HospitalInspections.org

Based on observation, staff interviews and record review the facility failed to ensure for 6 patients that all clinical information remains confidential and out of site of the general public.

Findings;

Observation on 12/05/2011 at 9:10 AM on the second floor hall out side of room 219 revealed a the medical record of the patient in room 219 stored between the hand rail and the wall.

Observation on 12/05/2011 at 9:12 AM on the second floor hall out side of room 280 revealed a the medical record of the patient in room 280 stored between the hand rail and the wall.

Observation on 12/05/2011 at 9:19 AM revealed two computer monitors left unattended at the nurse work station one on each side of the hall, facing the general traffic area in the west hall on the third floor. No one was observed at either monitor.

Observation on 12/05/2011 at 9:30 AM revealed two computer monitors left unattended at the nurse work station one on each side of the hall, facing the general traffic area in the north hall on the second floor. No one was observed at either of the nurse work stations.

The Systems Director of Performance Improvement was present at the time and acknowledged the computers should have timed out and not been left on revealing the patients information. She stated the computer times itself off and changes to the screen saver when there is no activity.
On 12/08/2011 at 11:00 AM an interview was conducted with the Director, Health Information Management/Privacy Officer. She stated during the orientation process the employees are informed of the policies and procedures for taking appropriate measures to maintain confidentiality of electronic protected health information that is being used at the workstations. She also stated the computers are equipped with a screen that when touched with the hand goes into sleep mode so the screen is not visible.
A review of the 2011/2012 HIPAA Training orientation and general training revealed training in signing off computers when leaving a work area and making sure the computer screens containing protected health information are not visible to others not involved with the patient.
A review of the policy on Workstation Use dated 04/03/2008 revealed all workstations that have access to electronic protected health information shall automatically logoff from access to electronic protected health information after 30 minutes of inactivity. The policy on Workstation Security states Any workstation that could display protected health information on a monitor or machine should employ the use of safeguarding of the protected health information. Safeguards such as position of monitor away from public view or the use of privacy screens to distort the view.
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Based on observation, interview and record review the hospital failed for 2 of 48 observations, for patient #22 to ensure medication was given as ordered and within accepted standards of practice.

FINDINGS:

1. On 12/07/2011 during the 10:25 AM medication administration, RN, (Registered Nurse), #1 was observed taking a Omeprazole 40 milligrams (mg). Levothyroxine 112 micrograms (mcg), and Famotidine 20 mg to patient # 22.

2. The Medication Administration Record dated 12/07/2011 indicated the Omeprazole was to be given daily before breakfast at 7:30 AM.

At 10:40 AM in an interview with RN # 1 she revealed she had not given the medication before breakfast. She did not realize she had a medication to give before breakfast.

An interview with the Director of Pharmacy Spring Hill Regional Hospital on 12/07/2011 at 11:30 AM revealed Omeprazole was scheduled before breakfast and is normally given between 7 and 7:30 AM to administer on an empty stomach and due to metabolism.

A review of the literature from Clinical Pharmacology, dated 2011 titled Omeprazole, Administration Information indicated "Administer on an empty stomach, 30 minutes before meals".

3. The review of the Levothyroxine Administration Information from Clinical Pharmacology dated 2011 and furnished by pharmacy revealed: Administer on an empty stomach with a full glass of water at least 30-60 minutes before breakfast. Administer apart from medications known to decrease absorption.

The time indicated on the Medication Administration Record for Levothyroxine was 10:00 AM.

On 12/07/2011 at 10:40 AM in an interview with RN #1 she stated she did not question the time for the administration of the Levothyroxine.

4. On 12/07/2011 at 11:30 AM an interview with the Director of Pharmacy Brooksville Regional Hospital was conducted. When state the hospital system SAM (safe administration medication system) is noted to give medication at a particular time. The routine hospital medication administration time is 10:00 AM unless the physician orders a different time. The physician for this patient did not order the thyroid medication for a particular time. The system defaulted to 10:00 AM as the time to give the medication. She further stated the pharmacy should have recognized the duplicate therapy for Famotidine and Omeprazole.

In an interview was conducted on 12/08/2011 at 8:45 AM with the Director of Pharmacy Brooksville Regional Hospital, revealed that the pharmacy system flags Levothyroxine (Synthroid) to be given as recommended by the drug manufacturer. In this case the Levothyroxine would be flagged to be given before breakfast at the early medication time of 7:30 AM. He also stated that both hospitals are on the same pharmacy system.

The review of the package information for Levothyroxine (Synthroid) revealed: Synthroid is administered as a single daily dose, preferably one-half to one-hour before breakfast. Synthroid should be taken at least 4 hours apart from drugs that are known to interfere with its absorption. Under information for patients reads: Agents such as iron and calcium supplements and antacids can decrease the absorption of levothyroxine sodium tablets. Therefore, levothyroxine sodium tablets should not be administered within 4 hours of these agents.

Based on Medical record review, staff interviews and facility document review the facility failed for 3 of 3 outpatients, (#14, #15, and #17) to complete the Post-Anesthesia discharge record.

FINDINGS:

1. Review of the Post-Anesthesia discharge note section of the Perioperative Consultation form for patient #14 dated 11/22/2011 was left blank except for the signature.

2. Review of the Post-Anesthesia discharge note section of the Perioperative Consultation form for patient #15 dated 11/28/2011 was left blank.

3. Review of the Post-Anesthesia discharge note section of the Perioperative Consultation form for patient # 16 dated 11/23/2011 was left blank except for the signature.

4. The review of the policy for Anesthesia: Anesthesia Continuum of Care effective 11/11 revealed: A post anesthesia evaluation must be completed and documented no later than 48 hours after surgery or a procedure requiring general, regional or monitored anesthesia care. For moderate sedation a different documentation form describing post procedure status is required. The post anesthesia assessment must be conducted by a qualified anesthesiologist or anesthesia provider under the immediate supervision of an anesthesiologist. The post anesthesia assessment must include, at a minimum:

Respiratory function, including respiratory rate, airway potency and oxygen saturation
Cardiovascular function, including pulse rate and blood pressure
Mental status
Temperature
Pain
Nausea and vomiting
Postoperative hydration
The 48 hour time period begins at the point the patient is moved into the recovery area, though the assessment of the patient may not begin until the patient is sufficiently recovered from the acute administration of anesthesia so as to participate in the evaluation. For outpatients, the assessment must occur before discharge from the facility.

5. An interview was conducted with the Systems Director of Performance Improvement on 12/06/2011 at 3:00 PM. She stated the policy of the hospital was to have the post-anesthesia discharge note completed within 48 hours and the medical staff had been informed of the policy.

On 12.08/2011 at 11:30 AM and interview was conducted with the Director of Health Information Management/Privacy Officer. She stated the patient records are reviewed for completeness including signatures.

Based on Medical record review, staff interviews and facility document review the facility failed for 2 of 6 patients, (#17 and #19) to complete the Post-Anesthesia discharge record.

FINDINGS:

1. Review of the Post-Anesthesia discharge note on the Perioperative Consultation form dated 11/28/2011 for patient #17 was left blank.

2. Review of the Post-Anesthesia discharge note on the Perioperative Consultation form dated 11/29/2011 for patient #19 was left blank except for the signature.

3. The review of the policy for Anesthesia: Anesthesia Continuum of Care effective 11/11 revealed: A post anesthesia evaluation must be completed and documented no later than 48 hours after surgery or a procedure requiring general, regional or monitored anesthesia care. For moderate sedation a different documentation form describing post procedure status is required. The post anesthesia assessment must be conducted by a qualified anesthesiologist or anesthesia provider under the immediate supervision of an anesthesiologist. The post anesthesia assessment must include, at a minimum:

Respiratory function, including respiratory rate, airway patency and oxygen saturation
Cardiovascular function, including pulse rate and blood pressure
Mental status
Temperature
Pain
Nausea and vomiting
Postoperative hydration
The 48 hour time period begins at the point the patient is moved into the recovery area, though the assessment of the patient may not begin until the patient is sufficiently recovered from the acute administration of anesthesia so as to participate in the evaluation. For outpatients, the assessment must occur before discharge from the facility.

4. An interview was conducted with the Systems Director of Performance Improvement on 12/06/2011 at 3:00 PM. She stated the policy of the hospital was to have the post-anesthesia discharge note completed within 48 hours and the medical staff had been informed of the policy.

On 12.08/2011 at 11:30 AM an interview was conducted with the Director of Health Information Management/Privacy Officer. She stated the patient records are reviewed for completeness including signatures.