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Based on observation, interview, and record review, the facility failed to ensure signage was at the entrance, and patient care areas to inform patients of their EMTALA rights, and to inform patients a provider was not on site 24/7; and failed to ensure the facility had policies and procedures for EMTALA requirements. This has the potential to affect all patients who receive care in the facility. Findings include:

During an observation on 4/1/19 at 2:30 p.m., the emergency department EMTALA sign was sitting on a counter, behind a medication storage unit, and was propped against the wall with other items sitting in front of it. The EMTALA sign was not near the entrance of the emergency department or in an area noticeable to patients entering the emergency department. Staff member A stated the sign should be posted on the wall. Staff member A stated she would have staff post the sign, at the entrance, in the patient waiting area.

During an observation and interview on 4/2/19 at 8:00 a.m., there was an 8 x 10- inch EMTALA sign sitting on the desk, behind a plant, at the main registration desk. The sign was partially obstructed by the plant. The sign was not in an area that would be highly visible to patients registering at the desk. Staff member A stated she would ensure a sign was placed at the registration desk that was highly visible to the patients registering. Staff member A stated the main registration desk was sometimes used by patients registering to be seen by the emergency department.

During an observation and interview on 4/2/19 at 8:05 a.m., the front registration desk, waiting areas and entrances, did not have signage that showed the hospital did not have a provider on site 24/7. Staff member A stated the facility had made signs and she was not aware that they had not been posted. Staff member A stated she would obtain the signage and make sure it was placed at the main registration desk.

During an interview on 4/3/19 at 8:30 a.m., staff member B stated the facility did not have policies and procedures that addressed EMTALA requirements. Staff member B stated some of the facility's policies and procedures had not been installed into the new electronic system used by the facility.

Based on observation and interview, the facility failed to ensure patient care areas were disinfected after use and in-between patients to mitigate transmission of infections and communicable diseases in the radiology and therapy department. This has the potential to affect all patients receiving care and services in the radiology and therapy departments. Findings include:

During an observation and interview on 4/1/19 at 3:07 p.m., staff member C stated the radiology department used the green top PDI Sani-Wipes HB to cleanse all patient beds and equipment after use and in-between patients. The instructions on the wipes showed the surface area was to be kept wet for 10 minutes to provide disinfection of the surface. Staff member C stated she was not aware that the surface had to remain wet for 10 minutes. Staff member C stated the staff did not ensure the surface was wet for 10 minutes during the disinfection process.

During an interview on 4/2/19 at 3:48 p.m., staff member K stated she was new to her position and did not know which PDI Sani-Wipes were being used in each department of the hospital. Staff member K stated she would provide staff education as soon as possible to ensure all staff were consistent with the disinfecting process recommended by the product's manufactures recommendations for use.

During an observation and interview on 4/3/19 at 10:20 a.m., staff members D and E stated they used the PDI Sani-wipes HB to cleanse the patient equipment and mats. Staff members D and E stated they did not realize the disinfection requirements for the wipes showed the surface had to be kept wet for 10 minutes. Staff members D and E stated when they have used the wipes to disinfect they have not kept the surface wet for 10 minutes.

During the exit meeting on 4/3/19 at 7:15 p.m., staff member B stated she would fax the Policy and Procedure for disinfecting patent equipment and care areas. No submission was received.

Based on interview and record review, the facility staff failed to ensure a patient of child bearing age had been assessed for pregnancy prior to receiving radiologic studies¹ for 1 (#19) of 21 sampled patients in accordance with acceptable standards of practice. Findings include:

Patient #19 was admitted to the Emergency Department on 8/23/18 with diagnoses including multitrauma [sic] related to rollover motor vehicle collision and an open head injury. She was transferred via helicopter to a level-2 trauma center later that day for a higher tertiary of care.

Patient #19's electronic medical record lacked documentation showing staff had obtained, or checked, the status of pregnancy prior to radiological studies being performed by the facility. Radiographs and laboratory tests were performed prior to patient #19 being transferred to another hospital.

During an interview on 4/3/19 at 2:35 p.m., staff member C stated there was no way to know if staff had obtained a pregnancy status for patient #19 prior to obtaining radiography films. Staff member C stated the radiology technician was ultimately responsible for documenting the status of pregnancy prior to administering radiology studies, but there was no way of knowing if it had been done for this patient. Patient #19's medical record lacked this information.

Reference:

¹ https://www.who.int/tb/advisory_bodies/impact_measurement_taskforce/meetings/prevalence_survey/imaging_pregnant_arc.pdf

"The effort made to identify unsuspected pregnancy must be commensurate with the risk of not detecting a pregnancy."

Based on observation, interview, and record review, facility staff failed to maintain the confidentiality of patient protected health information (PHI) and guard against loss, destruction, or unauthorized use by keeping a "shred box" at the main nurse's station, the radiology department, laboratory department, and in the main entrance registration area (see C-308).

Based on interview and record review, the facility failed to ensure there was a designated member responsible for maintaining medical records and ensuring all records were completed, accurately documented, and were readily accessible for 1 (#16) of 21 sampled patients. Findings include:

Patient #16 was admitted to the facility on 10/29/18. The electronic medical record lacked nursing notes, assessments, and a care plan.

During an interview on 4/2/19 at 3:40 p.m., staff member B stated the electronic medical record lacked vital content for patient #16's record; no nurse's notes, assessments, and care plan were available. Staff member B stated it was possible the medical record for patient #16 had been scanned into someone else's record, but there was no way of knowing. Staff member B stated the medical records department did not have a designated member responsible for maintaining records.

During an interview on 4/3/19 at 8:30 a.m., staff member B stated, "Not all policies and procedures are installed into our system in medical records because we do not have a strong department. There are people doing pieces of it. Two people do the scanning and one person takes care of storage."

Based on interview and record review, the facility failed to ensure all admission history and physical exams, and discharge summaries, had been timed by the authenticating author for 19 (#s 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20) of 21 sampled patients. Findings include:

1. Patient #1 was admitted to the facility on 2/22/19.

A review of patient #1's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

2. Patient #2 was admitted to the facility on 3/1/18.

A review of patient #2's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

3. Patient #3 was admitted to the facility on 11/18/18.

A review of patient #3's electronic medical record lacked evidence showing the emergency room note had been time-stamped when authenticated by the author.

4. Patient #4 was admitted to the facility on 12/30/18.

A review of patient #4's electronic medical record lacked evidence showing the emergency room note had been time-stamped when authenticated by the author.

5. Patient #5 was admitted to the facility on 3/22/19.

A review of patient #5's electronic medical record lacked evidence showing the emergency room note had been time-stamped when authenticated by the author.

6. Patient #6 was admitted to the facility on 5/15/18.

A review of patient #6's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

7. Patient #8 was admitted to the facility on 12/24/18.

A review of patient #8's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

8. Patient #9 was admitted to the facility on 1/16/19.

A review of patient #9's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

9. Patient #10 was admitted to the facility on 3/6/19.

A review of patient #10's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

10. Patient #11 was admitted to the facility on 3/31/18.

A review of patient #11's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

11. Patient #12 was admitted to the facility on 11/12/18.

A review of patient #12's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

12. Patient #13 was admitted to the facility on 12/17/18.

A review of patient #13's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

13. Patient #14 was admitted to the facility on 3/22/19.

A review of patient #14's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

14. Patient #15 was admitted to the facility on 7/26/18.

A review of patient #15's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

15. Patient #16 was admitted to the facility on 10/29/18.

A review of patient #16's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

16. Patient #17 was admitted to the facility on 8/28/18.

A review of patient #17's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

17. Patient #18 was admitted to the facility on 1/22/19.

A review of patient #18's electronic medical record lacked evidence showing the admission history and physical exam, and his discharge summary, had been time-stamped when authenticated by the author.

18. Patient #19 was admitted to the facility on 8/23/18.

A review of patient #19's electronic medical record lacked evidence showing the emergency room note had been time-stamped when authenticated by the author.

19. Patient #20 was admitted to the facility on 8/4/18.

A review of patient #20's electronic medical record lacked evidence showing the emergency room note had been time-stamped when authenticated by the author.

During an interview on 4/2/19 at 1:20 p.m., staff member B stated all electronic medical records should have been time-stamped at the time of authentication by the author. Staff member B stated she would consult with the information technologist (I.T.) as to why medical records were not time-stamped.

During an interview on 4/3/19 at 2:55 p.m., staff member B stated she had discussed the missing time-stamping on electronic medical records with I.T. and was told there was a problem with the software program.

Based on observation, interview, and record review, facility staff failed to maintain the confidentiality of patient protected health information (PHI) and guard against loss, destruction, or unauthorized use by keeping a "shred box" at the main nurse's station, the radiology department, laboratory department, and in the main entrance registration area. This practice has the potential to affect all patients receiving care at the facility. Findings include:

During an observation and interview on 4/1/19 at 3:00 p.m., a large cardboard box labeled, "Shred Bin," was found under a desk at the main nurse's station. The box was wide open, it did not have a lid, and visible PHI could be seen at the bottom of the box. Staff member F stated discarded PHI was put into the box marked, "Shred Bin," until the PHI could be shredded. Staff member F stated facility staff, including housekeeping, maintenance, and information technologist, had access to the PHI in the open box at the nurse's station.

During an interview on 4/1/19 at 3:08 p.m., staff member G stated nursing staff were responsible with, "Emptying the shred box, into the locked janitorial room, every few weeks." A large, secured, 96-gallon, collection bin was observed in the janitorial room.

During an observation and interview on 4/1/19 at 3:35 p.m., a large cardboard box labeled, "Shred," was found under a table in the radiology department. The box was wide open, it did not have a lid, and visible PHI dated 3/24/19, was observed in the bottom of the box. Staff member C stated she was responsible for emptying the shred box once a week. Staff member C stated facility staff, including housekeeping, maintenance, and information technologist, had access to the PHI inside of the opened box in the radiology department.

During an observation and interview on 4/1/19 at 3:55 p.m., several medium-sized cardboard boxes with visible PHI found under three staff members' desks at the registration area. Staff member H stated each box was "tossed daily." Staff member H stated facility staff, including housekeeping, maintenance, and information technologist, had access to the PHI inside of the opened boxes at the registration desk.

During an observation and interview on 4/1/19 at 4:31 p.m., a large cardboard box labeled, "Shred," was found under a table in the laboratory department. Staff member I stated the open shred box in the laboratory was emptied every 2-3 weeks by the manager. Staff member I stated only housekeeping and maintenance had access to the secured laboratory department. Staff member I stated she would inquire about getting secured bins for PHI at working stations of the laboratory department.

During an interview on 4/1/19 at 4:44 p.m., staff member B stated she was making an inquiry into getting several secured shred bin containers for all the departments of the hospital. She stated she had several options and sizes available for ensuring all PHI was kept in secured collection bins in each department.

During an observation on 4/2/19 at 8:00 a.m., three cardboard boxes that contained PHI were sitting at each registration area at the front registration desk. The cardboard boxes were not secured with a lock and the PHI was exposed to anyone that was behind the registration desk. Several staff members were able to walk into the area to include nursing staff, maintenance staff, and housekeeping staff.

Review of the facility's policy, Information Technology Safeguards, revised 11/30/18, read, "The (facility name) is entrusted by individuals and required by law to ensure the security of individually identifiable health information. This protected health information (PHI) is preserved by law and regulatory requirements and those laws and regulatory requirements will be upheld by each individual involved with this organization."