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Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) Surgical Services administrative staff failed to ensure surgical staff tested the disinfecting solution in 1 of 1 disinfecting buckets. Surgical Services administrative staff identified an average of approximately 6 laparoscopic procedures per month.

Failure to test the disinfecting solutions prior to each use could potentially result in the disinfecting solution lacking sufficient strength of the active ingredient to kill all microorganisms, resulting in the spread of infectious microorganisms between patients.

Findings include:

1. Observations, during a tour of the sterile hallway, on 4/4/11 at 3:05 PM revealed 1 of 1 large basin contained Aldahol Solution.

2. Review of the Aldahol Solution Test Log, revealed surgical services staff failed to document the Aldahol Solution test results in the log book prior to each use.

3. During an interview, at the time of the tour, Staff A, OR/ER Registered Nurse, stated surgical services staff tested the Aldahol Solution prior to each use but did not document the test results in the log book.

4. Review of the manufacturer's directions for Aldahol Solution, copyright 2009, revealed in part, "The [active ingredient] concentration of Aldahol should be monitored at the beginning of each day, or more frequently if indicated..."
5. Review of CAH policy/procedure on 4/4/11 titled, "Use of Aldahol Glutaraldehyde Solution", dated revised 1/11, revealed in part, "Test Aldahol solution prior to each use with Glutaraldehyde Monitor Test Strips and document in log book. . . "



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Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to secure patient radiology medical records in 1 of 1 basement storage area against unauthorized access. The CAH Radiology Manager identified approximately 500 patient radiology medical records stored in the basement storage area. The CAH Radiology manager identified the CAH radiology staff perform approximately 740 radiology in-patient and out-patient exams per year.

Failure to secure medical records against unauthorized access could potentially result in unauthorized disclosure of patient information, including name, date of birth, or social security number.

Findings include:

1. Review of the CAH policy/procedure on 4/4/11 titled, "Information Security Policy", dated revised 1/17/11, revealed in part, "All medical records stored in the basement will be enclosed in a locked area. Each department will have their own designated key, accessible only by that department."

2. Observations during a tour of the basement storage area on 4/4/11 at 1:30 PM with the Health Information Manager and the Facility Manager revealed:

a. 4 shelving units approximately 6 feet tall, with 5 shelves per unit, filled with radiology medical records, which contained patient names, date of birth, and results of all radiology procedures performed on the patient.

b. 2 shelves approximately 4 feet wide, filled with radiology medical records, which contained patient names, date of birth, and results of all radiology procedures performed on the patient.

3. During an interview at the time of the tour, the Facilities Manager stated 4 maintenance staff have keys to the basement door and could unlock the door for all other CAH departments that have areas of storage in the basement. The Health Information Manager acknowledged CAH staff other than Radiology and Health Information staff could access the unlocked patient medical records in the basement storage area, without a need to know the information in the medical records.




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