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Based on observation and staff interview the Critical Access Hospital (CAH) radiological staff failed to remove outdated supplies in 1 of 1 intravenous (IV) cart and 1 of 1 technician work area. The radiological manager reported approximately 25 IV contrast procedures a month.

Failure to remove outdated supplies could potentially expose patients to supplies not guaranteed sterile or potentially less effective.

Findings included:

1. Observations during a tour of the radiology department on 2/28/11 at 2:40 PM, revealed the following outdated supplies:
a. 8 of 11 - #18 gauge Insyte IV catheters expired 3/09 and 2 of 11 - # 18 gauge Insyte IV catheters expired 11/08 in an Intravenous (IV) cart located in the Computerized Tomography (CT) examination room. The radiology manager reported at the time of the observation, radiology staff used the IV catheters for IV contrast procedures.
b. 2 of 2 Providine/Iodine swab sticks expired 3/09, 1 of 1 - 16 fluid ounce (oz) bottle of Hydrogen Peroxide expired 8/08 and 1 of 1 - 16 fluid oz bottle of Rubbing Alcohol expired 10/08 in a cabinet in the "tech" workstation.

2. During an interview on 2/18/11 at the time of the observation in the CT room, the radiology manager acknowledged the outdated supplies in the IV cart and tech work station. The radiology manager stated, "I can tell you I went through the bottom of this [IV] cart about 3 weeks ago obviously I didn't look at the top drawers. I will throw all of these items away immediately."

3. During an interview on 3/1/11 at 8:30 AM, the radiology manager reported the radiology department implemented an outdate log for all supplies in the radiology department and radiology personnel would be responsible for checking and documenting outdate inspections."

4. Review of policies and procedures revealed the hospital lacked a policy for outdated supplies. During an interview on 3/2/11 at 2:00 PM, the Chief Nursing Officer (CNO) stated, "Our policy would be all outdated supplies be removed from patient care areas and are not available for patient use."

Based on observation and staff interview the Critical Access Hospital (CAH) radiological staff failed to remove outdated supplies in 1 of 1 intravenous (IV) starting cart and 1 of 1 technician work area. The radiological manager reported approximately 25 IV contrast procedures a month.

Failure to remove outdated supplies could potentially expose patients to supplies not guaranteed sterile or potentially less effective.

Findings included:

1. Observations during a tour of the radiology department on 2/28/11 at 2:40 PM, revealed the following outdated supplies:
a. 8 of 11 - #18 gauge Insyte IV catheters expired 3/09 and 2 of 11 - # 18 gauge Insyte IV catheters expired 11/08 in an Intravenous (IV) starting cart located in the Computerized Tomography (CT) examination room. The radiology manager reported radiology staff uses the IV catheters for IV contrast procedures.
b. 2 of 2 Providine/Iodine swab sticks expired 3/09.
b. 1 of 1 - 16 fluid ounce (oz) bottle of Rubbing Alcohol expired 10/08 and
1 of 1 - 16 fluid oz bottle of Hydrogen Peroxide expired 8/08 in a cabinet in the "tech" workstation. The radiology manager stated, "I will throw all of these items away immediately."

2. During an interview on 2/18/11 at the time of the observation in the CT room, the radiology manager acknowledged the outdated supplies in the IV cart and tech work station. The radiology manager stated, "I can tell you I went through the bottom of this [IV] cart about 3 weeks ago obviously I didn't look at the top drawers."

3. Review of documentation presented to the survey team on 3/1/11 at 8:30 AM, by the radiology manager revealed, " Upon inspection of the radiology department, it was determined there is no consistent process to eliminate outdated supplies. The radiology department will begin an outdate log for the supply room and any supplies kept in the exam rooms. All radiology personnel will be responsible for checking and documenting outdate inspections."

3. During an interview on 3/2/11 at 2:00 PM, the Chief Nursing Officer stated, "I don't think we have a formal policy for outdated supplies but our hospital policy would be all outdated supplies be removed from patient care areas and are not available for patient use."

Based on observation and staff interviews, the Radiology Department and Health Information Management staff failed to secure all medical records in the Radiology and Health Information Management (HIM) staff failed to secure all medical records against unauthorized access. The CAH radiology staff reported a daily census of 2 inpatients and 20 outpatients. The CAH nursing staff reported a daily census of 8 inpatients.

Failure to secure medical records against unauthorized access could result in identity theft or unauthorized disclosure of personal medical information.

Findings include:

1. During an interview on 2/28/11 at 2:25 PM, the radiology manager stated environmental service staff cleaned the radiology department including the record storage area and front office in the evening unsupervised. The radiology manager acknowledged that environmental services staff could access patient medical records and did not have a need to know the patient's medical information.

2. Observations during a tour of the radiology department on 2/28/11 at 2:55 PM, revealed a drawer with a mammography log, which contained patient names, date of birth, medical record number, diagnosis and the radiological procedure performed. During an interview, at the time of the observation the radiology manager stated environmental services staff cleaned the department in the evening unsupervised. The radiology manager acknowledged that environmental services staff could access information contained on the mammography log did not have a need to know the patient's medical information.

3. During an interview on 2/28/11 at 3:23 PM, Staff A, Environmental services staff stated, "I clean the radiology department. They [radiology staff] are not there when I'm cleaning."

4. Observations during a tour of the HIM offices on 3/2/11 at 7:40 AM revealed:
a. 22 boxes that contained active patient medical records.
b. 17 charts that contained deceased patient medical records.

5. At the time of the observation, Staff B, HIM technician, acknowledged that staff had stored patient medical records in an unsecured location. Staff B also verified that housekeeping staff had key code access to the HIM office and cleaned unsupervised after hours.

6. The CAH lacked policies and procedures that identified unauthorized access to confidential patient information.

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