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Based on observation, interviews, and document review, the facility failed to ensure patient electronic medical records and patient identifiers were safeguarded from unauthorized use.

This failure created the potential for unauthorized individuals to gain access to patient electronic medical records and patient identifiers.

FINDINGS:

POLICY

According to Centura Health Data Security Policy (1.2), the facility will practice information security to protect the confidentiality, integrity and availability of sensitive information including personal health information, and sensitive financial, business, insurance, personnel and technical information.

According to Patient Rights and Responsibilities, each patient should expect confidentiality of all communication and medical records related to their care.

1. The facility staff did not close the computer screen on patient electronic medical records in the Emergency Department (ED) to prevent unauthorized use.

a) On 10/18/16 at 3:13 p.m. a tour of the ED was conducted with Chief Nursing Officer (CNO) #6. At 3:17 p.m., it was noted a computer on wheels was unattended in the hallway. Patient Sample A's electronic medical record was open on the computer screen and was visible to the surveyor. Information containing demographics with patient identifiers was able to be seen on the computer screen.

Several staff members, including two nurses (Registered Nurses #13 and #14), one physician (Physician #12), and CNO #6 walked past the computer without closing the patient's electronic medical record. At 3:24 p.m., an ED receptionist came from the nurse's station and closed the computer screen. During the observation CNO #6 stated the computer should not have patient information visible if there wasn't any staff at the computer. S/he stated the computer was supposed to automatically log off after a certain time of no activity.

b) On 10/18/16 at 3:57 p.m., an interview was conducted with CNO #6, ED Director #17 and Nurse Manager #22 who stated staff were supposed to close down the computer screen when they left the computer to protect patient confidentiality. The expectation was patient information wasn't visible for the public to see.

c) On 10/20/16 at 2:22 p.m., an interview was conducted with CNO #6 who stated s/he had expected staff to be careful with patient confidentiality. CNO #6 stated usually computers were facing backwards in the ED so they weren't available for other individuals to view. S/he further stated, it wasn't okay to leave the patient's medical record open even in emergency situations.

Based on observations, interviews, and document review the facility failed to supply emergency medications to a code blue cart used for the resuscitation of patients. Further, the facility failed to follow a standard process to ensure code blue carts were maintained.

This failure created the potential for a delay of care to patients in need of emergent resuscitation.

FINDINGS:

POLICY

According to Emergency Medication Storage and Security, medications are in adequate and proper supply in the pharmacy and acute care patient areas. Emergency medications are inspected, secured, controlled and replaced by a pharmacist or his designee. Emergency medication are available in unit-dose, age specific, and ready to administer forms whenever possible. The Director of Pharmacy or his designee shall work with the appropriate individuals to ensure that emergency drug carts and emergency storage areas are checked, and replaced as soon as possible after their use. Emergency medications are located in high risk areas of the hospital. If the contents of the container are used or the seal is broken, pharmacy is notified as soon as possible to replace the medications. Pharmacy will check areas as needed to assure replacement of medications. The emergency medications are routinely checked monthly by the pharmacy department during the floorstock inspection process.

According to Code Blue Cart Maintenance - 144th, the pharmacologic contents of the Code Blue (CB) cart will be monitored for expiration dates and replaced by Pharmacy. There is to be a CB cart in the unit at all times. Prior to removing a used cart, a new cart should be obtained from Pharmacy. A change in the pharmacy lock number from one daily check to the next means the cart has been opened; there should be documentation on the CB checklist that a full check was performed by Pharmacy and the department after opening the cart. Intubation bag is to be left on the code blue cart along with the blue bin containing the defibrillator pads and accessories. An RN or designee is to drop the used/open medication tray to the Pharmacy to be restocked then proceed on to supply chain where the used cart and intubation bag will be dropped off for restocking. Pharmacy associates will be responsible for restocking used or expired medications and replacing medication trays. When a new CB cart is requested from the pharmacy, the cart should be registered in the log book on the page corresponding to the CB pharmacy tray number. The department, where the cart will be located, is to be specified.

1. The facility failed to establish a standard process to exchange used CB carts and ensure all CB carts were equipped with emergency medications necessary for patient resuscitation.

a) A tour of the facility's radiology department on 10/17/16 at 9:51 a.m. revealed a locked CB cart with a top drawer labeled medications. The upper right corner of the CB cart contained a medication expiration sticker labeled 11/16. When the medication drawer of the CB cart was opened, it was revealed the CB cart did not contain emergency medications

b) Review of the Code Blue Cart and Supplies Checklist for the Radiology CB Cart revealed a new lock number was documented on 08/01/16. There was no documentation on the Code Blue Cart and Supplies Checklist showing a full check was performed by Pharmacy or the Radiology Department. This was in contrast to policy.

c) On 10/17/16 at 9:51 a.m., an interview was conducted with the Radiology Charge Registered Nurse (RN) #1 who stated the Intervention Radiology (IR) RN was in charge of checking the CB cart daily. RN #1 stated Pharmacy staff was in charge of ensuring emergency medications were present in the CB cart.

d) During an interview with RN #2 on 10/17/16 at 9:58 a.m., s/he stated emergency drugs were supposed to be present in the top drawer of the CB cart. Pharmacy staff was supposed to check the medications monthly for expired medications. RN #2 stated as long as there was a sticker on the top right corner of the cart indicating the expiration date, s/he assumed emergency medications were present. S/he stated there was not a reason to open the CB cart to perform the checks. RN #2 stated s/he assumed s/he changed the cart at the end of 08/16, but was unable to find documentation a full check was done at that time.

e) During an interview on 10/17/16 at 10:23 a.m., Pharmacy Technician #3. stated the pharmacy used to keep track of what locks were on the CB carts of each department; however, this changed due to staff's non-compliance. S/he stated the log book was not updated when CB carts were exchanged. This was in contrast to facility policy.

f) During an interview on 10/17/16 at 10:30 a.m., Pharmacy Manager #4 stated it was important to have emergency medication readily available on the CB carts in case of a cardiac arrest or any other like situation. S/he further stated the sticker on the radiology CB cart was probably on there from a previous medication tray. Manager #4 stated pharmacy should have looked in the medication drawer of the CB cart before the cart left the pharmacy to ensure emergency medications were present. S/he stated the pharmacy did not keep logs of the medication trays stocked in CB carts. This was in contrast to facility policy. Manager #4 further stated there was not a designated staff member assigned to perform checks on the CB carts.

g) During an interview on 10/20/16 at 11:01 a.m., the facility's Regional Director of Pharmacy (Director #5) stated s/he expected emergency medications to be available to treat patients. S/he further stated the CB cart should be stocked with the emergency medications. Director #5 stated the facility should introduce a new process which ensured the CB cart checks were completed by an assigned employee.

h) During an interview on 10/20/16 at 2:22 p.m., Chief Nursing Officer (CNO) #6 stated not having emergency medications available on the CB carts would cause a delay in care to patients during emergency situations. CNO #6 further stated all carts need to have the emergency medications available.

Based on observation, interviews, and document review, the facility failed to ensure outdated medications were removed from stock according to the manufacturer's expiration date.

This failure created the potential for patients to receive expired medications.

FINDINGS:

POLICY:

According to Medication Security and Storage, all expired/outdated medications are to be removed from stock in the pharmacy.

According to Code Blue Cart Maintenance-84th Avenue (SANHC), all contents of the intubation bag and Code Blue (CB) cart will be monitored daily by Nursing/Respiratory staff for expiration dates. If any expired supplies or expired pharmalogical agents are found, the cart will be swapped out for a new cart.

According to Code Blue Cart Maintenance (SANHC) the cart will be examined for expiration of medications and supplies daily. Additionally, notify pharmacy when medications are due to expire by the end of that month. Pharmacy associates will be responsible for restocking used or expired medications and replacing medication trays.

1. The facility failed to ensure outdated intravenous fluids (IVF) were removed from 2 of 2 medication rooms on 4 South.

a) On 10/17/16 at 11:11 a.m., a tour of 4 South was conducted with Registered Nurse (RN) #18 and Chief Nursing Officer (CNO) #6. During the tour 1 bag of Hospira 500 ml D5NS was found in Medication Room #1, with an expiration date of 09/01/16 and 9 bags of Hospira 1 L D5.25NS were found in Medication Room #2, with an expiration date of 08/16. CNO #6 stated the central supply department was responsible for stocking and monitoring outdated supplies. S/he further stated the expired IV fluids shouldn't be used.

b) An interview was conducted with Supply Chain Employee #21 on 10/18/16 at 10:19 a.m., who stated all staff members were to keep notice of expiration dates in medication rooms and in CB carts. S/he stated any expired items were to be replaced immediately. Supply Chain #21 stated, the biggest worry was when IV fluids expired as they would probably lose their effectiveness if expired.

c) On 10/20/16 at 9:28 a.m., an interview took place with Pharmacy Manager #4 who stated when medications were outdated or expired, they no longer considered the medications as stable or sterile. S/he stated it would be wrong to use expired medications as they would not have its full effectiveness.

2. The facility failed to ensure outdated IV medications were removed from Code Blue (CB) carts.

a) On 10/17/16 at 10:50 a.m., a tour of the Peri-operative unit was conducted with Manager #19 and Director #20. The tour revealed a CB cart with 2 injection vials of Calcium Chloride (1gram/100mg/ml) with an expiration date of Oct 1, 2016. Manager #19 stated the pharmacy sticker placed on the outside of the CB cart indicated the date of which medications were due to expire; the sticker indicated the expiration date of 10/16. A review of the Core Cart Supply list revealed the Calcium Chloride 1gm/10 ml had expired on 10/1/16.

b) On 10/18/16 at 7:30 a.m., a tour of Room 3 of the 84th Emergency Department (ED) was conducted with RN #8 which revealed 2 expired injection vials of Calcium Chloride with printed expiration dates, Oct. 1, 2016 in the CB cart. RN #8 stated, the white sticker on the outside of the cart, dated 11/30/16, indicated a pharmacy technician had checked medications for expiration dates and the they weren't to expire until then. S/he stated nurses performed daily checks of the CB cart and verified medications were not outdated by looking at the date on the white sticker.

c) An interview was conducted with Clinical Director #9 on 10/18/16 at 10:30 a.m., who stated, expired Emergency Medications should be discarded as they are not as effective if used after the printed expiration date.

d) On 10/20/16 at 11:01 a.m., a telephone interview was conducted with the Regional Director of Pharmacy (Pharmacist #5) who stated medications were expected to be available and ready to use for patient treatment and not be expired. Pharmacist #5 stated if access to emergency medications was not available, it would cause a delay in patient care.

e) On 10/20/16 at 9:09 a.m., an interview with Pharmacy Technician #24 was conducted. S/he stated s/he relied heavily on the date posted on the sticker on the outside of the CB cart to determine when medications expired rather than the contents for individual expiration dates. Pharmacy Technician #24 stated it was an oversight when s/he read the exterior sticker, dated 10/16, and believed the medications didn't expire until 10/31/16 rather than 10/01/16. Pharmacy Technician #24 stated the outdated medications should have been removed.

Based on the onsite recertification survey, completed November 8 through November 10, 2016, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code tags K131, K162, K211, K222, K321, K324, K344, K351, K353, and K363. See survey event ID #73O821 for full details of the cited deficiencies.

Based on observations, interviews, and document review, the facility failed to ensure a clean and sanitary patient care environment. Further, the facility failed to ensure staff discarded outdated blood culture bottles which could be used in identifying an infection in both adult and pediatric patients.

This failure created the potential for transmission of bacteria, cross contamination, and delayed or missed identification of infections creating negative patient outcomes.

FINDINGS:

POLICY

According to the policy Hand Hygiene, the primary purpose of routine hand hygiene is the removal of dirt and transient contaminants acquired while providing patient care or by contact with environmental sources. Hand hygiene is the single most important process for interrupting the transmission of organisms from person-to-person, and preventing healthcare-acquired infections. The World Health Organization outlines "Five Moments for Hand Hygiene" as before touching a patient, before clean or aseptic procedures, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. [Hand Hygiene should be done] before performing invasive procedures such as starting an IV or manipulation of indwelling devices, before handling medication and clean equipment such as patient charts, computer monitors, keyboards and mouse, IV pumps. When moving hands from a contaminated body site to a clean site during patient care. Before putting on gloves and after removing your gloves.

According to Infection Prevention and Control Program, wear gloves when there is a potential for the hands to have contact with blood, body fluids, mucous membranes and/or non-intact skin of all patients. Wear gloves when performing venipuncture or other vascular access or invasive procedures. Always remove gloves and perform hand hygiene before leaving the work area.

REFERENCE

According to the facility's Nursing Skills Medication Administration: Subcutaneous Injection, the first step in the procedure is to perform hand hygiene and don (put on) gloves.

According to the facility's Medical Staff Regulatory Handbook medical staff should follow safe injection practices to administer medications. Follow these guidelines: Hand hygiene, hand hygiene, hand hygiene. Wear gloves when performing venipuncture or other vascular access procedures or invasive procedures. Hand Hygiene must be performed before and after direct patient contact, after contact with a patient's intact skin, after handling objects or touching surfaces that are near the patient, before donning gloves, after removing gloves. When moving from a contaminated body site to a clean body site during patient care. When entering a patient room and when you leave a patient care room. No exceptions.

According to the World Health Organization (WHO) Guidelines on Hand Hygiene in Healthcare, gloves should be worn when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes or non-intact skin will occur. When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to either another body site (including non-intact skin, mucous membrane or medical device) within the same patient or the environment.

According to the BacT/ALERT Culture Bottle manufacturer's recommendations, do not inoculate (introduce cells into) the culture bottles beyond the expiration date indicated.

1. The facility failed to perform hand hygiene or wear personal protective equipment while performing patient care, placing patients and staff at risk for infections.

a) On 10/18/16 at 3:13 p.m. Registered Nurse (RN) #13 was observed obtaining intravenous (IV) access for Patient B. RN #13 performed hand hygiene prior to donning gloves. RN #13 then proceeded to assemble the IV supplies and removed Patient B's clothes for access. With the same gloved hands, RN #13 cleansed the insertion site and obtained IV access. RN #13 did not perform hand hygiene directly before an aseptic task.

After IV access was obtained, RN #13 gathered trash and placed it into garbage. RN #13 then assessed Patient B with the contaminated gloved hands. RN #13 did not change gloves and perform hand hygiene after body fluid exposure and before patient contact as outlined in facility policy.

b) On 10/18/16 at 3:38 p.m. RN #14 was observed administering an IV medication to Patient A in the Emergency Department (ED) room 4. RN #14 performed hand hygiene and put on gloves. S/he then placed a blood pressure cuff on to Patient A's arm before reaching into his/her pocket for additional supplies to administer the IV medication. RN #14 failed to perform hand hygiene and glove change and s/he touched the supplies and before administering the patient's IV medication.

c) On 10/19/16 at 8:43 a.m. RN #11 was observed administering insulin subcutaneous to Patient C. RN #11 performed hand hygiene prior to entering Patient C's room. RN #11 then used the computer to access the medication orders and scanned the patient's armband for identification. RN #11 proceeded to administer the subcutaneous medication into Patient C's left upper arm. RN #11 did not perform hand hygiene before an aseptic task, further RN #11 injected insulin subcutaneous into Patient C's right upper arm without wearing gloves This was in contrast to facility policy.

d) During an interview on 10/18/16 at 3:57 p.m., the ED Director (Director #17) stated hand hygiene was to be done upon entering and exiting a patient's room and after patient procedures. Director #17 expected the staff to change gloves and perform hand hygiene after touching contaminated supplies. S/he expected the staff to follow the facility's policies. Director #17 stated hand hygiene was important to prevent the spread of germs between patients and staff.

f) During an interview on 10/20/16 at 12:34 p.m. Infection Preventionist (IP) #10 stated his/her expectation was staff followed the WHO guidelines for hand hygiene and the use of personal protective equipment.

g) During an interview on 10/20/16 at 2:22 p.m. Chief Nursing Officer (CNO) #6 stated his/her expectation was staff followed the facility's policy and guidelines regarding hand hygiene and the use of personal protective equipment. CNO #6 further stated when hand hygiene was not followed the patient was at an increased risk for infection. CNO #6 further stated gloves should have been worn by RNs to protect against infection. CNO #6 stated proper glove use was important to protect staff from obtaining and spreading infections.

2. The facility failed to perform hand hygiene during 2 of 2 procedural case tracers.

a) Observations conducted on 10/19/16 revealed the following breaches in hand hygiene and donning of personal protective equipment during Patient #29 scope procedure:

i) At 2:30 p.m. RN #15 was observed documenting on the computer cart when s/he was asked to refill a syringe which was connected to the scope being used on Patient #29 for the procedure. RN #15 took the syringe with the same gloved hands used during documentation on computer cart, refilled the syringe to be used on the scope being used for Patient #29's procedure. RN #15 then returned to charting on the computer cart with the same gloved hands. No glove change or hand hygiene was performed before or after coming into contact with Patient #29's surroundings.

ii) At 2:34 p.m. RN #15 opened a new bottle of medication to be used during Patient #29's procedure with the same gloved hands used during documentation on the computer cart and refilling the used syringe.

iii) At 2:40 p.m. RN #15 grabbed supplies from the main supply cabinet in the procedure room with same gloved hands that were used to refill the syringe that was attached to the scope during the patient's procedure. No hand hygiene was done after being exposed to the patient and main supply cabinet.

During an interview on 10/20/16 at 10:04 a.m. the observations during Patient #29's procedure were reviewed with RN #15. RN #15 stated s/he should have changed gloves and performed hand hygiene after patient contact and before documenting on the computer desk. Additionally, RN #15 stated hand hygiene should have been performed prior to removing supplies from the main cabinet. S/he stated supplies in the main cabinet were used on other patients. RN #15 stated this posed a risk for cross contamination and increased risk of infection to patients.

b) Observations conducted on 10/19/16 revealed the following breaches in hand hygiene during Patient #19's operation:

i) At 9:53 a.m. Anesthesiologist #16 scratched his/her shoulder and removed a stethoscope off his/her neck. S/he then touched the computer, after which s/he drew up IV medication and administered the IV medication to patient with his/her bare hands. No hand hygiene or donning of gloves was completed prior to patient care.

ii) At 9:57 a.m. Anesthesiologist #16 left the patient care area to place an unused medical device in a cart. Upon return to patient care area, Anesthesiologist #16 used his/her bare hands to elevate the patient's head of the bed via remote attached to the patient's bed. S/he then proceeded to draw up an IV medication to be used during the operation into a syringe, label it, and placed the medication on the anesthesia table. Anesthesiologist #16 continued to touch his/her surroundings with his/her bare hands including a chair,the anesthesia machine, and the top of his/her head. After which, Anesthesiologist #16 touched Patient #19's forehead to assess the patient with a piece of equipment. No hand hygiene was performed prior to touching the patient.

iii) At 10:05 a.m., Anesthesiologist #16 used his/her bare hand when touching his/her cell phone then placed hands on his/her own head. S/he then administered IV medication to Patient #19 without donning gloves or performing hand hygiene.

iv) At 10:17 a.m., Anesthesiologist #16 left the patient area, retrieved label stickers from a binder. After labeling a syringe with the retrieved stickers, Anesthesiologist #16 proceeded to touch Patient #19's forehead to assess patient with a piece of equipment. Hand hygiene was not performed before or after s/he touched patient. After assessment of equipment attached to Patient #19, Anesthesiologist #16 returned to his/her computer to document assessment.

v) At 10:28 a.m. Anesthesiologist #16 had bare hands in his/her scrub pockets then proceeded to administer IV medication to Patient #19 without performing hand hygiene or donning gloves. S/he then proceeded to pick up debris located on the floor and discard trash using bare hands, after which s/he documented on computer without performing hand hygiene.

vii) At 10:34 a.m., Anesthesiologist #16 used his/her bare hand to adjust Patient #19's bed with a remote. After touching the equipment, Anesthesiologist #16 donned gloves without performing hand hygiene, then placed gauze into Patient #19's mouth. S/he then removed the gloves and performed H/H. At 10:40 a.m., Anesthesiologist #16 entered information into the same computer which was contaminated earlier at 10:28 a.m. and proceeded to administer IV medication to the patient without performing hand hygiene.

During an interview on 10/19/16 at 2:33 p.m. observations noted during Patient #19's procedure were reviewed with Anesthesiologist #16. S/he stated hand hygiene should have been completed before and after touching the patient. Anesthesiologist #16 further stated hand hygiene should have been done before administering IV medications. S/he stated hand hygiene was important so infections and bacteria were not spread between the staff and patients.

A Medical Staff Handbook containing Anesthesiologist #16's signature served as acknowledgment of his/her training. The Medical Staff Handbook stated outlined moments when hand hygiene should be done.

c) During an interview on 10/20/16 at 12:34 p.m., IP #10 stated his/her expectation was staff followed the WHO guidelines for hand hygiene and the use of personal protective equipment.

3. The facility did not ensure culture bottles were not expired prior to a patient's blood draw.

a) A tour of the facility's offsite location on 10/18/16 at 8:40 a.m. revealed 1 pediatric blood culture bottle with an expiration date 10/10/16, 1 anaerobic blood culture bottle with an expiration date 10/9/16, and 1 aerobic culture bottle with an expiration date 9/02/16 found in a drawer in exam room 3. The same room contained a lab tray on the counter with another pediatric blood culture bottle with an expiration date 10/10/16.

A tour of exam room 2 at 9:15 a.m. the same day revealed 1 pediatric blood culture bottle with an expiration date 10/10/16.

b) During an interview on 10/18/16 at 8:55 a.m. RN #7 stated the blood culture bottles found in the exam rooms could be used on patients. This was in contrast to the manufacture's recommendations. RN #7 further stated s/he did not know if the blood culture bottles were good to use. RN #7 did not believe there was a process to monitor the expiration dates of blood culture bottles.

c) During an interview on 10/18/16 at 9:20 a.m. Charge RN #8 stated the blood culture bottles would get rejected in the lab if the bottles were expired. S/he stated the microbiology lab would notify the RN who drew the blood cultures. The RN would talk to the ordering physician to determine if the patient needed to come back to the facility or follow up with PCP to draw a new set of blood cultures. S/he further stated some patients were discharged or transferred after the blood cultures were drawn and the patients were no longer at the facility. If physician thought the ordered blood culture was needed the patient would have to have another blood draw. Charge RN #7 stated the expired blood culture bottles should be discarded.

d) During an interview on 10/20/16 at 12:34 p.m., IP #10 stated the facility should not have any expired blood culture bottles. IP #10 stated collecting blood cultures in expired bottles would delay the establishment of an infection. S/he further stated identification and management of a patient's infection was very important. IP #10 stated the rejection of blood culture specimens should have been prevented by checking the expiration date on the bottles. Expired blood culture bottles should be discarded.

e) During an interview on 10/20/16 at 2:22 p.m. Chief Nursing Officer (CNO) # 6 stated if an expired blood culture bottle was used, the patient would have to be re-drawn. S/he further stated if antibiotics were started after the first blood draw, the re-draw would not be accurate. CNO #6 stated blood cultures needed to be done timely for treatment to be most effective. S/he stated the expired blood culture bottles should have been discarded.