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Based on document review, observation, and interview, it was determined that for 1 of 1 Mother Baby Unit, the Hospital failed to ensure that patient information was secured to prevent unauthorized access. This had the potential to affect the privacy of 21 patients on census on 4/15/19.

Findings include:

1. The Hospital's policy titled, "HIPAA [Health Insurance Portability and Accountability Act]" (approved 7/24/17), was reviewed on 4/16/19 and included, "These Health Information Privacy Policies and Procedures implement our obligations to protect the privacy of individually identifiable health information that we create, receive or maintain as a health care provider... Except for uses or disclosures to the patient, to a health care provider for treatment purposes... [Hospital] will make reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose..."

2. The Hospital's policy titled, "Patient Rights and Responsibilities" (approved 4/14/19), was reviewed on 4/16/19 and included, "...A patient has privacy rights established under the Health Insurance Portability and Accountability Act (HIPAA)..."

3. An observational tour of the Mother Baby Unit was conducted on 4/15/19, between 1:30 PM and 3:30 PM. There were 21 patients on census, and each patient had a binder that was kept on the outside of their room door (facing the hallway), which contained the patient's personal and medical information, including: the patient's name; date of birth/age; gender; admission date; medical record number; social security number; address; phone number; insurance policy number; medical, surgical and family history; laboratory results (test results for sexually transmitted diseases, i.e. HIV - Human Immunodeficiency Virus); consent forms for general medical procedures and surgeries; postnatal depression scale, Ebola screening questionnaire; newborn consent for vaccination; newborn hearing screening results; newborn identification record; and neonatal stabilization & resuscitation record. The binders/charts were accessible to other patients and visitors and was not supervised by an authorized staff member at all times.

4. An interview was conducted with the Mother Baby Unit Director (E#5) on 4/15/19 at 2:32 PM. E#5 stated that "...anyone can walk up and look at a chart but it hasn't been a problem..." E#5 stated that staff are not always present in the hallway to supervise each patient's chart.

5. An interview was conducted with the Associate Vice President of HIPAA/Patient Privacy (E#8) on 4/16/19 at 11:11 AM. E#8 stated that he would not expect anyone walking in the hallway, patient or visitor, to have access to another patient's health information, such as social security number, insurance information, medical history, laboratory results, etc.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #25) patient records reviewed on the 14 West Medical Unit, the Hospital failed to ensure that the patient's pain level was reassessed following administration of a narcotic pain medication.

Findings include:

1. The Hospital's policy titled, "Pain" (approved 2/26/19), was reviewed on 4/16/19 and required, "...For intravenous medication administration, reassess patient for the following within 60 minutes: Pain level; Sedation level; Respiratory rate; Respiratory quality; Respiratory noise..."

2. The clinical record of Pt. #25 was reviewed on 4/15/19. Pt. #25 was a 58 year old female, admitted on 4/13/19, with a diagnosis of partial small bowel obstruction. A physician's order dated 4/14/19 included, "morphine [narcotic pain medication] injection 2 mg [milligrams]... every 2H [2 hours] PRN [as needed]... reason: Breakthrough Pain..." The medication administration record indicated that 2 mg of morphine was given intravenously on 4/15/19 at 5:41 AM. The clinical record lacked documentation of a pain reassessment within 1 hour following the administration of morphine.

3. An interview was conducted with a Registered Nurse (E#7) on 4/15/19 at approximately 11:00 AM. E#7 stated that a pain reassessment should be completed within one hour following IV (intravenous) pain medication administration. The patient's pain level and respiratory status should be documented. E#7 stated that she could not find any documentation in the record of the pain reassessment.

Based on observation, document review and interview, it was determined that for 1 of 2 Physicians (MD #2) and 1 of 1 SRNA (Student Registered Nurse Anesthetist - E#19), the Hospital failed to ensure medication vial tops were cleaned prior to inserting a needle and withdrawing medication.

Findings include:

1. On 4/17/19 at approximately 10:45 AM, OR (operating room) 26 was observed. An Anesthesia Resident (MD #2) opened 2 vials of medication and withdrew the contents of the vials without cleansing the injection sites of the vials with alcohol first.

2. The Hospital policy titled, "Medication Management" (Approval date 5/9/17), included, "Pre-mixed vials, R.N. (Registered Nurse)/Pharmacist/physician: 1. Remove protective dust cap and cleanse injection site on vial with alcohol pad..."

3. The above findings were discussed with the Senior Vice President and Chief Operating Officer/Chief Nursing Executive (E #30) on 4/17/19 at approximately 12:30 PM. E #30 stated, "The medication vial top should be wiped with an alcohol pad."


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4. An observational tour of the 5th floor Surgical Department was conducted on 4/17/19, between 10:10 AM and 11:10 AM. At approximately 10:36 AM, in OR (Operating Room) suite #6, a SRNA (E#19) opened 3 medication vials, and drew out the medication without disinfecting the injection site of the vial.

5. An interview was conducted with the OR Assistant Unit Director (E#20) on 4/17/19, at approximately 11:00 AM. E#20 stated that any non-sterile medication vial injection sites should be wiped with alcohol and allowed to dry before inserting the syringe needle.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on April 15-18, 2019, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

On 10/22/19 Life Safety Code monitoring survey was conducted
The requirements of 42 CFR Subpart 482.41, Physical Environment, are NOW MET.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on April 15-18, 2019, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review, observation and interview, it was determined that for 1 of 1 Visitor (Z #1) and 1 of 1 Housekeeper (E#3), the Hospital failed to ensure appropriate PPE (personal protective equipment) was in use to maintain isolation precautions.

Findings include:

1. On 4/15/19 at 3:00 PM, the Hospital's signage titled, "Droplet Precautions" (revised 6/2018) was reviewed and required, "...Visitors: Wear a surgical or procedural mask upon entering a room..."

2. On 4/15/19 at 3:10 PM, the Hospital's policy titled, "Transmission-Based Precautions" (7/16/2018) was reviewed and required, "...Contact Precautions...Gloves and gown must be removed and discarded before leaving the patient room..."

3. On 4/15/19 at approximately 10:00 AM, Pt #7's clinical record was reviewed. Pt #7 was a 63 year old female admitted to the MICU (Medical Intensive Care Unit) with the diagnosis gastrointestinal hemorrhage (bleeding from the intestines) with hematemesis (vomiting of blood). Pt #7's physician orders, dated 4/15/19, included, "droplet isolation." On 4/15/19, at approximately 10:10 AM, Pt #7's room was observed to have a Droplet Precaution (precaution to prevent spread of germs by coughing and sneezing) signage outside the door. The signage included, "...Visitors: Wear a surgical or procedural mask upon entering room..." On 4/15/19 at approximately 10:10 AM, Z #1 (visitor) was observed inside Pt #7's room without a mask.

4. On 4/15/19 at approximately 10:20 AM, Pt #38's clinical record was reviewed. Pt #38 was a 79 year old female admitted to the MICU (Medical Intensive Care Unit) on 3/6/19 with the diagnosis ovarian cancer. Pt #38 was on contact isolation for VRE (vancomycin resistant enterococcus - infection). Pt #38's physician orders, dated 3/11/19 included, "contact isolation." On 4/15/19 at approximately 10:30 AM, the Housekeeper (E #3) was observed wearing an isolation gown in the hallway after leaving Pt #38's contact isolation room.

5. On 4/15/19, at approximately 10:10 AM, an interview was conducted with E #1 (Assistant Unit Director - Medical Intensive Care Unit). E #1 stated that Z #1 should have been wearing a mask in Pt # 7's room. E #1 stated that E #3 should have removed PPE prior to leaving Pt #38's contact isolation room.


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B. Based on document review, observation, and interview, it was determined that for 2 of 2 staff (E#31 and E#32) conducting OR (operating room) turnover cleaning, the Hospital failed to ensure that staff disinfected the room from top to bottom, as required. This could potentially affect the patient entering the OR after cleaning.

Findings include:

1. The Hospital's policy titled, "Environmental Cleaning for the Operating Room - For End of Procedure and Terminal Cleaning" (revised 1/3/18), was reviewed on 4/17/19 and required, "...Using a microfiber cloth treated with 'house disinfectant' disinfect OR in a clockwise pattern, from the door, cleaning from high to low and clean to dirty..."

2. An observational tour of the 7th floor Surgical Department was conducted on 4/17/19, between approximately 11:20 AM and 11:55 AM. At approximately 11:35 AM, in OR (Operating Room) room #30, two Environmental Service staff (E#31 & E#32) were observed cleaning the room following a surgical procedure. At approximately 11:36 AM, E#31 was wiping down the surgical table and carts, while E#32 began mopping the floor. At approximately 11:39 AM, E#31 wiped the overhead lights (after cleaning the surfaces beneath the lights).

3. An interview was conducted with the Director of Environment Services (E#29) on 4/17/19 at 2:30 PM. E#29 stated that cleaning should be done from high to low. E#29 stated that the lights should have been cleaned first, then the tables/equipment, and the floor last.

Based on observation, document review and interview, it was determined that for 1 of 1 Scrub Technician, (E #18), the Hospital failed to ensure the sterile field was maintained. This could potentially allow for contamination of the sterile supplies for the case scheduled in Operating Room 26.

Findings include:

1. During observation of OR 26, on 4/17/19, a Scrub Technician (E #18) dropped a package of paired gloves on the floor. E #18 picked up the package from the floor and proceeded to open the package over the sterile field, potentially contaminating the sterile field.

2. The Hospital policy titled, "Sterile Supplies" (approval date 4/5/19), included, "... items are compromised when a package is torn, dropped, wet, damaged or otherwise suspected of being contaminated."

3. The above findings were discussed with the Senior Vice President and Chief Operating Officer/Chief Nursing Executive (E #30) during an interview on 4/17/19. E #30 stated that the item dropped on the floor should have been discarded.