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Based on facility document reviews and staff interviews, the facility failed to create, maintain, and routinely evaluate a current list of contracted services.
This failure created the potential for services to be performed without contractual oversight, and for services to be performed outside the contracted service's scope of practice.

FINDINGS:

1. The facility failed to maintain and evaluate a current list of contracted services.

a) On 12/11/12 at 4:00 p.m., an interview was conducted with the facility's Chief Clinical Officer (CCO) in regards to the existence of a list of contracted services. The CCO attempted to locate a list of contracted services, but was unable to produce such a list. The CCO then stated the facility did not keep a list of contracted services, or a list of the scope and services of the contracted services.

b) During the same interview, the facility's Chief Clinical Officer (CCO) was asked to explain how the contracted services were evaluated for quality and performance. The CCO stated the facility did not maintain a list of contracted services, and that without a list of contracted services and scopes, that the facility did not have a way to track and ensure that each contracted service and scope was evaluated.

Based on facility document reviews and staff interviews, the facility failed to create and maintain a current list of contracted services.
This failure created the potential for services to be performed without contractual oversight, and for services to be performed outside the contracted service's scope of practice.

FINDINGS:

1. The facility failed to maintain a current list of contracted services.

a)On 12/11/12 at 4:00 p.m., an interview was conducted with the facility's Chief Clinical Officer (CCO) in regards to the existence of a list of contracted services. The CCO attempted to locate a list of contracted services, but was unable to produce such a list. The CCO then stated the facility did not keep a list of contracted services, or a list of the scope and services of the contracted services.

Based on the manner and degree of deficiencies cited, the hospital failed to be in compliance with the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights.

The facility failed to meet the following standards under the Condition of Patient Rights:

Reference Tag A 0123 Notice of Grievance Decision:
The facility failed to create a procedure to handle patient complaints and grievances in a manner that was consistent with established regulations.

Reference Tag A 0131 Informed Consent:
The facility failed to ensure that each patient was afforded the right to provide informed consent for treatment.

Reference Tag A 0132 Advanced Directives:
The facility failed to ensure that each patient was afforded the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives.

Reference Tag A 0144 Care in a Safe Setting:
The facility failed to maintain a safe environment to protect the health and safety of patients.

Reference Tag A 0168 Restraint or Seclusion:
The facility failed to ensure that restraints were used only with the order of a physician or other licensed independent practitioner.

Based on facility policy reviews, document reviews and staff interviews, the facility failed to create a procedure to handle patient complaints and grievances in a manner that was consistent with established regulations.
This failure created the potential for patient complaints and grievances to be unaddressed and the potential for system-wide quality issues to be unaddressed, as the facility would be unable to track and trend complaints and grievances.

FINDINGS:

1. The facility failed to properly document and track actions taken to address patient complaints.

a) On 12/10/12 at 3:00 p.m., an interview was conducted with the facility's Patient Advocate. The Patient Advocate provided the surveyors with his/her patient complaint log, containing all the complaints s/he had received from patients, either during in-person interviews, through hand-written letters, or through patient surveys, since November of 2012. S/he stated s/he had just started the position in November 2012 and was unaware of a facility complaint/grievance log maintained before that time. The Patient Advocate's log contained hand-written accounts of patient complaints, with little to no documentation of follow-up regarding the complaint. The surveyors requested to view follow-up on certain complaints and provided a list of those complaints to the Patient Advocate.

b) On 12/12/12 at 9:00 a.m., an interview was conducted with the facility's Patient Advocate regarding the follow-up of patient complaints. The Patient Advocate provided the surveyors with a list of follow-ups for the complaints that s/he stated s/he had compiled from email exchanges between him/her and the department managers. When asked if there was a formal procedure for documentation of complaint resolution or escalation of a complaint to a grievance s/he stated there was no procedure and no formal documentation. The Patient Advocate was then asked if there was a formal system or program to track and trend complaint and/or grievance data, and the Patient Advocate stated there was not a formal system and/or program.

c) On 12/12/12 at 10:30 a.m., the facility's policy entitled "Patient Complaints/Comments or Grievances" was reviewed with the facility's Chief Clinical Officer. The policy stated "Any patterns of complaints will be addressed with the department involved or through Leadership/Department Managers meetings". The facility's Chief Clinical Officer verified this was the facility's current grievance policy and stated there was only one grievance for the year and no documentation of any other grievances.

d) On 12/12/12 at 2:00 p.m., an interview was conducted with the Medical Surgical Nurse Manager. The Medical Surgical Nurse Manager was asked to describe his/her documentation regarding follow-up for patient complaints. S/he stated that s/he did not keep any documentation regarding follow-up with patients or staff regarding patient's complaints. The Medical Surgical Nurse Manager was then asked to describe the process for escalating a complaint to a grievance. The Medical Surgical Nurse Manager stated s/he would inform the facility's Chief Clinical Officer, but there would be no written documentation of this process. The Medical Surgical Nurse Manager was asked if s/he had escalated any complaints to grievances in the past year, and stated that s/he had escalated "some", but could not recall specifics about those complaints. The Medical Surgical Nurse Manager also stated that the facility's House Supervisor would handle complaints on the weekend, when the Medical Surgical Nurse Manager was not available. The Medical Surgical Nurse Manager was asked how communication was maintained between him/herself and the House Supervisor. S/he stated there was no communication log to document interactions or relay information regarding unresolved complaints and/or grievances.

e) On 12/12/12 at 12:00 p.m., the facility's policy entitled "Disclosure on Patient Rights and Responsibilities" was reviewed. The policy stated "All patients seeking care or treatment in our facility have the right to: T. Receive written notice from the hosptial when a grievance is filed, that contains the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance and the results of the grievance process, and the date of completion". The facility's Chief Clinical Officer verified this was the current policy.

Based on medical record review and staff interview the facility failed to ensure that each patient was afforded the right to provide informed consent for treatment. This failure resulted in the potential violation of each patient's right to make informed decisions in regards to their care and for the patient's to not be informed of their rights upon admission.

Findings:

1. The facility failed to obtain informed consent (or document efforts to obtain such consent) from 3 (Sample patients #7, 11, and 17) of 20 patients reviewed.

a. A review of Sample Patient # 7's medical record revealed that the patient was admitted to the facility on 12/02/12. The patient's record did not contain a consent for admission to the hospital. The patient was transferred to another facility on 12/04/12. The record did not contain documentation of any efforts to obtain consent from the patient or a legal representative, nor did the record contain documentation of why consent could not be obtained.

b. A review of Sample Patient #11's medical record revealed that the patient was admitted to the facility on 10/15/12. The patient's record did not contain a consent for admission to the hospital. The patient was discharged home on 10/22/12. The record did not contain documentation of any efforts to obtain consent from the patient or a legal representative, nor did the record contain documentation of why consent could not be obtained.

c. A review of Sample Patient #17's medical record revealed that the patient was admitted to the facility on 11/20/12. The patient's record did not contain a consent for admission to the hospital. The patient was transferred to another facility on 11/23/12. The record did not contain documentation of any efforts to obtain consent from the patient or a legal representative, nor did the record contain documentation of why consent could not be obtained.

d. An interview with the facility's Director of Medical Records conducted on 12/12/12 at 3:56 p.m. confirmed that Sample Patient #11's medical record did not contain a consent for admission.

e. An interview with the facility's Chief Clinical Officer conducted on 12/12/12 at 4:28 p.m. confirmed that Sample Patient #17's medical record did not contain a consent for admission.

Based on medical record review and staff interview the facility failed to ensure that each patient was afforded the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives. This failure resulted in the potential violation of each patient's right to be educated about their right to formulate advance directives and right to have the hospital be informed of such directives.

Findings:

1. The facility failed to document the education of patients regarding their rights to formulate advance directives (or document if the patient had such directives) in 5 (Sample patients #7, 11, 13, 15, and 16) of 20 patients reviewed.

a. A review of 20 sample records was conducted on 12/12/12. The review revealed that Sample Patients' #7, 11, 13, 15, and 16 medical records did not contain a form that the facility utilized to document the education and inquiry of each patient that presented to the hospital in regards to advance directives.

b. An interview was conducted with the facility's Chief Clinical Officer on 12/12/12 at 2:53 p.m. S/he stated that the facility's staff had not been consistent with providing patients with the "blue form" (which was used to document the education of patients on their right to formulate advance directives) since the facility had switched to the computerized documentation system in October.

c. An interview was conducted with the facility's Director of Medical Records on 12/12/12 at 3:56 p.m. S/he stated that the facility used to have the form for advance directives on a blue sheet of paper. S/he stated that since the facility had gone to a computerized documentation system, the form was changed to a white sheet of paper and were occasionally missing the form.

Based on facility tours and staff interviews, the facility failed to maintain a safe environment to protect the health and safety of patients.
This failure contributed to the potential use of expired supplies during patient procedures.

FINDINGS:

1. The facility had expired medical supplies located throughout the patient care areas and the procedure areas.

a) On 12/11/12 at 9:30 a.m., a tour of the facility's surgical area was conducted with the facility's OR Nurse Manager. The surgical area's storage room contained 1 bottle of hand sanitizer with an expiration date of 01/11 and 1 opened bottle of 1% Lidocaine with no hand-written opened date or expiration date. The post-anesthesia care area's emergency cart had defibrillator pads that had a manufacturer's expiration date of 05/2012. The OR Nurse Manager verified these findings and immediately removed the items.

b) On the same tour, the OR's fluid warmer was viewed. The fluid warmer contained 3 bags of IV solution with no dates written as to indicate when the IV solutions were placed in the warmer or when the IV solutions should be removed. The OR Nurse Manager was unable to identify when the IV solutions had been placed in the warmer. When asked how long the IV fluids should be stored in the warmer, the OR Nurse Manager stated s/he was unsure, but believed it was 14 days.

c) On the same tour, the OR's Pre-Operative/Post Anesthesia Care Unit storage area was viewed. The room contained 4 individual iodine scrub brushes resting on shelves and 1 large box of iodoine scrub brushes, all with an expiration date of 11/12. The OR Nurse Manager verified the expiration dates.

d) On 12/11/12 at 10:30 a.m., a tour of the facility's emergency room was conducted with the facility's Chief Clinical Officer (CCO) and the ER Nurse Manager. In the ER trauma bay, several drawers were inspected and contained 1 half empty bottle of Betadine with no documented expiration date or opened date, 1 blood gas syringe with a manufacturer's expiration date of 11/12, 1- 22 gauge IV catheter with a manufacturer's expiration date of 04/09, and 1 bottle of opened Xylocaine with a hand written expiration date of 11/16. Within the trauma bay there were two xeroform petroleum dressings that had manufacturer's expiration dates of 01/2010 and 02/2010. Additionally, there were iodine scrub brushes with manufacturer's expiration date of 11/2012. The emergency cart contained one 16 gauge intravenous catheter with a manufacturer's expiration date of 12/2009 and two 16 gauge intravenous catheters with manufacturer's expiration dates of 10/2010. The facility's ER Nurse Manager verified the expiration dates and immediately discarded the items.

e) During the same tour, the ER storage room was inspected and contained 2 full boxes of 20 gauge IV catheters with a manufacturer's expiration date of 09/12. The ER manager verified the expiration dates and immediately discarded the items. Within the storage room were two multi-dose vials of lidocaine with handwritten expiration dates of 11/25 and 11/28. The ER manager verified the expiration dates and immediately discarded the items.


f) During the same tour, the ER eye cart in the storage room was inspected and contained 2 eye patches, each with a manufacturer's expiration date of 10/09, and 1 opened, half empty tube of antibiotic ointment with no hand-written opened or expiration date. The ER manager verified these findings and immediately discarded the items.


g) During the same tour, the ER's fluid warmer was viewed. The fluid warmer contained 6 bags of normal saline solution. Of the 6 bags, handwritten dates were written on the outside of each bag. One of the bags of IV fluid had a handwritten date of 10/10/12 on the package, one bag of IV fluid had a handwritten date of 12/8 on the package, one bag of IV fluid had a handwritten date of 12/9 on the package, one bag of IV fluid had a handwritten date of 12/10 on the package, and two bags of IV fluid had handwritten dates of 12/24 on the packages. The ER manager was asked to explain the meaning of the hand-written dates on the packaging. The ER manager stated s/he was unsure if the hand-written date represented the expiration date or the day the IV fluid was placed in the fluid warmer. The fluid warmer also contained three bags of Mannitol solution that had no handwritten dates written on the packaging. When the ER manager was asked how long the Mannitol solution was stored in the fluid warmer, s/he stated s/he was unsure.

h) On 12/11/12 at 1:30 p.m. a tour of the ICU was conducted with the facility's Chief Clinical Officer and the ICU Charge Nurse. The ICU's glucometer kit was viewed and contained 2 vials of glucometer test solutions with a hand-written date on each vial of 03/12. The ICU charge nurse verified that the test solutions were expired and immediately removed the items from the patient care area.

i) On 12/12/12 at 1:00 p.m., the facility's policy entitled "Storage of Medication" was reviewed. The policy stated "G. Medication that is beyond the manufacturer's expiration date will not be used. In accordance with USP recommendation, multi-dose vials will expire 28 days after opening. H. Pharmacy personnel will perform monthly unit inspections for proper drug storage and removal of outdated medications." The facility's Chief Clinical Officer verified this was the current policy.

j) On 12/12/12 at 3:00 p.m., an interview was conducted with the facility's pharmacist and the facility's Chief Clinical Officer (CCO). The pharmacist stated that it was policy to date IV fluids with an expiration date and to remove the IV fluids from the fluid warmer after 30 days. The pharmacist further stated that it was the responsibility of the nursing staff to date and remove IV fluids in a timely fashion. The pharmacist and the facility's CCO attempted to locate a policy stating this, but were unable to locate such a policy.

Based on medical record review and staff interview the facility failed to ensure that restraints were used only with the order of a physician or other licensed independent practitioner. This failure resulted in the restraint of a patient without the medical direction that was required.

Findings:

1. Sample patient #7 was restrained without an order that directed their use.

a. A review of sample patient #7's medical record was conducted on 12/12/12. The patient was restrained while s/he was on a mechanical ventilator from 12/02/12 through 12/03/12. The record did not have a physician's order for the use of the restraints.

b. An interview conducted with the facility's Chief Clinical Officer on 12/12/12 at 2:53 p.m. confirmed that the paper record of the patient did not contain a physician's order for the patient's restraint episode.

c. An interview conducted with the facility's Risk Manager on 12/12/12 at 3:48 p.m. confirmed that the paper record of the patient did not contain a physician's order for the patient's restraint episode.

Based on facilty observations, policy reviews and staff interviews, the facility failed to ensure that all drugs and biologicals were prepared and administered in accordance with Federal and State laws.
This failure contributed to the potential for administering the wrong and/or expired medication to the wrong patient.

FINDINGS:

1. The facility failed to properly label and store medications.

a) On 12/11/12 at 9:30 a.m., a tour of the facility's surgical area was conducted with the facility's OR Nurse Manager. During the tour, the facility's endoscopy suite was observed. The lower drawer of the endoscopy suite's anesthesia cart was unlocked and contained three 20 milliliter syringes, each filled to the 20 milliliter line with a white substance. None of the three 20 milliliter syringes were labeled in any fashion to identify what the substance was, when it had been placed in the 20 milliliter syringes, or to whom the substance was to be administered.

b) During the same tour, an interview was conducted with the Cerfitied Registered Nurse Anesthetist (CRNA) on duty. The CRNA stated that the 20 milliliter syringes each contained 20 milliliters of a medication called Propofol and that s/he had drawn the Propofol into the 20 milliliter syringes at 8:00 a.m. that morning. The CRNA stated s/he planned to administer these 20 millilliter syringes of Propofol to patients undergoing procedures that morning. The CRNA stated that s/he should have labeled the 20 milliliter syringes to identify what they contained.

c) On 12/12/12 at 12:15 p.m., the facility's policy entitled "Administration and Care of Medications" was reviewed. The policy stated to "i. Read the label three times (before removing from unit package, before opening, before giving to the patient)" and "ii. Never use medicine from unlabeled containers". The facility's Chief Clinical Officer verified this was the current policy.

Based on the manner and degree of deficiencies cited, the hospital failed to be in compliance with the Condition of Participation of Medical Record Services. The hospital failed to have a medical record service that had administrative responsibility for medical records. The hospital failed to ensure that a complete medical record was maintained for every individual evaluated or treated in the hospital.

The facility failed to meet the following standards under the Condition of Medical Record Services:

Reference Tag A 0442 Security of Medical Records:
The facility failed to ensure medical records were protected from unauthorized access and/or use.

Reference Tag A 0466 Content of Medical Record - Informed Consent:
The facility failed to ensure that each medical record contained documentation that reflected that the patient was afforded the right to provide informed consent for treatment.

Reference Tag A 0468 Content of Medical Record - Discharge Summary:
The facility failed to ensure that each record contained a discharge summary as required in regulation.

Based on facility tours and staff interviews, the facility failed to ensure medical records were protected from unauthorized access and/or use.
This failure contributed to the potential for unauthorized personnel to gain access to protected patient health information.
FINDINGS:

1. The facility had unsecured medical records, which were easily accessible for unauthorized use, in public areas of inpatient units.

a) On 12/11/12 at 1:30 p.m., a tour of the facility's medical surgical unit was conducted with the facility's Chief Clinical Officer (CCO) and Medical Surgical Nurse Manager. During the tour, patient medical records were visualized in open racks at individual desks that were utilized by the nursing staff. During the tour, the desks and the patient medical records were often left unattended.

b) During the same tour, an interview was conducted with the Medical-Surgical Nurse Manager. S/he stated that the patient's medical records were always left at the individual nurse desks and that the nurses were often not sitting at the individual desks, thereby leaving the records unattended. S/he opened the patient medical records to display the unsecured medical record's content to the surveyors. The unsecured patient medical records contained personal demographic and insurance information, as well as information regarding the patient's medical condition.

c) On 12/12/12 at 12:30 p.m., the facility's policy entitled "Medical Records-Health Information Systems Department- Scope of Services" was reviewed. The policy stated "The scope of services also encompasses efforts made to provide: Demonstrate balance of proper levels of security versus ease of access". The facility's Chief Clinical Officer verified this was the current policy.

Based on medical record review and staff interview the facility failed to ensure that each medical record contained documentation that reflected that the patient was afforded the right to provide informed consent for treatment. This failure resulted in the potential violation of each patient's right to make informed decisions in regards to their care and for the patient's to not be informed of their rights upon admission.

Findings:

1. The facility failed to obtain informed consent (or document efforts to obtain such consent) from 3 (Sample patients #7, 11, and 17) of 20 patients reviewed.

a. A review of Sample Patient # 7's medical record revealed that the patient was admitted to the facility on 12/02/12. The patient's record did not contain a consent for admission to the hospital. The patient was transferred to another facility on 12/04/12. The record did not contain documentation of any efforts to obtain consent from the patient or a legal representative, nor did the record contain documentation of why consent could not be obtained.

b. A review of Sample Patient #11's medical record revealed that the patient was admitted to the facility on 10/15/12. The patient's record did not contain a consent for admission to the hospital. The patient was discharged home on 10/22/12. The record did not contain documentation of any efforts to obtain consent from the patient or a legal representative, nor did the record contain documentation of why consent could not be obtained.

c. A review of Sample Patient #17's medical record revealed that the patient was admitted to the facility on 11/20/12. The patient's record did not contain a consent for admission to the hospital. The patient was transferred to another facility on 11/23/12. The record did not contain documentation of any efforts to obtain consent from the patient or a legal representative, nor did the record contain documentation of why consent could not be obtained.

d. An interview with the facility's Director of Medical Records conducted on 12/12/12 at 3:56 p.m. confirmed that Sample Patient #11's medical record did not contain a consent for admission.

e. An interview with the facility's Chief Clinical Officer conducted on 12/12/12 at 4:28 p.m. confirmed that Sample Patient #17's medical record did not contain a consent for admission.

Based on medical record review and staff interview the facility failed to ensure that each record contained a discharge summary as required in regulation. This failure had the potential to create an incomplete record for patient's further post-hospitalization care.

Findings:

1. Two (Sample patients #12 and 20) of 20 records reviewed did not have a discharge summary documented in their medical record greater than 30 days after the patient's discharge.

a. A review of Sample Patient #12's record was conducted on 12/12/12. The patient was admitted to the hospital on 10/30/12 and was discharged 11/08/12. The record did not contain a discharge summary.

b. A review of Sample Patient #20's record was conducted on 12/12/12. The patient was admitted to the hospital on 10/29/12 and was discharged 11/05/12. The record did not contain a discharge summary.

c. An interview conducted with the facility's Director of Medical Records on 12/12/12 at 3:55 p.m. confirmed that the record did not contain a discharge summary. S/he stated that the facility had requested that the physician complete one, but had not provided one to date.

d. An interview conducted with the facility's Chief Clinical Officer on 12/12/12 at 4:33 p.m. confirmed that the record did not contain a discharge summary.

Based on policy reviews and staff interviews, the facility failed to have provisions to automatically stop the administration of drugs and biologicals after a reasonable amount of time, as pre-determined by the medical staff.

This failure contributed to the potential for medications to be administered beyond the time when the medication order should be re-evaluated by the physician.

FINDINGS:
1. The facility failed to implement automatic stop-orders for medications.

a) A review of the facility's policy and procedures, revealed that the facility did not have a policy to require the cessation of administration of medications and/or biologicals after a time that had been pre-determined by medical staff.

b) On 12/11/12 at 10:00 a.m., an interview was conducted with the facility's pharmacist. The facility's pharmacist stated that the facility did not have a policy that addressed the initiation of automatic stop order for medications. S/he stated that the closest thing the facility had to a stop order was in regards to the administration of Toradol, which would be stopped after 8 administered doses.

An unannounced onsite recertification survey was conducted (see event ID #3ET221) December 17 through the 19th, 2012 by a Life Safety Code Inspector and included an inspection for compliance with the fire safety requirements of NFPA (National Fire Protection Association) 101, Life Safety Code, (2000 edition) and NFPA 99 Health Care Facilities (1999 Edition). The facility failed to comply with the regulations set forth. Deficiencies were cited under Life Safety Code tags K0018, K0038, K0048, K0050, K0052, K0056, K0062, K0076, K0078, K0106, K0144, K0147 and K0154.
See survey event ID #3ET221 for full details of the cited deficiencies.

Based on facility tours and staff interviews, the facility failed to provide an environment that prevented the potential transmission of infectious and communicable diseases.

This failure contributed to the potential exposure of staff and patients to infectious and communicable diseases.

FINDINGS:

1. The facility failed to clean surgical instruments per manufacturer's guidelines.

a) On 12/11/12 at 9:30 a.m., a tour of the facility's surgical area was conducted with the facility's OR Charge Nurse. During the tour, the facility's surgical instrument cleaning area was viewed and an interview was conducted with the Surgical Cleaning OR Tech. The Surgical Cleaning OR Tech was asked to explain the cleaning process for the surgical instruments. The Surgical Cleaning OR Tech stated s/he cleaned the surgical instruments in a cleaning solution that s/he mixed prior to putting them through the washer. When asked how the cleaning solution was mixed, s/he stated that s/he mixed the solution in a bucket that s/he estimated was approximately a five gallon bucket and then administered four to five pumps of cleaning solution. S/he stated there was no marking on the bucket to indicate the level of water in the bucket or how many gallons it could hold. S/he then read the manufacturer's instructions on the cleaning solution to the surveyors and was unable to verbalize how s/he was able comply with the manufacturer's instructions without knowing the exact amount of water contained in the bucket.

Based on facility tours and staff interviews, the facility failed to ensure medical records were protected from unauthorized access and/or use.
This failure contributed to the potential for unauthorized personnel to gain access to protected patient health information.
FINDINGS:

1. The facility had unsecured medical records, which were easily accessible for unauthorized use, in public areas of inpatient units.

a) On 12/11/12 at 1:30 p.m., a tour of the facility's medical surgical unit was conducted with the facility's Chief Clinical Officer (CCO) and Medical Surgical Nurse Manager. During the tour, patient medical records were visualized in open racks at individual desks that were utilized by the nursing staff. During the tour, the desks and the patient medical records were often left unattended.

b) During the same tour, an interview was conducted with the Medical-Surgical Nurse Manager. S/he stated that the patient's medical records were always left at the individual nurse desks and that the nurses were often not sitting at the individual desks, thereby leaving the records unattended. S/he opened the patient medical records to display the unsecured medical record's content to the surveyors. The unsecured patient medical records contained personal demographic and insurance information, as well as information regarding the patient's medical condition.

c) On 12/12/12 at 12:30 p.m., the facility's policy entitled "Medical Records-Health Information Systems Department- Scope of Services" was reviewed. The policy stated "The scope of services also encompasses efforts made to provide: Demonstrate balance of proper levels of security versus ease of access". The facility's Chief Clinical Officer verified this was the current policy.