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Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
Main Hospital Building
K12: Class of Construction did not meet non-combustible standards of a Type II (2,2,2)
K15: The facility did not provide room finishes that had rated wall finishes.
K18: The facility did not provide corridor separation doors that had smoke-tight seals at meeting edges, smoke-tight corridor frames, and positive-latching hardware.
K25: The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations, and rated wall construction.
K29: The facility did not enclose hazardous rooms that had rated doors, taped joints on rated walls and did not enclose hazardous rooms with closer on the doors.
K38: The facility did not provide egress paths at all times, and paths with sufficient headroom.
K 40: The facility did not ensure corridor doors had the required width.
K 47: The facility did not provide an exit sign when the egress path is not readily apparent.
K 48: The facility did not maintain a written evacuation plan that contained all the elements that had staff trained on life safety procedures
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K64: Failed to properly inspect fire extinguishers.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K72: The facility failed to provide exit access corridors that were free from obstructions.
K75: The facility failed to limit trash containers to 32 gallons and not to exceed .5 gallon per square foot of floor area.
K77: The facility did not provide medical gas piping as required by NFPA 99.
K106: The facility failed to provide proper maintenance to a Type I essential electrical system.
K130: The facility failed to provide unoccupied rooms from opening onto stairs or exit passageways and failed to provide a barrier to prevent people from going beyond the level of exit discharge.
K144: The facility did not test the emergency electrical generator in accordance with requirements.
K145: The facility did not provide a Type I essential electrical system that was properly divided.
K147: Electrical system did not meet the minimum regulations for NFPA 70.
K211: The facility did not provide alcohol based hand rub dispensers that were properly installed.
Oregon Clinic: K130 The facility failed to provide a reliable method to get out of the building.
Stoughton Clinic: K130: The facility failed to provide a safe path to a public way.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on review of available maintenance records, observation and interview with facility staff the hospital failed to maintain all patient care equipment in 2 of 9 (Medical Surgical Unit and Geriatric Psychiatric Unit) patient care areas.

Per findings of Surveyor #22198:

On 01/03/11 during the initial tour at 11:50 a.m. during initial tour of the hospital 9 patient care areas were identified; X-ray, Medical Surgical Unit, Intensive Care Unit, Geriatric Psychiatric Unit, Day Surgery, Surgery (including Pre-Operative holding and Post Anesthesia Care), Out Patient Service (examples: Infusion Therapy, Urgent Care Laboratory), Therapy (Physical and Occupational) and Emergency Services.

On 01/03/11 during the initial tour at 11:50 a.m. Surveyor #22198 along with Performance Improvement A identified 2 mechanical lifts for patient use that failed to have preventative maintenance labels.

Medical Surgical Unit
"EZ Lift 400#" and "EZ Lift 600#". Performance Improvement A told Surveyor #22198 that the hospital had Biomedical as the hospital preventative maintenance source.

Surveyor #22198 requested preventative maintenance information for both "EZ Lift 400#" and "EZ Lift 600#" from 01/03/11 at the time of finding, until 01/05/11 at the exit, however the hospital failed to provide supporting documentation to ensure that "EZ Lift 400#" and "EZ Lift 600# had preventative maintenance performed per manufacturers recommendations to ensure the safety of the patient who used it.

Geriatric Psychiatric Unit
On 01/04/10 during a tour of the Geriatric Psychiatric Unit at 10:15 a.m. Surveyor #22198 observed a metal unit identified by the Unit Manager F as a "blanket warmer". A Bio medical label was attached indicating the warmer had been last checked in April 2010 (9 months ago).

A sign taped to the door stated the blanket warmer was not to be set above 120 degrees Fahrenheit (F). No exterior thermometer was found.

Surveyor #22198 open the door to look for an dependent or independent temperature gauge to confirm the internal temperature, none was found. However, the gauge for setting the blanket warmer temperature was on the inside and set at 140 degrees F, 20 degrees above the maximum temperature noted on the sign.

Unit Manager F confirmed that staff had no way to ensure the temperature of the warmed blankets to prevent potential burns from the blanket warmer.

Unit Manager F confirmed Bio-medical engineer was responsible for preventative maintenance.

On 01/04/11 at 10:15 a.m. Surveyor #22198 requested preventative maintenance information , along with any reports or requests sent to Bio medical since April 2010 for maintenance or repair on the blanket warmer. A second request was made at the daily conference 01/04/11 at 5:00 p.m.

The facility failed to provide further documentation.

On 01/04/11 at 10:20 am Surveyor #22198 found from August 2010 to present (01/04/11) there were 22 missing entries on the daily preventative maintenance check completed by unit staff for the emergency crash cart.

Unit Manager F confirmed the missing entries; however was not certain who was responsible to ensure the staff completed the daily preventative maintenance checks for the emergency crash cart.

On 01/05/11 at 7:55a.m. during an interview Vice President (VP) Patient Services B confirmed to Surveyor #22198, it was each Unit Manager's was responsible to ensure their staff performed any required tasks including daily preventative maintenance checks.

On 01/04/11 continuing on with the Geriatric Psychiatric Unit tour, a patient food supply refrigerator was also found with large cracks and holes on the inside. Broken insulation and food product could be observed in the large cracks and holes.

No preventative maintenance label was found. The Unit Manager F confirmed, the unit had not contacted biomedical or submitted a repair or request for removal of the patient food stored in supply refrigerator.

Based on observation, and staff interviews, the facility to install proper ventilation systems. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 2 of the 35 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/3/2011 at 1:45 pm surveyor #12187 observed in the #1 smoke compartment on the 3rd floor in the ICU rooms, 372 & 371, that during a review of facility documents, the facility failed to install a proper ventilation system in the toilet room. The ventilation requirement is that there be 10 air exhausts. This observed situation was not compliant with CFR 482.41(c). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operation), staff B (Environmental Services Manager), staff C (President), and staff D (Lead Maintenence Worker).

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
Main Hospital Building
K12: Class of Construction did not meet non-combustible standards of a Type II (2,2,2)
K15: The facility did not provide room finishes that had rated wall finishes.
K18: The facility did not provide corridor separation doors that had smoke-tight seals at meeting edges, smoke-tight corridor frames, and positive-latching hardware.
K25: The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations, and rated wall construction.
K29: The facility did not enclose hazardous rooms that had rated doors, taped joints on rated walls and did not enclose hazardous rooms with closer on the doors.
K38: The facility did not provide egress paths at all times, and paths with sufficient headroom.
K 40: The facility did not ensure corridor doors had the required width.
K 47: The facility did not provide an exit sign when the egress path is not readily apparent.
K 48: The facility did not maintain a written evacuation plan that contained all the elements that had staff trained on life safety procedures
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K64: Failed to properly inspect fire extinguishers.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K72: The facility failed to provide exit access corridors that were free from obstructions.
K75: The facility failed to limit trash containers to 32 gallons and not to exceed .5 gallon per square foot of floor area.
K77: The facility did not provide medical gas piping as required by NFPA 99.
K106: The facility failed to provide proper maintenance to a Type I essential electrical system.
K130: The facility failed to provide unoccupied rooms from opening onto stairs or exit passageways and failed to provide a barrier to prevent people from going beyond the level of exit discharge.
K144: The facility did not test the emergency electrical generator in accordance with requirements.
K145: The facility did not provide a Type I essential electrical system that was properly divided.
K147: Electrical system did not meet the minimum regulations for NFPA 70.
K211: The facility did not provide alcohol based hand rub dispensers that were properly installed.
Oregon Clinic: K130 The facility failed to provide a reliable method to get out of the building.
Stoughton Clinic: K130: The facility failed to provide a safe path to a public way.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on observations and 1 of 1 interviews with facility staff (B), the hospital failed to ensure that the facility is kept clean, maintained, and arranged so as to provide a sanitary environment for the prevention of potential contamination or infection.


Findings include:

During a tour of the facility's emergency department on 01/05/2011 at 12:15 PM it was discovered that doors on linen cabinets in exam rooms 1,2,3 and 4 were left open thereby exposing the linen to contaminants in those rooms. This was confirmed per interview with staff B on 01/05/2011 at 6:00 PM.


22198

During an initial tour of the facility on 01/03/11 at 11:55 a.m. with Performance Improvement Staff A Surveyor #22198, standing in a corridor that accommodated the outpatient surgical department, Post Anesthesia Care Unit (PACU) and the Surgical Suite, Surveyor noted the door to PACU had two vertical half doors that were open directly into the PACU.

Surveyor #22198 walked over to the PACU open door and observed another double vertical door inside PACU was opened and racks of what looked like sterile supplies were observed.

Surveyor #22198 asked Staff A where the inside door lead to? PI Staff A confirmed it was directly into the restricted surgery department.

On 01/03/11 at 11:40 a.m. Day Surgery RN J told Surveyor #22198, that the doors into PACU were difficult to open, related to the vertical doors locking mechanism, so staff between PACU and day surgery left them open to make it easier and quicker to enter.

On 01/03/11 at 4:30 p.m. Nurse Surveyor #22198 and Engineer Surveyor #12187 reviewed the gap space for both vertical double doors (PACU and Surgery) and noted gaps where the door closers met. An airflow test was completed by Surgical Nurse E with Surveyors #22198 & 12187 present, and confirmed airflow was flowing from the non-clean (PACU and corridor) to clean (sterile surgical area).

Engineer #12187 confirmed airflow should flow from clean to dirty (non-clean).

On 01/03/11 during the initial tour between 11:25 a.m and 12:25 p.m. in the Geriatric Psychiatric Unit Surveyor #22198 noted peeling wall paper in patient rooms.

The dirty storage (soiled utility) room was not labeled as a dirty room and had no number identifiers. Staff had both clean and dirty items housed in this room, that included biohazardous waste, eyewash station, fire extinguisher, clean mop heads and clean paper towels, cleaning solutions, dirty linen and trash.

On 01/04/11 at 10:35 a.m. during a complete tour of the Geriatric Psychiatric Unit additional infection control issues were identified.
Kitchenette #1
The ice machine for patient use had white crusted material.
The microwave was dirty with old food debris on the interior and dried debris on the rotating glass plate.
The counter drawers container old coffee grounds, dust and dirt, also contained the clean lids to cover water cups.

Kitchenette #2
An opened coffee packet was found in a drawer, however no way to identify when it had been opened.
The Patient Refrigerator had large cracks and missing pieces in the door and interior, that food product was falling into the holes. The refrigerator had dried food debris.

Unit Manager F told Surveyor #22198, that there was no assigned staff or cleaning schedule for the 2 kitchenettes. All findings on the Geriatric Psych Unit were confirmed by Manager Staff F.

On 01/03/11 at 12:10 p.m. during initial tour in the Imagining Department, Surveyor #22198 entered a room identified by Performance Improvement Staff A as the Echocardiogram room. This room was identified as being a patient care area were echocardiograms are performed.

An outdoor coat was hanging inside this room, along with a bottle of water. X-ray technology Coordinator Staff K told Surveyor the coat and water belong to a contracted staff (L) not a patient.

X-ray technology Coordinator Staff K told Surveyor #22198, that the facility has locker rooms for staffs personal belongings. X-ray technology Coordinator Staff K confirmed it was not a standard of practice in the facility for staff to bring personal belongings into a patient care area.

Contracted Imaging Staff L told Surveyor #22198, no one had informed her she could not bring personal items into a patient care area while performing tests.

Contracted Imaging Staff L told Surveyor #22198, earlier on 01/03/11 L had been in another facility performing contracted services on patients in the other facility.

Contracted Staff L told Surveyor as a contracted employee, L fills her shift with patients and procedures from multiple facilities to fill a day and to complete contracted assignments.

On 01/03/11 during initial tour of the Emergency Department (ED)at 12:20 p.m. Performance Improvement Staff A and Surveyor #22198 identified an incubator outside the ED in a hall.

The incubator was cleaned and cover, however a cord and stick pad was noted plugged into the incubator.

Performance Improvement Staff A confirmed to Surveyor #22198, that the cord was a temperature monitoring device and should not have been on the clean incubator.

On 01/04/11 at 8:55 a.m. Engineer Surveyor #12187 and Nurse Surveyor #22198 reviewed the storage area (identified as the "old kitchen storage"). Also present during this observation and interview were Plant Operations Staff H and Environmental Service Coordinator I.

Inside what used to be a series of connected refrigerators and freezers was now being used by environmental services as storage.

In order to gain access to any of these storage areas, staff had to enter the first storage area, which was used for clean storage.

Beyond that you entered a door that housed Biohazardous waste (pharmaceutical waste). There was no way to bring in waste product or remove waste product. Environmental Service Coordinator I handed Surveyor #22198 multiple pages of possible waste products that could be brought in for disposal, that ranged from medication to formaldehyde.

Environmental Service Coordinator I told Surveyor #22198 no one told the Environment Services they were not allowed to house waste product in this room, inside the clean supply room.

01/05/11 at 7:30 a.m. during a tour of the imaging department Engineer Surveyor #12187 and Nurse Surveyor #22198, Plant Operations Staff H entered room #1269. This room was labeled dirty utility room, however the room had multiple purposes.

In an interview with contracted Plant Operations Staff H , Surveyors #22198 and #12187 were told that room #1269 was used as a janitors closet that included mixing cleaning supplies, emptying used supplies, and supply storage.

Imagining Staff N told Surveyors Imagining staff uses the room for cleaning the transvaginal probe used during transvaginal procedures. Cidex was mixed and wasted in the sink. Clean mop heads, towels were on the counter next to the sink where Cidex was mixed and the cleaning was done.

On 01/05/11 at 8:30 a.m. Infection Control Preventionist Staff T and Surveyor #22198 reviewed the above findings.

On 01/05/11 at 9:00 a.m. during an observation of medication pass Surveyor 322198 observed Registered Nurse (RN) donning gloves for administering nasal spray to Patient #7. After administration of nasal spray removed gloves cleaned hands with alcohol based gel, then proceeded to pick up the nasal spray bottle ungloved and place it into the medication drawer, without cleaning hands.

On 01/05/11 at 10:30 a.m. during an observation of a wound dressing change of a vacuum system for Patient #9, Surveyor #22198 observed the following:

RN Staff P and Q set up the dressing change supplies on the lower pull out section of the patients tray table where newspapers, coffee, water and writing supplies were laying, without washing off the surface, before laying out the clean pad to open supplies on.

RN Staff P after washing hands and donning clean gloves to commence the procedure, grabbed the rim of a used garbage can and moved it closer to the bedside, then proceeded to start the dressing change without removing the gloves or washing hands.

While RN Staff Q was assisting with the wound care and dressing change, RN Staff Q grabbed the cord to shut the window with her clean hands and gloves. RN Staff Q did not clean her hands after touching the cord but instead continued to assisting RN Staff P by providing cleaning supplies; cleaning spray solution, and clean gloves.

RN Staff P, after removing the old dressing reached over to shut off alarming suction machine, without removing or washing hands continued on with the dressing changes.

After dressing change was completed and Tegaderm applied to seal the wound RN staff P attached the new suction tubing section, without changing gloves or washing hands turned on the wound vacuum suction machine.

The suction failed, RN Staff Q left the the supply table removed gloves, however failed to wash hands. Q went into a supply cabinet in the room, and took out additional Tegaderm.

The spray bottle and measuring tape used on Patient #9 after being used were placed on Patient #9's sink, then later removed, the tape measurer was disposed of and the cleaning spray was put away, however the sink was never cleaned off. Both RN's Q and P confirmed that the sink is used by Patient #9 as well as staff, and potentially visitors.

After the old dressing and supplies were removed Staff Q continued using the same gloves to clean up after Patient #9 removing her coffee cup from the tray table and adjusting the table items, looking out the closed blinds, then removing the tray table cover used during the dressing change.

The tray table was not cleaned after the procedure was completed.

Findings were reviewed with RN's Staff P and Q, who both confirmed they were aware of the cross contamination, that had occurred.

On 01/05/11 at 11:20 a.m. an observation of blood sugar check and insulin administration by RN Staff R for Patient #26.

Vice President of Patient Services B provided Surveyor with the current hospital policy entitled: "Blood Sugar Testing" Originated 08/98, last reviewed on 02/19/10, 1 of 3 pages with 2 additional reference pages notes:

IV. Safety Precautions: " Isolation bags for meters are available for those patients with special or contact considerations". (page 3)

VII. Patient Testing Procedure: "#12. Clean monitor after each patient use and before storage". (page 3)

VII. Maintenance: " The exterior of the meter should be cleaned after each patient use and before storage".(page 4)

Patient #26 was on droplet precautions for pneumonia, and during the procedure, Patient #26 was observed coughing multiple times, while RN Staff R was in the room performing testing and providing insulin..

RN Staff R standing less than 12 inches from Patient #26's side completed blood sugar check and then with the hand held blood sugar machine holding it less than 12 inches from patients face to show Patient #26 the results of the testing. RN R set the hand held blood sugar testing device on Patient #26's bed, that was 24 inches from Patient #26's side.

RN R then picked up supplies disposed on the lancet, and 2 x 2 and set the hand held blood testing device on a counter top removed the mask and gloves worn during the procedure used alcohol based gel to clean hands, proceeded to pick up the contaminated hand held testing device and left the room.

RN R set the hand held blood sugar testing device on the nurses station desk, and retrieved the insulin supplies for insulin administration from a locked cabinet and a drawer. Drew up insulin, entered the Medical Surgical floor handed the insulin filled syringe to another RN for confirmation of dosing, took back the syringe and returned to Patient #26's room to provide insulin.

After insulin administration RN R returned to the nurses station, picked up the contaminated hand held blood sugar testing device with bare hands and placed it into the housing container. The housing container was labelled "ICU" and held additional lancets, quality control liquids for quality control machine testing, and the trouble shooting booklet.

RN R confirmed the blood sugar testing machine was used for multi patients however the ICU only had one patient today.

These findings were reviewed with RN R, who failed to acknowledge the cross contamination of the environment related to handling the contaminated testing device, and did not clean the hand held testing device or its housing before Surveyor #22198 left the department. Surveyor reported the observation and interview to Vice President of Patient Services B, who confirmed the policy for blood sugar testing requires cleaning between patients and prior to storage.

Based on review of 6 of 30 records (#1,16,17,18,22,25 ), interview with staff and review of facility policies and procedures the hospital failed to assure entries were properly timed and dated.

Findings include:

Per surveyor #20878 the following were reviewed over the course of the dates of the survey (01/03, 01/04 and 01/05/2011).

Per interview with staff B on 01/05/2011 at 4:30 PM all orders should be co-signed within 48 hours and all entries should be signed and dated. Hospital policies confirm this; General Conduct of Care in the Medical Staff Policy Manual dictates; "The ordering practitioner shall authenticate such orders (verbal) within the guidelines set by the State of Wisconsin and the Joint Commission by signing and dating." These guidelines state orders should be signed within 48 hours.

Patient (pt.) #1's clinical record contained a verbal order taken on 01/03/2010 which was not authenticated until 03/15/2010. It also contained 2 other telephone orders from 01/03/2010 which were not authenticated by the physician until 01/11/2010.

Pt. #16's clinical record contained a telephone order written on 12/21/2010 which had yet to be authenticated. A history and physical in this record was dictated on 12/20/2010 was not signed by the physician.

Pt. #17's clinical record contained a telephone order written on 12/16/10 which was signed by the physician with no date or time.

Pt. #18's clinical record contained two telephone orders written on 12/20/10 which were signed by the physician with no date or time.

Pt. #22's clinical record contained emergency department forms from 08/10/2010 which were missing times on the transfer form and the physicians initial exam note.

Pt. #25's clinical record contained a telephone orders written on 12/30/10 and 12/31/2010 which were not signed by the physician until 01/04/2011.

These findings were confirmed per interview with staff B on 01/05/2011 at 5:00 PM.



22198

Findings per record reviews conducted by Surveyor #22198:

On 01/04/10 the following medical record findings were reviewed and confirmed by Vice President (VP) of Patient Services B.

Patient # 2
Patient # 2 admitted and discharged on 10/18/10 medical record was incomplete, missing times for physician notification.

The Physician Order form was not dated or timed.

Physicians Emergency Records had a diagnosis entered on the form (#6903) however the writer failed to time, date or authenticate the entry.

A pre-printed sheet that listed patient problems, medications, immunizations, health maintenance and allergies had a hand written entry "ventricular defect", however the writer failed to time, date or authenticate the entry.

Patient #3
A two page pre-printed medication order reconciliation form; dated 04/30/10 had 5 adjustments made from "stopped" to "ordered" medications. The staff who made the adjustments in Patient #3 ' s medical record failed to acknowledge the date or time of the changes and scribbled out instead of lining through the changes to ensure all of the medical record was legible.

05/12/10 12:50 p.m. "clarification" orders were confirmed with a contracted Registered Nurse (RN). The two RN's failed to include the primary care physician (PCP) in on the clarification order and the order was never authenticate by the PCP, however, the order was initiated. VP of Patient Services B confirmed Registered Nurses to not have prescriptive authority in the hospital.

05/13/10 at 12:35 p.m. an RN accepted a telephone order indicating discontinuation of "all" scheduled medications. Keep "all" PRN medications. VP of Patient Services B confirmed medication orders must list the specific medication to be discontinued or ordered. The use of "all" medication is not accepted.

05/07/10 at 3:20 p.m. the Pharmacist wrote for clarification from the medication reconciliation/transfer report, however the order was never authenticated by the PCP.

Admission order from 05/07/10 was not timed, therefore can not be confirmed the authentication for the admission orders can not be confirmed authenticated within the 48 hours required for a verbal/telephone orders.

The writer wrote "DNR" in the admission order.

The most current policy entitled: Do Not Resuscitate/No Code, originated on 8/91 last reviewed 06/01/10, notes that "Do Not Resuscitate" is to be spelled out the policy utilized quotation marks around the spelled out word:
Policy, page 2 III. Procedures: The Physician should:
#3. "Write an explicit order for "Do Not Resuscitate" or limitations and/or termination of treatment".
#4 "Co-sign verbal or telephone orders for "Do Not Resuscitate/No Code" within 24 hours".
The physician signed the order on 05/09/10 at 7:23 a.m. The authentication for the admission order dated 05/07/10 (not timed) failed to meet the more stringent hospital policy, noting a Do Not Resuscitate must be authenticated within 24 hours.

A medication reconciliation/transfer report/order taken as a telephone order on 05/07/10 was not timed, however the physician failed date or time the authentication.

Contracted Hospice Services fail to time their medical records entries on 05/17/10, 05/14/10 05/13/10 and 05/07/10.

On 05/07/10 the contracted Hospice nurse failed to authenticate the entry in the medical record.

A medication profile listing Patient #3's medications 4 blacked out entries that made the medical record entries illegible.

On 01/05/11 at 2:20 p.m. the following medical records were reviewed and confirmed with Unit Clerk Staff U.

Patient # 6
Patient #6 had 7 informed consents for psychotropic medications. Each of the 6 psychotropic medication consents had blacked out information on them. All 6 consents listed 05/03/1955 as Patient #6's date of birth. According to Patient #6's profile and the rest of Patient #6's medical record, Patient #6's date of birth is 08/04/1941.

Patient # 10
Patient # 10 had 9 Social Services entries that were not timed. Interview with Masters prepared Social Service (MSW) Staff V confirmed the entries were not timed. MSW V told Surveyor they do not time any of the entries in the medical records, and was aware of the medical records requirement for timing and dating medical records entries.

Additional records for Patients #11 and #12 confirmed Social Service entry in Patient's #11 and #12 were not timed.

Patient #11
Patient #11 had 3 Verbal orders dated 01/04/11 that were not authenticated. Unit Clerk Staff U confirmed to Surveyor #22198, that the Unit Psychiatrist would not be back to the hospital until Friday 01/17/11, and had no way to authenticate the Verbal orders within the 48 hour time frame.

On the admission information sheet for Patient #11, an RN wrote "DNR" next to the advanced directives information/questions and then had the family of Patient #11 sign the sheet, next to the abbreviation "DNR". Interview with Unit Manager F on 01/05/11 at 3:20 p.m. confirmed medical abbreviations are not accepted terminology for providing patients or family ' s medical information.

Patient #12 had 3 verbal orders dated 12/25/10, 12/30/10 and 12/31/10, however the authentications failed to meet the 48 hour requirement.

On 12/30/10 between 6:16 p.m. and 7:30 p.m. the staff failed to complete documentation for every 15 minute suicide checks.

On 01/05/11 at 4:15 p.m. Unit Clerk Staff W reviewed and confirmed the following:

Patient #9 had 2 of 3 pages of a medication reconciliation/order form were not authenticated by the physician.

The pre-operative check-list form required pre-operative baseline vital signs; none were documented on the form. Review of all pre-operative documentation failed to produce the required baseline vital signs.

Patient #13 01/05/11 Ortho Progress notes were not timed.

A history and physical dated 12/21/10 then reviewed for surgery on 01/03/11 requiring general anesthesia, was not timed to indicate that the physician had reviewed the history and physical prior to the surgical procedure.

01/03/11 the pre-operative check-list form required pre-operative baseline vital signs; none were documented on the form. Review of all pre-operative documentation failed to produce the required baseline vital signs. The preoperative check-list also required the surgeon to mark the site prior to surgery, and no documentation that this preventative measure was completed. Patient #13 had a right sided surgical procedure.

Based on observation, interview and record review the hospital failed to keep confidential 4 of 4 (#31, 32, 33 and 34) protected patient information in x-ray records that were removed the x-ray record storage area and 1 of 3 medical records storage areas secured.

Findings include:

On 01/03/11 at 12:10 p.m. during initial tour in the Imagining Department, Surveyors #22198 and 20878 along with Performance Improvement A entered a room identified by Performance Improvement Staff A as the Echocardiogram room.

The room #1280 was identified as echocardiogram room.

No imaging staff were present during this initial observation, however PI A confirmed to Surveyor #22198, that 4 x-ray folder containing protected health information for Patients #31, 32, 33 and 34, were left on the counter top, in a unsecured room without imaging staff present.

Protected health information was identified as patient name, date of birth medical, record number, date and type and date of procedure along with the actual hard copy of each x-ray each patient (#31, 32, 33 and 34) had taken.

A binder was also on the counter top next to the x-rays, with 6 pages of patient listed that included these 4 patients (#31, 32, 33 and 34) as well as patients from other facilities, that included name of patient, date of birth, physician/cardiologist, and date of service

PI A confirmed staff, visitors and patients would have access to this area.

PI A left this area to find Imaging Technician Coordinator K, who confirmed the room #1280 was left unsecured, and that the hall way outside room #1280 was unrestricted and not monitored, and always was in a hall way that had patient changing rooms.

Imaging Technician Coordinator K told Surveyor #22198, that Contracted Imaging Staff L had removed the x-rays from x-ray storage to complete the contracted workload for today.

Imaging Technician Coordinator K confirmed to Surveyor #22198, the 6 pages within the binder containing Protected Health Information belonged to Contracted Imaging Staff L.

Imaging Technician Coordinator K told Surveyor #22198, that Contracted Imaging Staff L was currently on the nursing unit.

On 01/03/11 at 4:30 p.m. during an interview Contracted Staff L confirmed to Surveyor #22198, that the hospital did not provide education or training of Protected Health Information (PHI) or Health Insurance Portability and Accountability Act (HIPAA).

Contracted Staff L confirmed to Surveyor #22198, the contract Agency did not provide PHI or HIPAA education or training.

01/03/11 at 4:35 p.m. during an interview and review of the hospital's policies and procedures for the protection and security of medical records, Medical Imaging Manager M confirmed to Surveyor #22198, that the hospital requires all PHI is to be kept confidential, and kept in a secure area.

Medical Imaging Manager M confirmed to Surveyor #22198, that the hospital did not provide PHI or HIPAA education or training to their contracted staff.

Medical Imaging Manager M confirmed to Surveyor #22198, that the Quality Assurance Program (QAP) for contracted services did not include oversight or monitoring of contracted staff use of the hospital patients PHI.

A copy of the QAP for contracted services that confirmed no monitoring of contracted services use and protection of PHI was done, was provided to Surveyor #22198 by Vice President of Patient Services B on 01/04/11 at 7:30 a.m.

On 01/04/11 after a review of Contracted Staff L ' s personnel file confirmed no education or training for PHI or HIPAA was documented. Findings were reviewed at the daily conference 01/04/11 at 4:30 p.m.

On 01/03/11 at 12:10 p.m. during initial tour in the Imagining Department, Surveyors #22198 and 20878 along with Performance Improvement A observed a door ajar and entered the room. X-ray folders containing PHI were removed by Surveyor #22198 and reviewed. No x-ray or medical records staff were in the room for interview.

On 01/04/11 at 3:30 p.m. during a tour and interview Privacy Officer C responsible for the medical records department confirmed to Surveyor #22198, the x-ray department was one of three areas containing medical records.

Surveyor #22198's tour of the x-ray department with Privacy Officer C confirmed the x-ray department left the back door of the x-ray medical records storage ajar for easy staff access.

Privacy Officer C confirmed to Surveyor #22198, that the room did not scheduled staff located in the medical records storage room to prevent unnecessary staff or public from entering to gain access to patient's PHI.

Privacy Officer C confirmed to Surveyor #22198, that there was no staff located in the room currently, however the back door was unsecured and open to a public access hallway that was not monitored.

Privacy Officer C acknowledged to Surveyor #22198, that all medical records should be secured and protected.