HospitalInspections.org

Based on observation, policy review, and staff interviews, it was determined the facility failed to ensure that medical records were secured from non-hospital staff/visitors.
The findings include: Review of the facility policy titled "release of medical information" revealed the facility had a policy in place to ensure confidentiality of medical information. According to the policy, employees were responsible for maintaining patient privacy and confidentiality and a breach of patient confidentiality may result in disciplinary action.
Observation during a tour of the medical surgical floor on June 1, 2010, at 1:50 p.m., revealed medical records were stored inside metal cabinets located down each hallway. The metal cabinets were hanging on the wall outside the patient rooms. Further observation revealed the metal cabinets were unlocked/unsecured, allowing the medical record to be accessible to visitors/non-hospital staff.

Interview with the Director of Nursing on June 1, 2010, at 2:00 p.m., revealed the medical records were kept in medical cabinets near patient rooms for the physicians and staff to document. According to the Director of Nursing, the metal cabinets had key locks but the cabinets were never locked. The Director of Nursing stated the Unit Clerk monitored the three hallways where medical records were stored.

Interview with the Unit Clerk on June 2, 2010, at 1:00 p.m., revealed the Unit Clerk's duties included reading charts, noting physician orders, answering the telephone, etc. At the time of the interview staff was standing at the desk talking with the Unit Clerk. Further observation revealed staff blocked the Unit Clerk's view of the hallways where the metal cabinets/medical records were located.

Interview with the Risk Manager on June 2, 2010, at 6:45 p.m., revealed "some" medical information was kept on the computer but "most" medical information was located in the medical record. The Risk Manager stated medical records were kept in pull-down cabinets outside the patient rooms. The Risk Manager stated the cabinets were used as a desk for staff to chart. The Risk Manager stated the Unit Clerk "manned" the metal cabinets and according to the Risk Manager, the metal cabinets which contained medical information were in view of the Unit Clerk. The Risk Manager was present at the nursing desk on June 2, 2010, at 1:00 p.m., when the Unit Clerk's view was blocked by staff standing at the desk. The Risk Manager stated, "I could see how that might be a problem."

Based on interviews and a review of documentation, the facility failed to ensure performance improvement projects had been conducted for all departments of the facility. Interviews revealed the facility had failed to ensure the Physical Therapy Department of the facility had participated in the hospitalwide quality assurance program.

The findings include:

A review of the facility's Performance Improvement (PI) Plan for 2010 revealed the objective of the plan was to provide a collaborative, interdisciplinary, facilitywide framework for designing processes, monitoring performance through data collection, analyzing current performance, and improving and sustaining performance. The process was formulated to enable enhancements to be made in the services offered and to enable the achievement of providing the highest quality of care.

Interview with the Director of the Physical Therapy (PT) Department of the facility on June 2, 2010, at 10:40 a.m., revealed the Physical Therapy Department had not participated in the facilitywide PI program. The Director of the PT Department stated the PT Department had developed criteria for the PT Department to monitor for the purpose of performance improvement but had not been asked to submit the information or participate in the facility's program.

Interview with the Performance Improvement Director on June 2, 2010, at 5:50 p.m., revealed the Physical Therapy Department had not been included in the facilitywide PI program due to an oversight. Although the PI Director stated physical therapy services were reviewed as part of the medical record review, the Director stated there had not been a PI plan developed specifically for the PT Department as required by the PI Plan.

Based on interview and a review of policies, the facility failed to ensure necessary training had been provided to ensure the competency of dietary personnel. Interview and a review of documentation revealed planned training for dietary personnel to ensure personnel competencies in their respective duties had not been conducted.

The findings include:

A review of the facility's policies revealed a policy related to in-service training of dietary personnel. According to the policy, the Director of the Food and Nutrition Services was to schedule in-services appropriate to meet the needs of the Food and Nutrition Services Department. The policy required the Director to maintain an in-service calendar that indicated dates of in-services conducted and by whom, as well as maintain a record of those in attendance. The Director was required by policy to post in-service schedules with sufficient advance notice so as to insure that the entire dietary staff received notification. In addition, the policy required dietary staff to attend the scheduled in-services and any missed in-services were to be made up.

Interview with the dietitian on June 2, 2010, at 10:05 a.m., revealed the dietitian was employed on a part-time basis, was present at the facility three days a week, and available by telephone on other days. The dietitian reportedly had not planned in-services for personnel in the Dietary Department. The dietitian stated the training should be conducted on a quarterly basis, and stated the Dietary Manager conducted the training.

Interview with the Dietary Manager on June 2, 2010, at 10:10 a.m., revealed the Dietary Manager directed the services and personnel in the Dietary Department. Interview revealed the Dietary Manager provided "on the job" training for staff in the Dietary Department and the Manager relied on the dietitian to provide planned in-service training to dietary personnel. The Dietary Manager stated the "on the job" training was not documented and that there had not been any planned in-services in the Dietary Department since September 2008 for dietary personnel to ensure competencies in the employee's respective duties.

Based on observation, interview, and a review of menus, the facility failed to ensure the menus met the nutritional needs of the patients. Interview and observation revealed the facility did not always follow the scheduled menu and did not document when substitutions were made.

The findings include:

Interview with the Dietary Manager on June 1, 2010, at 3:40 p.m., revealed the facility utilized a planned seven-day cycle menu for patients in the facility. Observation of the evening meal preparation on June 1, 2010, and a review of the posted menu revealed the meal prepared was not the meal that had been planned on the menu for June 1, 2010. According to the Dietary Manager, a food item on the menu for the evening meal on June 1, 2010, was not available and staff substituted the evening meal with the evening meal that had been scheduled for June 2, 2010. However, the substitution had not been recorded on the menu in order to avoid repetition of meals. In addition, the Dietary Manager stated a substitution had also been made for the noon meal on June 1, 2010. The Dietary Manager stated "chicken pot pies" had been substituted for the noon meal for patients of the facility during the noon meal on June 1, 2010, because staff thought the patients would enjoy the substitution. The substitution had not been recorded. A review of diet orders for patients in the facility on June 1, 2010, revealed the physician-requested diets included orders for 4-gram sodium, heart healthy, and 1800-calorie American Diabetic Association (ADA) diets. The Dietary Manager stated substitutions were not always recorded and the dietitian had not always been consulted regarding substitutions. The Dietary Manager was uncertain if the substitution of the meal prepared at noon on June 1, 2010, had met the nutritional needs/requirements of the patients.

Interview with the facility's dietitian on June 2, 2010, at 10:05 a.m., revealed the dietitian was available at the facility three days a week and available by telephone on remaining days. The dietitian stated she had not been consulted regarding the substitutions of the noon and evening meal on June 1, 2010. The dietitian was unaware facility staff did not always document menu substitutions in order for the nutritional requirements and specific diet needs of the patients to be determined. In addition, the dietitian stated the substitution of the chicken pot pie at the noon meal on June 1, 2010, had not been an approved meal substitution, and was uncertain if the substitution had met the nutritional needs of the patients, especially patients on diabetic or sodium-controlled diets.

A review of a facility policy regarding menu planning revealed the menus were to be reviewed by the dietitian to determine the nutritional adequacy and menu variety based on the approved Diet Manual.

Based on observation and interview it was determined the Condition of Participation: Physical Environment was not met. The facility failed to maintain the physical environment to ensure the safety and well-being of patients.


A full Life Safety Code survey was initiated and concluded on June 2, 2010. Life Safety Code, 42 CFR 483.70, deficiencies were cited that determined the Condition of Participation for Physical Environment at 42 CFR 482.41 was not met. Refer to tag K052.