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Based on observation, interview, and record review, the facility failed to ensure patient health care information was secured from unauthorized access at all times, by not safeguarding protected healthcare information prior to its destruction in the West Campus Medical Professional Center. Findings include:

During an observation on 7/24/19 at 9:30 a.m., by the nurse's desk located in an open patient care area in the infusion center was a blue plastic wastepaper basket with a white recycling logo on the front. The basket lid was open, not covered or locked, and it contained patients' protected health information.

During an observation on 7/24/19 at 9:45 a.m., in all the nurse's stations, on the fourth floor of the West Campus Professional Medical Center, were blue plastic wastepaper baskets with a white recycling logo on the front. The baskets were open, not covered or locked, and each basket contained patients' protected health information.

During an interview on 7/24/19 at 9:45 a.m., staff member YY stated patient PHI was thrown into the blue wastepaper baskets and the baskets were emptied nightly by the cleaning staff.

During an interview on 7/24/19 at 9:45 a.m., staff member K stated there were no locked shred bins located at the nurse's stations on the fourth floor of the West Campus Professional Medical Center. He stated the blue wastepaper bins were emptied by the cleaning staff every night and brought to a locked bin used to secure PHI waiting for destruction. He said staff had reviewed and signed the facility's Confidentiality Agreement.

During an observation on 7/24/19 at 10:00 a.m., in all the nurse's stations located on the third floor of the West Campus Professional Medical Center were blue plastic wastepaper baskets with a white recycling logo on the front. The baskets were open on the top and were not covered or locked. The baskets contained patients' protected health information.

During an observation on 7/24/19 at 10:15 a.m., in all the nurse's stations located on the second floor of the West Campus Professional Medical Center were blue plastic wastepaper baskets with a white recycling logo on the front. The baskets were open on the top and were not covered or locked. The baskets contained patients' protected health information.

During an observation on 7/24/19 at 10:30 a.m., in all the nurse's stations located on the first floor of the West Campus Professional Medical Center, were blue plastic wastepaper baskets with a white recycling logo on the front. The baskets were open on the top and were not covered or locked. The baskets contained patients' protected health information.

During an interview on 7/24/19 at 10:30 a.m., staff member ZZ stated any PHI should be covered and protected from unauthorized use. She stated the West Campus Professional Medical Center did not have locked bins for securing PHI prior to destruction. She said the nurse's stations used the blue plastic wastepaper bins with the white recycling logo to hold patient healthcare information to be destroyed. Staff member ZZ stated those bins were emptied nightly by the cleaning staff. She stated the cleaning staff had signed the facility's confidentiality agreement and she could not guarantee the PHI in the unsecured blue bins were always completely safe from unauthorized access.

A review of the facility's policy and procedure titled, Security and Disposal of Patient Records and any Other Related Patient Documents, showed, "...I. All Medical Staff and [Hospital] employees: A. Patient records and any other documents containing patient information (documents with any patient identifier, such as name, number, etc.) that are not considered part of the permanent medical record are disposed of in special containers and shredded. IV. Housekeeping: A. Empty the containers at regular intervals and verify that the paper documents are placed in locked bins. These bins are then held for shredding by a local recycling center."

Based on observation, interview, and record review, facility staff failed to provide aseptic patient care by not changing contaminated gloves for 1 (#20); and failed to ensure ultrasound machines used in the radiology department and in the intensive care unit were disinfected after patient use for patients receiving ultrasound services and for 1 (#6) of 39 sampled patients. Findings include:

1. During an observation on 7/23/19 at 11:00 a.m., staff member AAA completed endotracheal suctioning for patient #20, who resided in the Intensive Care Unit. He sanitized his hands and donned clean gloves. He placed a scanner on the patient's wrist band and began inputting numbers on a touch screen computer. He checked for breath sounds with a stethoscope and placed his gloved hands on the patient's bed rail. Staff member AAA put more information into the computer, while wearing the same gloves. He coughed into his wrist three times, then proceeded to suction the patient endotracheal tube and cleaned her mouth with a swab. Staff member AAA did not sanitize his hands or don clean gloves after coughing and touching the computer, during the treatment, and prior to suctioning the endotracheal tube and cleaning the patient's mouth with a swab.

During an interview on 7/25/19 at 8:40 a.m., staff member P stated the patient care was to be as aseptic as possible, but it could not be a sterile procedure. He stated the computer would always be contaminated but it would be "best practice" to change gloves prior to the procedure, but later stated he was referring to tracheal care, not suctioning.

During an interview on 7/25/19 at 8:40 a.m., staff member BBB stated he would not don gloves until he was ready to provide direct care to the resident.

Review of the facility's Hand Hygiene Policy and procedure showed, "Decontaminate hands with alcohol based waterless antiseptic agent before having direct contact with patients, and after contact with a patients intact skin (as in taking a blood pressure.)"


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2. During an observation and interview on 7/22/19 at 1:48 p.m., staff member V used a portable ultrasound machine from radiology to examine patient #6's arm to assist with placing a PICC line (Percutaneously Inserted Central Catheter). After staff member V had completed the procedure, she used a green topped Sani-wipe HB to disinfect the ultrasound machine. Staff member V stated she used the wipes for the disinfection process and would wipe the probe for 30 seconds with the wipe. Staff member V stated she did not know the amount of time the equipment had to remain wet to ensure it was disinfected. Staff member V read the instructions on the wipe's container. The instructions showed the area being cleansed was to remain wet for ten minutes for it to be disinfected. Staff member V stated she had used the ultrasound machine "five times so far today" and did not keep the areas she cleansed wet for the required ten minutes to ensure it was disinfected prior to use on another patient.

During an interview on 7/23/19 at 3:21 p.m., staff member Z stated the ultrasound manufacturer recommended the radiology department use the green top Sani-cloth HB to clean the ultrasound machines and then wipe dry with a cloth as it was discoloring the probe cable. Staff member Z stated all the ultrasound machines were disinfected in this manner. Staff member Z stated the department did not maintain a ten-minute wet contact time due to the recommendations made by the manufacturer of the ultrasound machines. Staff member Z stated he was checking other options with the manufacturer.

A request for the manufacture information and recommendations for disinfecting the ultrasound machines was requested on 7/22/19 at 4:58 p.m. No information was received prior to the exit of the survey.