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Based on observations and interview, the hospital failed to maintain or repair furniture in 1 of 2 patient care units (East Wing).

Findings:

1. On 11/13/19 at approximately 2:35 PM, in the East Wing Dining Room, eight of ten chairs and one rocking chair were observed to be gouged with missing vanish and four of six tables were observed with bubbled surfaces and broken edges. These gouged surfaces, bubble surfaces, and broken edges created a surface which could not easily be cleaned and sanitized.

2. On 11/13/19 at approximately 2:35 PM, in the East Wing Day Room, one of one side table was observed to be gouged with missing vanish and the vinyl head rest area on one of five recliners had several broken areas. The gouged surface and the broken areas in the vinyl created a surface which could not easily be cleaned and sanitized.

All of the above findings were confirmed with the Director of Facilities Management at the time of the observation.

Based on observations and interview, the Governing Body failed to ensure a hospital policy was implemented in relation to removing food items when they had expired.

Finding:

The Governing body is responsible to ensure hospital policies are implemented. Based on observation, document reviews, and interview, the Governing Body has failed to ensure a hospital's policy was implemented as evidenced by the following:

The "Food Storage" policy, revised on 8/30/19, indicated "Stored food should be used or discarded in accordance with "use by" guidance"

On 11/12/2019 at approximately 3:15 PM, the following expired canned goods were observed:

- A can of Cream of Potato Soup with an expiration dated of 1/26/2018.

- A can of Cream of Celery Soup with an expiration date of 3/28/19.

- A can of Chicken with Rice Soup with an expiration date of 8/16/19.

- A container of Blue Cheese Dressing with an expiration date of 9/19/19.

- A can of Tomato Soup with an expiration date of 10/17/19.

These findings were confirmed with the Manager of Nutrition Services at the time of the observation.

Based on record review, observations, and interview, the hospital failed to ensure paper medical records were kept in a location to prevent unauthorized use in 1 of 2 inpatient units (East Wing).

Findings:

The hospital's "Protected Health Information (PHI) Safeguards" policy states, "Northern Light Health policies and state and federal laws establish basic administrative, technical and physical safeguards to maintain the confidentiality, integrity and security of PHI and ePHI[...]Paper PHI is considered secured when controlled access meets the following criteria: PHI is not stored in hallways or in common areas where unauthorized individuals can access the information and PHI is stored out of sight of unauthorized individuals, and is locked in a filing cabinet, room, or office desk when not supervised or in use".

On 11/13/19 between 9:00 AM and 9:30 AM, the door to the office, where patient records were stored, was observed to be open. The Vice President of Clinical Services immediately shut the door.

On 11/14/19 at 10:34 AM, in the East Wing, the office door was observed open and patient medical records were observed unsecured and readily accessible to unauthorized individuals. During this observation, there were no staff in the area. Survey staff went into the office area and waited for five minutes and no staff came to the office area. A surveyor then went and found a Certified Nursing Assistant (C.N.A.) who confirmed that the office door was open and the medical records were unsecured in the office. The C.N.A. stated, "The door is open most of the time and that there is usually a nurse around."