concerns and grievances according with the facility's policies and procedures was not promoted nor followed according with the following findings: a. The facility's policies related to abuse and neglect protocols includes procedures for the use of two mail boxes located in two different hallways to place concerns and grievances that residents and resident's relatives wish to report to the facility related with abuse and neglect situations. However both mail boxes were observed without locks and without any label to inform the purpose of the mailboxes. Based on the review of policies and procedures, facility in-service activities, personnel credential file (employee #28), it was determined that the facility failed to operationalize policies and procedures for screening and training employees who provide care at the skilled nursing facility and mailboxes to place grievances in are not labeled and secured which could affect twenty-eight out of twenty-eight admitted residents (residents #1 through #9 and random sample residents #1 through #19). Findings include: 1. Review of policies and procedures related to Abuse and Neglect protocols and resident interventions on 4/20/12 at 2:00 pm provided the following evidence: a. According with policies and procedures provided by the facility, all personnel who offer direct care at the facility must receive abuse and neglect in-service training. b. Evidence presented by the facility of personnel who participated in the Abuse and Neglect in-service training did not include the facility's contracted Dietitian (employee #28). c. No evidence was found that the facility performed back ground screening of the contracted Dietitian (employee #28), this includes obtaining information from previous employers or current employers and checking with the appropriate licensing boards and registries. | 2014-04-01 | ||
| 580 | 580 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2013-09-13 | 226 | F | F6TZ11 | Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The failure to develop and operationalize policies and procedures relative to training employees and making required reports of allegations of abuse, neglect, mistreatment, and misappropriation of property, had the potential to affect all residents of the facility and constituted Substandard Quality of Care. Findings: 1. Reporting: Review of the facility's abuse policy, titled, "Proteccion a Pacientes de Abuso, Negligencia, y Hostigamiento" (Protection of Patients from Abuse, Neglect, and Seclusion) revealed that it contained a section titled, "Reportar/Responder" (Report/Respond). Review of this section revealed that it did not address reporting requirements for any agencies outside of the facility, including the State Survey Agency (SSA). This policy failed to address the need for immediate reporting of suspected abuse/neglect to the SSA or other agencies (such as the Department for Families - Adult Protective Services) established by law. This policy did not address the requirement that the results of all abuse/neglect investigations the facility conducted were also to be reported to required agencies, including the SSA. Review of the reporting section of this policy revealed that the only reporting requirement listed in the policy was that all substantiated allegations of abuse or neglect were to be reported to the facility's Human Resources department. A second abuse policy, dated 2001 were also provided by the Administrator. This policy was titled, "Maneja de Patients Con Sospecha de Maltrator, Negligencia, Abuso y Hostigamiento por parte do un asociado, visitante, otro pacientes o medic" (Management of Patients with suspicion of abuse, neglect, or seclusion on the part of staff, visitors, other patients or doctors). This document was not labeled as one of the facility's (San Gerardo), but ins… | 2014-04-01 | ||
| 639 | 639 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2011-02-17 | 226 | D | 5V0111 | Based on the review of policies and procedures and interviews with nursing personnel related to the abuse and neglect protocol of the facility, it was determined that the facility failed to ensure that personnel are aware of policies and procedures on how to channel situations related with abuse and neglect (nursing personnel employee #21). Findings include: Review of policies and procedures related to Abuse and Neglect and interviews with nursing personnel related to the abuse and neglect protocol at the facility, it was found that one licensed practical nurse (employee #21) stated during an interview on 2/17/11 at 9:00 am that she did not remember how to channel situations related with abuse and neglect. | 2014-03-01 | ||
| 653 | 653 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2012-03-15 | 226 | C | OK6U11 | Based on the review of policies and procedures, facility in-service activities, personnel files and interview with the director of nursing (employee #2), it was determined that the facility failed to operationalize policies and procedures for screening and training employees who provide care at the skilled nursing facility. Findings include: 1. Review of policies and procedures related to Abuse and Neglect protocols and resident interventions on 3/15/12 at 9:00 am provided the following evidence: a. Abuse and Neglect in-service activities offered at the facility for the year of 2012 does not include all personnel who offer direct care to residents. b. According with policies and procedures provided by the facility, all personnel who offer direct care at the facility must receive abuse and neglect in-service training. c. Evidence presented by the facility of personnel who participated in the Abuse and Neglect in-service only include the registered nurses and licensed practical nurses. d. The director of nursing (employee #2) was interviewed on 3/15/12 at 9:36 am and she stated that only nursing personnel receive Abuse and Neglect training. | 2014-03-01 | ||
| 671 | 671 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2013-08-30 | 226 | F | ET9L11 | Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The failure to develop and operationalize policies and procedures relative to training employees and making required reports of allegations of abuse, neglect, mistreatment, and misappropriation of property, had the potential to affect all residents of the facility and constituted Substandard Quality of Care. Findings: 1. Reporting: During the entrance conference of the survey on 8/26/13 at 11:00am, interview with the Administrator revealed that that Registered Nurse (RN) 25 served as the Facility Abuse Coordinator and would be able to answer any questions regarding the facility ' s abuse and neglect prevention program. The facility provided an undated policy titled, " Manual de Normas y Procedimients Deteccion y Prevencion de Abuso y Negligencia " (Manual for the Norms and Procedures for Detection and Prevention of Abuse and Neglect) and stated that this was their abuse/neglect policy. Review of this policy revealed that under " Objectivos " (Objectives) the policy stated that it would use the seven components as a guide. However, review of this policy revealed that each of the seven required components was not addressed. Further review revealed the policy failed to provide procedures for reporting of allegations of abuse/neglect, misappropriation of resident property, and injuries of unknown origin which may indicate possible abuse or neglect. This policy failed to describe how and to whom residents, staff, and others should report suspected abuse and neglect. The policy also failed to describe the procedures the facility would use to report both initial allegations and the findings of each investigation to the State Survey Agency (SSA.) The policy did not reference time frames and failed to indicate that allegations of abuse must be reported immediately, while the findings of the investigation mus… | 2014-03-01 | ||
| 3 | 3 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2017-05-04 | 241 | H | 0 | 1 | ZOYB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification extended survey, observations during medication pass with the Registered Nurse (RN) (Employee #1) performed from 5/2/17 thru 5/4/17, it was determine that the facility failed to ensure that residents are treated with respect and dignity during delivery of nursing care, for 2 out of 28 residents (Resident #9 and Suplemental Sample Resident #11). Findings include: 1. During de medication pass on 5/3/17 at 9:37 am with the RN (Employee #1) on room [ROOM NUMBER]A it was observed that the RN was administering medication and explaining the medications to the resident and the physician (MD) (Employee #2) entered to the residents room without knocking the door and requesting permission to enter, and immediately started talking to the RN (Employee #1) ignoring the presence of the resident. During Interview with Administrator (Employee #3) on 5/3/17 at 3:12 pm, she stated: I already talk to the physician about the incident on room [ROOM NUMBER]A and he told me that he did not mention the name of the resident just the room number and the medication. But we are going to keep working on that. 2. Resident # 9 is a [AGE] years old male patient with a diagnostic of left femur fracture. On 5/04/2017 at 2:48 pm during interview resident # 9 was observed with pants' down to his knee, he stated I have my pants' down to my knees because I called the nurse 25 minutes ago because my diaper is wet. At 3:00 pm resident # 9 continued with the pant down to his knees and the diaper wet. At 3:05 pm the surveyor notified the administrator (employee #3) about the situation and the nursing personnel proceed to change resident # 9 diaper. The facility failed to ensure that residents are treated with respect and dignity during delivery of nursing care | 2020-09-01 |
| 49 | 49 | DAMAS HOSPITAL SNF | 405023 | 2213 PONCE BY PASS | PONCE | PR | 717 | 2017-05-25 | 241 | E | 1 | 1 | NJQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a recertification extended FOSS survey and complaint investigation PR 598, record review, facility's grievance report, and observations during ulcer care with the Register Nurse (RN) (employee #10) and investigation of 2 complaint performed by 2 residents with the Administrative Supervisor (Employee #3) performed on 5/22, 5/23, 5/24, and 5/25/17, it was determine that the facility failed to ensure that residents are treated with respect and dignity during delivery of nursing care, for 2 out of 13 residents (Resident #4 and #6). Findings include: 1. Resident #6 is a [AGE] years old male admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident #6 was discharge home on 5/18/17 at 12:50 pm. The close record review was performed on 5/25/17 at 2:00 pm. 2. During review of the compliant investigation performed on 5/24/17 at 10:30 am provides evidence that on 4/6/17 the Resident #6 filled a grievance. 3. During review of the facility compliant report provided evidence that the resident #6 referred that when the RN (Employee #11) went to room [ROOM NUMBER]A on 4/6/17 at 1:35 am she stated: I will not come back until 4:00 am. 4. During review of the facility compliant report provided evidence that the resident #6 referred that when the practical nurse (LPN) (Employee #12) went to room [ROOM NUMBER]A on 4/6/17 at 1:35 she stated: you only came to this facility for physical therapy and nothing more. During telephone interview with the resident #6 on 5/31/17 at 9:52 am, he referred: Those two comments made me feel like if I am annoying them and unwelcome. 5. The resident #6 referred on the grievance report that during 1:35 am thru 4:00am he called the nursing staff on multiple occasions because his bed position had cause him to have pain in the sacral ulcer area, and that produced repeated vomit episodes. 6. During review of the facility compliant investigation report performed on 5/24/17 at 10:30 am, the interview of the resident #6's wife… | 2020-09-01 |
| 132 | 132 | HIMA SAN PABLO CUPEY SNF | 405031 | CARR 844 KM 0 5 CUPEY BAJO | RIO PIEDRAS | PR | 928 | 2017-03-16 | 241 | F | 0 | 1 | LEID11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an initial certification survey, observations made of residents and interviews with personnel and resident, it was determined that the facility failed to ensure that residents receive services necessary to provide dignity related to comfortable temperature in the residents room, the use of plastic plates, plastic forks, knives, spoons and Styrofoam cups, and to promote residents' right for personal privacy during administration of subcutaneous injections for 3 out of 3 (Resident #1, #2, # and #3). Findings include: 1. Observation on 3/14/17 through 3/16/2017 from 7:15 am to 12:00 pm, of R1, R2 and R3 during breakfast and lunch meals revealed the residents were utilizing dishware consisting of plastic plates, plastic forks, knives, and spoons, and Styrofoam cups while eating meals in their beds. 2. During the initial tour and interview with residents #1, #2 and #3 on 3/14/17 at 7:15 am in their respective room they stated that the room at times is too cold for their comfort. They ask personnel to raise the temperature and they come. Also if the temperature it too hot they come and lower the temperature. Regulation standards require room temperatures between 71 F and 81 F, the facility must maintain safe and comfortable temperature levels to minimize the risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and colds. The facility failed to periodically measure temperature levels in resident's rooms to ensure compliance with regulations and no evidence was found that the facility is monitoring resident's preferences related to desired temperatures to ensure that this residents' dignity is maintained at its highest related to the temperature level. 3. The Registered Nurse (RN) (employee #1) was observed on 3/14/17 at 9:05 am performing a medication administration of [MEDICATION NAME] 30 mgs subcutaneously to Resident #1, the RN employee #1 exposed the residents' abdominal area and did not close completely the… | 2020-09-01 |
| 218 | 218 | MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE INC | 405030 | CALLE COSME REPARTO SAN LUCAS ENTRADA SECTOR CANEJ | RIO PIEDRAS | PR | 926 | 2016-02-12 | 241 | D | 0 | 1 | NNQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR), observations of delivery of care, and interview it was determined that the facility failed to ensure that residents (R) receive services in a manner that maintains the residents' dignity related to a written sign posted on the wall behind patient head indicating patient [MEDICAL CONDITION] condition in an effective and dignified manner for 1 out of 19 residents in the sample selection (R#6) Findings include: 1. Resident #6 is an [AGE] years old female admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was observed on 1/8/16 at 6:45 am during the initial tour. It was observed a written sign posted on the wall behind the patients head indicating No Vidente (Blind). During interview with the Director of Nurse (employee#5) on 2/9/16 at 10: 45 am revealed that the facility has different sign with symbols for the identification of patient with disabilities. Employee #5 stated: We have different sign with symbols like an eye for [MEDICAL CONDITION] resident and ear and mouth for mute and deaf resident. This also is posted in the nurse station for keep patient privacy and to identify that this resident need more assistance because of their condition . a. The facility failed to ensure that the nursing staff follows standards of practice for residents ' privacy and dignity in an effective and dignified manner. | 2019-04-01 |
| 346 | 346 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2014-09-12 | 241 | E | 0 | 1 | 2S3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. RR #1 is an [AGE] year old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. As secondary Diagnoses: [REDACTED]. The resident was admitted to the SNF for rehabilitation. During the observational tour on 8/27/14 at 10:10 a.m. it was observed that the resident had tangled hair at back of her head. The License Practical Nurse (LPN) employee #17 is observed after finishing bed bath, she combs resident's hair on both sides of her head and the hair portion over her forehead and did not comb the back of the head. After employee #17 left the room, the resident stated: She did not comb my hair well. She did not comb my hair at the back. I touch it and it feels hard. Also, it was observed that the resident had too much facial hair on the whiskers area, below the lower lip and at the nostrils. During interview on 8/27/14 at 11:00 a.m. the resident stated: My daughter buys a wax substance to remove facial hair. I don't like razors. The surveyor asks the resident if she wants her facial hair removed, resident stated: Yes, I wish that someone help me to take out this facial hair it looks ugly. According to the information provided by the resident, no one of the staff personnel ask her about her need of removing facial hair. No evidence was found of notifying resident's daughter by a phone call to bring facial hair removal to satisfy resident's need. The surveyors informed the facility ' s ' secretary to call resident's daughter and notify about resident's request. During interview with the resident on 8/28/14 at 10:00 a.m. resident stated: I think that my daughter brought something (for facial hair removal). After employee #17 finish bathing me I asked if she can help me about removing facial hair but she was quiet and went out of the room. During five (5) days of observations (8/25 thru 8/29/14), none of the nursing staff helped the resident to satisfy her grooming needs. 3. On 8/25/14 at 9:00 a.m during observational tour performed, the r… | 2017-06-01 |
| 458 | 458 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2012-07-20 | 241 | E | 0 | 1 | 93CN11 | Based on observations made of residents, it was determined that the facility failed to ensure that residents receive services in a manner that maintains or enhances the residents' dignity related to receiving grooming (haircuts) in an effective, clean and dignified manner for three out of thirty-four admitted residents (random sample residents #5, #6 and #7). Findings include: During observations of the outside covered storage area on 7/19/12 from 10:30 am till 2:00 pm, three residents (random sample residents #5, #6 and #7) were observed receiving haircuts. However, during this procedure, other facility personnel were working in this area cutting tiles for the janitor closet, garbage container were also left in this area, a mop was hanging from the wall and it was raining. The facility failed to designate an area where resident can receive grooming in an effective, clean and dignified manner. | 2015-07-01 |
| 528 | 528 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2011-03-18 | 241 | I | R1BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A mechanism to ensure that adequate body positioning is maintained for residents with physical limitations was not promoted and not followed as evidenced by the followings: a. Resident #4 is a [AGE] years old male admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was interviewed on 3/17/11 at 8:49 am and he stated that when he receives his breakfast, personnel in charge of him do not place him in an adequate body position and he does not feel comfortable. He also stated that personnel leave him in the same position after assisting him to eat and do not ask if he was comfortable. The resident was observed on 3/16/11 from 8:49 am through 9:18 am in the semi-sitting position lying on his left side touching the bed rail with his head when he called for assistance to change his position. The resident was bedridden due to his health condition and needs extensive assistance for bed mobility according with information found on the MDS section G (date of reference 3/4/11). The rehabilitation potential plan of care reviewed on 3/17/11 at 11:49 am provided evidence that bed mobility for the resident was not included and not considered during the development of the plan of care. The facility failed to consider the residents' preference to improve comfort and positioning during meals. 4. Resident #4 is a [AGE] years old male admitted on [DATE] with a [DIAGNOSES REDACTED]. During the initial tour on 3/16/11 at 9:47 am the resident stated that the other resident located at bed "B" in the same room was making a strange breathing noise all day and all night. The noise does not allow him to rest well. The resident was asked if the facility offered to change him to another room and he stated that they did not offer the possibility of changing him to another room. The facility failed to promote an environment where the resident felt comfortable and could rest appropriately. 5. A mechanism to ensure that the facility promotes care for residents in a… | 2014-04-01 | ||
| 581 | 581 | SAN GERARDO HOSP | 405022 | MSC 250 WINSTON CHURCHIL AVE 138 | RIO PIEDRAS | PR | 926 | 2013-09-13 | 241 | D | F6TZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner which promoted the dignity of each resident. Three of 15 residents in the standard sample (R3, R8, and R10) were not dressed and/or groomed in accordance with accepted standards. Findings: 1. a. Observation during initial tour on 9/9/13 at 10:30am revealed R8 lying in bed. The resident was wearing a disposable paper isolation gown which was see-through. The resident did not have a top sheet, blanket, or covering. R8's breasts were clearly visible through the disposable gown. The resident's incontinence brief was also visible, as the isolation gown was bunched up around the top of R8's body. Observation during initial tour revealed a large number of staff (including physicians and medical students) were in R8's room, where they were conducting grand rounds. Observation revealed that R8 continued to not be dressed in clothing at 11:30am, 1:30pm, and 3:10pm, R8's breasts were visible through the disposable gown until 3:10pm, when the resident was covered with a sheet after surveyor intervention. Review of R8's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/6/13, revealed the resident required extensive assistance from staff for dressing. b. Observation revealed R8 was not provided each meal in a dignified manner. Observation on 9/11/13 at 12:35 revealed Licensed Practical Nurse (LPN) 25 placed a Chux (a large disposable pad put under residents for incontinence) on R8 as a clothing protector, while she fed her lunch. 2. a. Observation on 9/9/13 at 12:20pm, 1:50pm, and 2:30pm revealed that R3 was in need of shaving. The resident had stubble and whiskers which were not neatly groomed. Observation on 9/9/13 at 3:45pm revealed a family member (F), in the room, shaving R3 with a disposable razor. Interview at this time with F3 revealed that although the resident had a bed bath the previous day, staff had not shaved the re… | 2014-04-01 | ||
| 640 | 640 | THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE | 405028 | CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS | RIO PIEDRAS | PR | 926 | 2011-02-17 | 241 | D | 5V0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the initial observational tour of resident's rooms with a Registered Nurse (RN) (employee #1) and interview, it was determined that the facility failed to ensure that residents receive services in a manner that maintains or enhances the residents' dignity related to verbally announcing that they were going to change the resident's "Pampers" which could be heard by the resident's roommate for one out of thirty-five admitted residents (Random Sample resident #25). Findings include: During the observational tour of resident's room [ROOM NUMBER] on 2/15/11 at 9:10 am with Registered Nurse (R.N) (employee #1), random sample resident #25 was observed lying on her bed and she was asked if everything was all right and she stated on 2/15/11 at 9:10 am that she was waiting for someone to change her disposable briefs. The resident stated that she can not control her bladder but staff come quickly to change the disposable briefs as soon as she calls. After the interview with the resident, the surveyors started walking out of the room and in a voice that could easily be heard by the resident in bed "A" (random sample resident #26) the R.N stated that she would send in a Licensed Practical Nurse (LPN) "to change her Pampers". The facility failed to ensure that personnel promote care in a manner that maintains or enhanced the resident's dignity and respect related to her self-esteem and self-worth. | 2014-03-01 |
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CREATE TABLE [cms_PR] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );