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Based on review of information provided to patients on admission, record review, and staff interview, the Critical Access Hospital (CAH) failed to document whether or not the patient executed an advance directive for 2 of 8 active swingbed patient (Patients #4 and #5) and 7 of 12 closed inpatient (Patients #9, #10, #11, #17, #18, #19, and #20) records reviewed. Failure to document whether the patient executed an advance directive limited the CAH's ability to implement the advance directive.

Findings include:

Review of information provided to patients at the time of admission occurred on 05/18/15. The information included a form titled, "Patient Care Classification," which directed staff to document whether or not the patient executed a living will, durable power of attorney for healthcare, or other advance directive.

Review of Patient #4, #5, #9, #10, #11, #17, #18, #19, and #20's medical records occurred on all days of survey. The records included the form described above, but identified staff failed to complete the form. Further review of the records failed to include evidence staff documented whether or not the patient executed an advance directive.

During an interview on 05/19/15 at 3:50 p.m., an administrative staff member (#4) stated she expected staff to utilize the form mentioned above to document whether the patient executed an advance directive.

ADMINISTRATION OF INSULIN

1. Based on observation, review of manufacturer's instructions, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff discarded insulin 28 days after opening the vial for 1 of 3 patients (Patient #1) observed during insulin administration. Failure to discard outdated insulin may result in patients receiving ineffective medication.

Findings include:

Review of the manufacturer's instructions for NovoLog insulin occurred on 05/18/15. The instructions, revised February 2015, identified staff should discard opened NovoLog vials after 28 days.

Observation on 05/18/15 at 12:05 p.m. identified a nurse (#5) drew up Patient #1's insulin dose into a syringe and verified the dose with a second nurse (#6). Both nurses failed to identify the "opened" date of 04/11/15 written on the insulin (37 days prior). After the surveyor identified the outdated insulin, one nurse (#6) stated staff should discard insulin 28 days after the first use.


INSULIN STORAGE

2. Based on observation, review of manufacturer's instructions, and staff interview, the Critical Access Hospital (CAH) failed to store in use insulin pens per manufacturer's instructions in 1 of 1 nursing medication room. Failure to store in use insulin pens at room temperature may result in patients receiving ineffective insulin.

Findings include:

Review of the manufacturer's instructions for Levemir and NovoLog Mix 70/30 FlexPens occurred on 05/19/15. These instructions, both revised February 2015, stated staff should store both types of insulin pens in use at room temperature.

Observation of the medication storage refrigerator near the nurse's station occurred on 05/19/15 at 9:30 a.m. with an administrative nurse (#2). Observation identified a Levemir FlexPen in use dated as opened on 05/17/15 and a NovoLog Mix 70/30 FlexPen in use dated as opened on 05/16/15.

During an interview on the morning of 05/19/15, an administrative nurse (#2) confirmed staff should store in use insulin pens at room temperature.


OUTDATED MEDICATIONS

3. Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications from 1 of 2 emergency drug storage areas (first floor treatment/emergency room). Failure to remove outdated medications may result in patients receiving expired and ineffective medications.

Findings include:

Review of the policy titled "Medication/Narcotic Outdates" occurred on 05/20/15. This policy, dated October 2014, stated, ". . . It is the policy of CHI [Catholic Health Initiatives] Community Memorial Hospital to ensure that all medications are used before outdated. All outdated medications are taken off the shelf and sent to Pharmacy for disposition . . ."

Observation of the first floor treatment/emergency room occurred on 05/19/15 at 8:50 a.m. with an administrative nurse (#2) and identified the following:
* two vials of magnesium sulfate expired November 2014 (located in the crash cart)
* one bag of dextrose solution expired March 2015 (located in the crash cart)
* one bag of heparin mixed with sodium chloride expired May 01, 2015 (located in the crash cart)
* one vial of lidocaine expired May 01, 2015 (located in a cupboard with suture supplies)

During an interview on the morning of 05/19/15, an administrative nurse (#2) confirmed the expiration dates of the medications found in the first floor treatment/emergency room.

INFECTION CONTROL PRACTICES DURING DIRECT PATIENT CARE

1. Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care relating to infection control practices for 7 of 8 patients (Patient #1, #3, #4, #6, #23, #24, and #25) observed during personal cares, medication administration, blood glucose monitoring, and housekeeping. Failure to follow established infection control practices may allow transmission of organisms and pathogens from patients to staff, to other patients, or to visitors, and from one environment to another.

Findings include:

Review of the policy titled "Handwashing & Hand Antisepsis" occurred on 05/20/15. This policy, dated December 2014, stated, ". . . Hand hygiene must be performed before and after patient contact, after touching contaminated objects and following glove removal . . . Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin . . . Decontaminate hands if moving from a contaminated body site to a clean body site during patient care . . . Decontaminate hands after contact with an inanimate object (including medical equipment) in the immediate vicinity of the patient . . ."

Review of the policy titled "Catheter - Foley/Leg Bag Maintenance" occurred on 05/20/15. This policy, dated March 2009, stated, ". . . Wipe the Foley cath/drainage bag junction with an alcohol wipe . . ."

- Observation throughout the day on 05/18/15 showed an unidentified housekeeping staff member walking about the facility, in the corridor of the patient rooms, and in and out of patient rooms with gloves on.

- Observation on 05/18/15 at 10:15 a.m. identified a nurse (#13) assisted Patient #1 to ambulate to the bathroom. After completing perineal cares and applying cream to the patient's buttocks, the nurse (#13) removed her gloves and assisted the patient to ambulate to her recliner. Once the patient sat in her recliner, the nurse (#13) adjusted the patient's chair, handed the patient some objects she asked for off her bedside table, and then washed her hands. The nurse (#13) failed to perform hand hygiene after completing perineal cares once getting the patient to a safe position.

- Observation on 05/18/15 at 10:35 a.m. identified a nurse (#5) entered Patient #4's room, donned gloves, cleansed the hub on the patient's PICC (peripherally inserted central catheter) with an alcohol pad, flushed the PICC, attached an intravenous antibiotic to administer into the patient's PICC, and exited the room. The nurse (#5) failed to perform hand hygiene prior to and after contact with Patient #4.

- Observation on 05/18/15 at 10:45 a.m. identified an aide (#14) donned gloves and wiped the end of the drain tube with a perineal wipe after emptying Patient #3's indwelling catheter.

During an interview on the afternoon of 05/20/15, an administrative nurse (#18) stated staff should wipe urinary catheter drain tubes with an alcohol pad, as per facility policy.

- Observation on 05/18/15 at 11:25 a.m. identified a nurse (#5) prepared a medication for Patient #6. While at the medication cart, the nurse (#5) dropped the pill directly onto the cart, picked the pill up with her ungloved hand, placed the pill back into the medication cup, and administered the medication to the patient. The nurse (#5) improperly administered a medication dropped onto the medication cart and touched with an ungloved/unsanitized hand and failed to perform hand hygiene prior to and after administering the medication to Patient #6.

- Observation on 05/18/15 at 11:38 a.m. identified a nurse (#5) donned gloves, tested Patient #1's blood glucose, and went back to the medication cart to continue administering medications. The nurse (#5) failed to perform hand hygiene prior to and after testing the patient's blood glucose.

- Observation on 05/18/15 at 11:40 a.m. identified an aide (#15) assisted Patient #1 to ambulate to the bathroom. After completing perineal cares, the aide (#15) removed her gloves, assisted the patient to her wheelchair, placed the patient's footpedals, handed the patient a cup of ice chips, and assisted the patient to the dining room. The aide (#15) failed to perform hand hygiene prior to contact with the patient and after completing perineal cares.

- Observation on 05/18/15 at 12:05 p.m. identified a nurse (#5) preparing Patient #1 and #23's insulin syringes. The nurse failed to perform hand hygiene prior to and after preparing the medications. During this observation, the nurse (#5) went to the dining room and administered insulin to Patient #1 and Patient #23. The nurse failed to perform hand hygiene prior to and after administering insulin to each patient.

- Observation on 05/18/15 at 3:30 p.m. identified two aides (#11 and #12) assisted Patient #25 with toileting. One aide (#11) completed frontal perineal cares and the second aide (#12) cleansed the patient's buttocks. Both aides (#11 and #12) removed their gloves and transferred the Patient back to her wheelchair using a mechanical lift. After the transfer, without performing hand hygiene, an aide (#12) combed Patient #25's hair, placed the footpedals onto the wheelchair, sanitized her hands, and assisted the patient to the activity room. After the transfer, without performing hand hygiene, the second aide (#11) donned gloves, placed the mechanical lift in the corridor, put away the patient's personal care supplies, washed her hands, and exited the patient's room. Both staff members (#11 and #12) failed to perform hand hygiene after completing perineal cares and prior to performing other tasks.

- Observation on 05/18/15 at 4:30 p.m. identified an aide (#11) assisted Patient #24 to ambulate to the bathroom where the patient completed her own perineal cares after voiding in the toilet. After transferring the patient back into her wheelchair, the aide (#11) washed her hands but failed to assist/encourage Patient #24 to perform hand hygiene after completing perineal cares.

On 05/20/15 at 11:15 a.m., an interview occurred with three administrative nurses (#2, #3, and #16). During this interview, an administrative nurse (#2) stated she expected staff to perform hand hygiene before and after contact with a patient and immediately after assisting a patient with perineal cares. A second administrative nurse (#16) stated staff should perform hand hygiene in between gloves changes when going from "dirty" to "clean." The other administrative nurse (#3) stated staff should assist/encourage patients to perform hand hygiene, especially if they completed their own perineal cares. This nurse (#3) also stated staff should not touch pills with ungloved hands and need to get a new pill after dropping one.


INFECTION CONTROL PROGRAM

2. Based on review of the infection control reports and meeting minutes and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, investigate, and control infections and communicable diseases for outpatients of the CAH for the past 12 of 12 months (May 2014 through April 2015) reviewed. Failure to identify and address incidents of infections among all patients has the potential for infections to go unreported, spread, or reoccur; affecting the health of all patients, personnel, and visitors of the CAH.

Findings include:

Reviewed on 05/20/15, the infection control program lacked evidence the CAH identified and recognized infections of outpatients. The infection reports and meeting minutes from May 2014 through April 2015 failed to include information and documentation of outpatients with known or suspected cases of infections and/or communicable diseases.

During an interview on 05/20/15 at 11:15 a.m., an administrative nurse (#3) stated she did not receive or request infection control information from outpatients, namely, the Emergency Room, therapy department, lab/radiology, and procedure/treatment patients. The staff member (#3) confirmed the CAH did not formally document and include outpatients in infection control surveillance.

The failure to document and perform surveillance among all patients of the CAH limited the CAH's ability to identify, monitor, track, control, and prevent infections.

Based on observation, internet reference review, policy/procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure dietary services provided in accordance with recognized dietary practices regarding sanitation in 3 of 3 food service/storage areas (kitchen, patient dining/activity room, kitchenette by nurse's station). Failure to follow recognized dietary practices regarding cleaning and sanitization placed patients and staff consuming food prepared in the kitchen at risk of contracting a food borne illness.

Findings include:

Review of an internet reference titled "Sanitizers for Food Contact Surfaces" occurred on 05/20/15. This undated reference, retrieved from http://www.gastongov.com/docs/environmental-health---food-lodging/2011/03/09/sanitizers-for-food-food-contact-surfaces, states, ". . . Chlorine-based sanitizers - provide at 50 to 100 ppm [parts per million concentration] . . ."

Review of the facility policy titled "Equipment, Materials and Cleaning" occurred on 05/20/15. This undated policy stated, ". . . 5. Cleaning and sanitizing procedures and cleaning schedules are to be followed. All working surfaces of food contact surfaces of equipment are to be cleaned and sanitized between periods of use, and all equipment non-food contact surfaces are scheduled for thorough cleaning and sanitized periodically as well."

Observation of the dietary department kitchen occurred on 05/19/15 at 11:00 a.m. with a dietary staff member (#8). Observation showed a bucket which the staff member (#8) stated contained a bleach (chlorine) solution used for cleaning surfaces. The staff member (#1) stated staff do not check the concentration of the chlorine in the bucket but kept test strips available in the kitchen if needed. The staff member (#8) tested the solution with a strip which identified a concentration of greater than 200 ppm (correct concentration for chlorine bleach sanitizers is 50-100 ppm). The staff member (#8) stated staff mix random amounts of water and chlorine together and lacked a specific "recipe" for mixing to ensure a consistent concentration each time.

Observation of the dietary department on the morning of 05/19/15 with a dietary staff member (#8) revealed the following:
*build-up of dust on the fan in the walk-in cooler
*build-up of crumbs and debris inside the cabinets and drawers in the kitchen and film on the outside of the cabinets and drawers

An interview with the dietary staff member (#8) occurred on 05/19/15 at 11:30 a.m. The staff member agreed the facility currently had no system in place for monitoring chemical concentration of the sanitizing buckets and stated the facility does not have a cleaning schedule for the fan in the walk-in cooler and the cabinets and drawers.

Observation of the patients' dining/activity room occurred on 05/19/15 at 11:45 a.m. with a dietary staff member (#8) and identified a build-up of food debris inside the microwave. The dietary staff member (#8) stated nursing and activity staff are responsible for the patients' dining/activity room.

During observation of the patients' dining/activity room on the morning of 05/19/15, an activity staff member (#9) stated housekeeping or nursing staff are responsible for cleaning the microwave and identified the facility does not have a cleaning schedule for the microwave. When asked how staff sanitize the tables used by the patients for dining and activities, the staff member (#9) stated she used a sanitizing solution of two capfuls of bleach with an undetermined amount of water and verified she does not check the concentration of the solution.

Observation of the kitchenette located near the nurse's station occurred on 05/19/15 at 12:00 p.m. with a dietary staff member (#8) and identified a scoop inside a container of powder to thicken patients' liquids. The staff member (#8) confirmed staff should not leave scoops inside containers and stated nursing staff are responsible for the kitchenette.

Based on review of a professional reference, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure nursing staff documented the time of reassessment after administration of as needed (prn) medications for 7 of 8 active swingbed patient (Patient #1, #2, #3, #4, #5, #6, #8) and 3 of 12 closed inpatient (Patient #13, #16, and #17) records reviewed. Failure to document the time of reassessment limited the nursing staff's ability to determine whether the medication achieved the desired effect in a sufficient time frame.

Findings include:

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, page 870, states, ". . . Administering Oral Medications . . . Evaluation . . . Return to the client when the medication is expected to take effect (usually 30 minutes) to evaluate the effects of the medication on the client. . . ."

- Review of Patient #13, #16, and #17's closed medical records occurred on all days of survey and identified the CAH admitted the patients during the time frame of December 2014 through May 2015. The records identified the patients required prn medications such as Tylenol (reduce fever, reduce discomfort), Zofran (reduce nausea), and Clonazepam (reduce anxiety) and showed nursing staff documented the administration of these medications on a form titled, "P.R.N. Medication Record." The form included a section to document results (effectiveness) of the prn medication, but nursing staff failed to identify the time of the results for the following:
*Patient #13 - administration of Tylenol two times.
*Patient #16 - administration of Zofran once and Tylenol three times.
*Patient #17 - administration of Clonazepam 11 times.

- Review of Patient #1, #2, #3, #4, #5, #6, and #8's active medical records occurred on 05/20/15 and showed nursing staff failed to document the time of reassessment after administration of prn medications to the patients in May 2015. This failure resulted in the following:
*Patient #1 - administration of Tylenol PM four times (a combination of Tylenol and Benadryl for sleep) and Robitussin (cough suppressant) 15 times
*Patient #2 - administration of Hydrocodone (used for moderate to severe pain) 23 times, Clonazepam 12 times, and Zofran two times
*Patient #3 - administration of Tylenol nine times and liquid antacid three times
*Patient #4 - administration of Tylenol three times
*Patient #5 - 16/17 times after Tylenol 650 milligrams (mg)
*Patient #6 - 10/10 times after Clonazepam 1 mg
*Patient #8 - 7/8 times after DuoNeb (lung/breathing treatment) and 2/2 times after Robitussin

During an interview on 05/20/15 at 3:45 p.m., an administrative nurse (#2) stated the CAH did not have a formal process for reassessment of prn medications, but stated nursing staff should evaluate the effectiveness of prn medications within a few hours of administration to ensure the medication provided relief.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure nursing staff administered medications in accordance with written and signed orders for 3 of 14 closed patient (Patient #12, #13, and #22) records reviewed. Failure to administer medications according to orders allowed nursing staff an opportunity to practice outside their scope.

Findings include:

- Review of Patient #12's medical record occurred on 05/19/15 and identified the CAH admitted the patient on 12/10/14 with diagnoses of right sided weakness, transient ischemic attack (TIA) verses cerebral vascular accident (CVA), and brain cancer. A provider order, dated 12/10/14 at 4:00 p.m., identified Ciprofloxacin (Cipro - an antibiotic) 400 milligrams (mg) intravenous (IV) two times a day for five days due to a urinary tract infection. Review of Patient #12's medication administration record (MAR) showed Cipro 400 mg IV two times a day for five days, scheduled twelve hours apart at 4:00 p.m. and 4:00 a.m., started on 12/10/14 at 4:00 p.m. The MAR identified two missed doses of Cipro on 12/12/14 at 4:00 a.m. and on 12/13/14 at 4:00 p.m. Review of the record failed to identify an order discontinuing the Cipro prior to completion of the five day course.

- Review of Patient #13's medical record occurred on 05/18/15 and identified the CAH admitted the patient on 01/29/15 with diagnoses of Influenza A, pneumonia, and weakness. A provider order, dated 01/30/15, identified an increase of Humalog (insulin) from 20 units (u) three times a day (TID) to 25 u TID. Review of Patient #13's MAR showed Humalog 25 u TID; scheduled at 7:30 a.m., 11:30 a.m., and 5:00 p.m.; started on 01/30/15 at 11:30 a.m.

A nurse note, dated 01/31/15 at 5:30 p.m., stated, "Took only 20 u Humalog because blood sugar only 79." Review of Patient #13's MAR showed Humalog 20 u administered on 01/31/15 at 5:00 p.m. Further review of the MAR showed Humalog 23 u administered on 02/01/15 at 5:00 p.m. Review of the patient's record failed to include evidence nursing staff contacted or notified Patient #13's provider for the above Humalog insulin administration as the doses differed from the order.

- Review of Patient #22's medical record occurred on 05/20/15 and identified the patient presented to the emergency room on 05/14/15 with neck pain following a motor vehicle crash. The record identified a nurse administered 30 mg of Toradol (used to decrease inflammation and pain) intramuscularly at 10:35 a.m., but failed to include evidence of a provider's order for the medication.

During an interview on 05/20/15 at 4:00 p.m., an administrative nurse (#2) confirmed nursing staff failed to administer Patient #12's Cipro and Patient #13's Humalog as ordered; and confirmed Patient #22's record lacked a provider order for Toradol. She stated nursing staff must follow provider orders and administer medications according to orders. The nurse (#2) stated she expected nursing staff to notify the patient's provider if staff could not follow orders, document the reasons, and the provider's response to this.

Based on review of Medical Staff Rules and Regulations, record review, and staff interview, the Critical Access Hospital (CAH) failed to maintain a medical record which included a completed discharge summary within 14 days of discharge in accordance with the CAH's rules and regulations for 5 of 12 closed inpatient (Patient #9, #12, #13, #15, and #16) records reviewed. Failure to maintain the medical record with a discharge summary limited the ability to determine the course of the hospitalization, the disposition of the patient, and provisions for follow-up care.

Findings include:

Review of the CAH's "Medical Staff Rules and Regulations" occurred on 05/20/15. These rules and regulations, adopted on 09/24/08, stated, ". . . B. Medical Records . . . 3. . . . Records of discharged patients shall be completed within 14 days. If, after 30 days have passed, the record still remains incomplete after all essential reports have been received and placed on the record, the local facility administrator shall notify the practitioner by certified mail that his privileges to admit patients may be suspended 5 days from the date of notice, and such practitioner shall remain suspended until the records have been completed. . . ."

Review of closed medical records occurred on all days of survey and identified the following:
*Patient #9 - admitted on 02/04/15 with diagnoses of transient ischemic attack (TIA), dysrhythmia, chronic bronchitis, and lung nodules - discharged on 02/08/15 - discharge summary dictated on 05/15/15, 96 days after discharge.
*Patient #12 - admitted on 12/10/14 with diagnoses of right sided weakness, TIA verses cerebral vascular accident (CVA), and brain cancer - discharged on 12/13/15 - discharge summary dictated on 03/03/15, 80 days after discharge.
*Patient #16 - admitted on 01/26/15 with diagnoses of Influenza A, gastritis, and dehydration - discharged on 01/30/15 - discharge summary dictated on 04/16/15, 76 days after discharge.
*Patient #13 - admitted on 01/29/15 with diagnoses of Influenza A, pneumonia, and weakness - discharged on 02/02/15 - discharge summary dictated on 04/19/15, 76 days after discharge.
*Patient #15 - admitted on 11/29/14 with diagnoses of hypotension, urinary tract infection, and pneumonia - discharged on 12/03/14 - discharge summary dictated on 02/08/15, 67 days after discharge.

During an interview on 05/20/15 at 2:20 p.m., a medical records staff member (#10) stated providers must dictate discharge summaries within 14 days after discharge according to the CAH's policies and confirmed Patient #9, #12, #13, #15, and #16's discharge summaries fell beyond the allowed timeframe for completion. The staff member (#10) confirmed the issue existed with a specific provider and stated despite ongoing quality assurance monitoring to achieve compliance, the issue remained.

Based on review of Medical Staff Rules and Regulations, record review, and staff interview, the Critical Access Hospital (CAH) failed to maintain reports of physical examinations (history and physical or H&P) in the medical record within 24 hours after admission in accordance with the CAH's rules and regulations for 3 of 8 active patient (Patient #2, #4, and #5 ) and 3 of 13 closed patient (Patient #9, #12, and #21) records reviewed. Failure to maintain the medical record with an H&P limited the staff's ability to utilize necessary information to monitor the patient's condition and provide appropriate care.

Findings include:

Review of the CAH's "Medical Staff Rules and Regulations" occurred on 05/20/15. These rules and regulations, adopted on 09/24/08, stated, ". . . B. Medical Records . . . 4. A complete history and physical examination shall in all cases be dictated within 24 hours after admission of the patient . . ."

Review of active medical records occurred on 05/20/15 and identified the following:
*Patient #2 - admitted on 01/16/15 with a diagnosis of metastatic brain cancer - H&P dictated on 01/30/15, 14 days after admission.
*Patient #5 - admitted on 03/11/15 with diagnoses of status post left hip fracture, Parkinson's, chronic atrial fibrillation, and hypertension - H&P dictated on 03/13/15, 48 hours after admission.
*Patient #4 - admitted on 04/17/15 with diagnoses of status post right hip fracture and a tunneling wound to her right thigh/hip - H&P dictated on 04/19/15, 48 hours after admission.

Review of closed medical records occurred on all days of survey and identified the following:
*Patient #21 - admitted on 04/29/15 with a questionable transient ischemic attack (TIA) - H&P dictated on 05/15/15, 16 days after admission.
*Patient #12 - admitted on 12/10/14 with diagnoses of right sided weakness, TIA verses cerebral vascular accident (CVA), and brain cancer - H&P dictated on 12/13/14, 48 hours after admission.
*Patient #9- admitted on 02/04/15 with diagnoses of TIA, dysrhythmia, chronic bronchitis, and lung nodules - H&P dictated on 02/06/15, 48 hours after admission.

During an interview on 05/20/15 at 2:20 p.m., a medical records staff member (#10) stated providers must dictate H&P's within 24 hours after admission according to the CAH's policies and confirmed Patient #2, #4, #5, #9, #12, and #21's H&P's fell beyond the allowed timeframe for dictation. The staff member (#10) confirmed the issue existed with a specific provider and stated despite ongoing quality assurance monitoring to achieve compliance, the issue remained.

Based on observation and policy and procedure review, the Critical Access Hospital (CAH) failed to maintain the confidentiality of patients' medical records during 2 of 3 days of survey (May 18-19, 2015). Failure to maintain and ensure the confidentiality of medical record information has the potential to allow unauthorized persons (other patients, visitors, other hospital staff) access to read and/or possibly remove confidential patient information.

Findings include:

Review of the policy titled "Confidentiality Policy" occurred on 05/20/15. This policy, reviewed December 2014, stated, ". . . It is the policy of Community Memorial Hospital to respect and protect the privacy rights of patients . . . All information (written, electronic, or verbal) associated with medical records . . . of any kind is strictly confidential . . ."

- Observation on 05/18/15 at 10:30 a.m. identified an unattended medication cart located in the corridor by patient rooms. Observation showed a nurse (#5) inside a patient room administering medications. The nurse left the Medication Administration Record (MAR) open and confidential patient identifying information remained visible to all patients, staff, and visitors walking by the medication cart.

- Observation on 05/18/15 at 4:10 p.m. identified an unattended medication cart located by the nurse's station. A nurse (#7) left the MAR open as she left the medication cart to administer medications to patients in their rooms. Observation identified confidential patient information remained visible to all patients, staff, and visitors walking by the nurse's station.

- Observation on 05/19/15 at 3:55 p.m. identified an unattended medication cart located by the nurse's station. A nurse (#7) walked back and forth from patient rooms to the medication cart as she administered medications. Each time the nurse walked away from the medication cart to a patient room, she left the MAR open and confidential patient identifying information remained visible to all patients, staff, and visitors walking by the nurse's station.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure privacy for 2 of 2 patients (Patient #1 and #23) observed receiving insulin in the dining room. Failure to provide patients personal privacy during medical treatment does not promote care in a dignified manner and may be an infringement on the patients' rights.

Findings include:

Observation on 05/18/15 at 12:13 p.m. identified a nurse (#5) administered insulin into Patient #1's left arm and Patient #23's right arm while both patients sat in the dining room eating their noon meal amongst other patients and staff.

During an interview on the morning of 05/20/15, an administrative nurse (#3) stated staff should administer insulin to patients in a private area.