HospitalInspections.org

Bringing transparency to federal inspections

2100 N MARTIN LUTHER KING, JR, BLVD

CLOVIS, NM 88101

PATIENT RIGHTS: PERSONAL PRIVACY

Tag No.: A0143

Based on record review, interviews and observations, the facility failed to maintain the personal privacy of patients including but not limited to the patient's location in the hospital; demographic information the hospital has collected on the patient, such as name, age, address; or information on the patient's medical condition. The Protected Health Information (PHI) was not protected for 9 (P (Patient) 13, P14, P15, P16, P17, P18, P19 P20 and P21) of 22 (P1 - P22) patients. This failed practice can lead to inappropriate disclosure of PHI and is likely to lead to an increased risk of misuse and breach of PHI.

The findings are:

A. Record review of facility policy titled, "HIPPA [Health Insurance Portability and Accountability Act]: Administrative, Technical and Physical Safeguards for PHI," dated 02/08/2023 stated, "2. Physical Safeguards: xi. Workforce should close electronic records containing PHI when not in use, log off computer workstations at the end of each shift."

B. During an observation on 09/19/2023 at 9:15 am of the emergency department nursing area, the following patient's information was revealed:

1) P13, P14, P15, P16, P17, P18, P19 and P20, patient information showed on computer screen #1 after registered nurse got up and left area, following PHI: patient name, room, age, complaint, diagnosis, risks and gender.

2) P14, patient information showed on computer screen #2 showed the following PHI: patient name, medical record number, account number, age, gender, orders, complaint, and risks.

C. During an observation on 09/19/2023 at 3:55 pm of Medical Surgical Unit at nurses station, computer screen was on and unattended showed the following PHI for P21: patient name, medical record number, financial account number, date of birth, and vital signs.

D. During an interview on 09/19/2023 at 3:56 pm, with Staff (S) 13, Interim Nurse Manager, when asked if computers should be left on and unattended with patient information showing, S13 answered, "No, we are supposed to close or lock the computer as soon as we get up."

E. During an interview on 09/20/2023 at 8:15 am with S3, Risk Manager, when asked what the policy is on securing electronic patient information, S3 answered, "If you are going to step away, you are supposed to lock your computer. We don't want any open computers with patient information."

NURSING SERVICES

Tag No.: A0385

Based on record review, observation and interview the facility failed to meet the Condition of Participation to ensure that a Registered Nurse maintain responsibility for the care of patients.
This deficient practice could likely lead to infection, serious injury or death for all patients at this facility.

The findings are:

A. Refer to Tag A-0395.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on record review and interview the facility failed to ensure the Registered Nurse maintained responsibility for the care of patients and supervise the nursing care for each patient for 2 ([P] patients P1 and P2) of 12 (P1-P12) patients. The facility failed to ensure that the registered nurses protect the patients from student nurses that were not adhering to standard precautions while providing patient care. This deficient practice could likely lead to infection, serious injury or death for all patients at this facility.

The findings are:

A. Record review of the document titled "Nursing and Allied Health Academic Clinical Faculty Resource Guide" "[Name of Hospital]/Clinical Education 2017:" "All [Name of Hospital] Nurses ...involved in supporting Learners will: place the safety and well-being of the patient above all other objectives ...supervise the Learner appropriately ..."

B. Refer to Tag A-0750

C. During interview on 09/19/2023 at 3:56 pm with S13 Medical Surgical Unit Charge Nurse, When asked who is ultimately responsible for the patient's care? S13 stated "the RNs are responsible."

D. During interview on 09/20/2023 at 12:10 pm with S2 Director of Nursing (DON), when asked Who is responsible for the patient's care the staff nurse or the student nurse? S2 stated "The primary nurse is one of our nurses and they coordinate care with the students ..."

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

Tag No.: A0747

Based on record review, observation and interview the facility failed to meet the Condition of Participation to protect the patients from exposure to infections, by failing to ensure that nursing staff and patient care providers adhere to standard precautions. This deficient practice could likely lead to infection, serious injury or death to all patients in this facility.

The findings are:

A. Refer to Tag A-0750.

INFECTION CONTROL SURVEILLANCE, PREVENTION

Tag No.: A0750

Based on observation, record review and interview, the facility failed to protect 2 (P (patients) 1 and P2) of 12 (P1-P12) patients reviewed, for potential infections by failing to ensure that registered nurses maintained responsibility for patient care and ensure that patient care providers such as nursing students adhered to standard precautions; and protect patients from potentially contaminated supplies that had been dropped on the floor. These deficient practices are likely to lead to infection, serious injury or death of all patients in the facility.

The findings are:

A. Record review of P2 medical record revealed the Medical Doctor (MD) orders: "Contact isolation status [medical staff are to wear gowns and gloves when entering a patient's room];" "Eyewear Protection isolation" [eye protection goggles to worn to protect eyes from splashes, sprays, and respiratory droplets]; and "Droplet isolation status [a face mask is worn by medical staff when in a room with a person with a respiratory infection]." All orders dated 09/12/23 0115 (1:15 am).

B. Record review of Centers for Disease Control and Prevention "Guidelines For Environmental Infection Control in Health-Care Facilities (2003) Last update: July 2019. Page 134 of 241 "H. Keep emergency doors and exits from PE (protective environment) [for example isolation rooms] rooms closed ..."

C. During an observation on 09/19/23 at 09:36 am during tour of Medical/Surgical Unit P2's room door was open.

D. During an interview on 09/20/23 at 10:54 am with S14 Infection Control Specialist, confirmed that the door to patient rooms on isolation " ...should be left closed."

E. Record review of policy title: "Standard Precautions for Infection Control" Reference Number: PC.PDS.148, Current Effective Date: 05/11/2021."
1. "2.2.2.4. Remove gown, apron, or other PPE [personal protective equipment-equipment worn to act as a barrier between an individual's skin, mouth, nose, or eyes and viral and bacterial infections] attire and perform hand hygiene before leaving the patient's environment to avoid transfer of microorganisms [an organism so small it can only be viewed under a microscope] to other patients or environments."

F. Record review of policy title: "Hand Hygiene" Reference Number: PC.PDS.194, Current Effective Date: 06/30/2022.
1. "1.1.1. Before Patient Contact: Perform hand hygiene between the last contact with objects outside the patient's room or cubical and the first contact with objects within the patient's immediate surroundings or contact with the patient."

2. "1.1.2 Before an Aseptic Task: Perform hand hygiene immediately before any aseptic [free from living microorganisms that can cause disease like bacteria or viruses] task as preparing or administering medication ..."

3. "1.2. After performing personal hygiene activities (for example, toileting, sneezing, coughing, and combing hair)."

G. During observation of Staff (S)12 [College Name] Student Nurse, on 09/19/23 at 9:34 am on the Medical/Surgical Unit, S12 came to P1 patient room with an isolation cart (a cart placed outside of a room containing PPE) and placed a liquid medication for infusion (a medication in a bag meant to be given directly into a vein), six alcohol pads (used for cleaning and disinfecting an area of the skin or intravenous access (a port used to administer fluids and medications directly into a vein)). S12 punctured the port without performing hand hygiene or cleaning the port with an alcohol pad. S12 put on an isolation gown and gloves without performing hand hygiene. Then S12 dropped the alcohol pads on the ground. S12 picked up the alcohol pads, placed them on the cart on top of the medication bag. S12 gathered the medication bag, the alcohol pads and the other supplies and entered the room without performing hand hygiene or changing gloves. During the observation on 09/19/23 at 9:36 am there were no registered nurses present to monitor S12 Student Nurse.

H. During an interview with S12 on 09/19/23 at 9:34 am, when asked "are you familiar with when to perform hand hygiene", S12 stated, "you need to talk to my instructor."

I. During interview with S8 RN Instructor [College Name] on 09/19/23 at 9:36 am, when asked who is responsible for the student nurses, S8 confirmed that the nursing instructors are responsible for the student nurses. When asked "do your students know how to perform hand hygiene", S8 stated "...um they should."

J. During observation of S7 [Name of College] Student Nurse, on 09/19/23 at 9:45 am on the Medical/Surgical Unit, S7 was observed walking from patient room wearing an isolation gown and gloves to the medication room, then from the medication room with a medication for infusion in their hands back to the patient room in the same isolation gown and gloves. S7 was observed touching her hair. S7 did not change gloves or perform hand hygiene. S7 picked up the medication for infusion and prepared to enter patient room.

K. During an interview with S8 RN Instructor [College Name] on 09/19/23 at 9:45. S8 RN Instructor was standing at the door to the patient room with S7 Student Nurse. When asked by surveyor "did your student [S7] perform proper procedure for standard precautions", S8 stated "yes."

L. During an interview with S13 Interim Nurse Manager of Medical Surgical Unit on 09/20/23 at 3:59 pm, S13 confirmed that a nurse or nursing student should not be walking around the unit in an isolation gown. S13 confirmed that hands should be washed or use hand sanitizer before putting on gloves and after taking them off, that gloves should be changed before preparing medications and after putting on an isolation gown. S13 confirmed that disposable supplies dropped on the floor should be discarded.