HospitalInspections.org

Based on policy review, observations, medical record review, and interviews, the facility failed to follow procedures ensuring the confidentiality of patients' records in Building A, on three patient care units (5300, 6500, and 2300) of 22 patient care units observed.

The findings included:

Review of facility policy number MR-900-021, last reviewed on 2/3/14, revealed, "...medical records will be maintained in secure and restricted areas...medical records required in the patient care areas will be maintained in a controlled setting with 24-hour staffing observation..."

Review of the facility's privacy and security policy number IM-900-018, effective date 12/10/14, revealed, "...Access is protected through use of safeguards for all media, electronic, and hard copy records such as...Physical controls such as keys, door key pads, security cards..."

Observations of Building A, on the 5300 wing, on 5/19/15 at 9:50 AM, revealed an unlocked cabinet in the hallway outside of Patient #25's room, with the patient's medical record, which included name, date of birth, diagnoses, written/signed prescriptions, and discharge instructions. Continued observations of the 5300 wing revealed an unlocked cabinet outside of Patient #26's room with the patient's medical record containing name, date of birth, diagnoses, medications, and restraint flow sheets. Continued observation of the 5300 wing revealed Patient #45's medical record, which contained the patient's name, date of birth, diagnoses, and medications, lying on a counter in the hallway outside of the patient's room, unattended, with no facility staff nearby or in line of sight.

Interview with 5300 wing Nurse Manager and Patient Safety Officer (PSO) #2, on 5/19/15 at 9:50 AM, in the 5300 hallway, confirmed that all patient records on the Fifth Floor were stored in unlocked cabinets in the hallway outside of the patients' rooms.

Observation and tour of Building A, on the 6500 wing, on 5/20/15 at 8:30 AM with PSO #1 and the Rehab Manager, revealed unsecured medical records at the desks in the hallways by patient rooms 6509, 6510 and 6506. No staff members were in sight of the unattended records or the hallway in close proximity.

Interview with PSO #1 and the Rehab Manager on 5/20/15 at 8:30 AM, in the hallway, confirmed the records were exposed and unattended.

Interview with the Director of Medical Records on 5/20/15 at 9:10 AM, in the Director's office, revealed she would "expect [medical records] to be kept out of view."

Observation and tour of Building A, on the 2300 wing, on 5/20/15 at 9:15 AM with the Director of Medical Records, revealed unsecured medical records at the desks in the hallways by patient rooms 2308 and 2312.

Interview with the Director of Medical Records on 5/20/15 at 9:15 AM, in the hallway on the 2300 wing, confirmed the medical records were unsecured and unattended.

Interview with Registered Nurse (RN) #1 on 5/20/15 at 9:20 AM, in the 2300 nursing station, confirmed the records were not supposed to be "out in the open", her "job is to make sure they are up and all cabinets are unlocked."

Interview with the Quality Manager on 5/20/15 at 9:45 AM, in the conference room, confirmed medical records were to be secured and all the cabinets were unlocked.

Based on observation, interview, and record review during a validation survey for Life safety, the facility failed to maintain the Conditions of participation for the physical environment to ensure the safety of the patients.
The findings included:
1. Observation, interview, and record review, with the Maintenance Director, at Johnson City Medical Center (Building A), on May 26 and 27, 2015 between 8:00 a.m. and 4:00 p.m. it was confirmed the facility failed to ensure sprinklers were maintained and properly installed, and failed to maintain the kitchen hood systems. (Reference Life Safety Tags: K056, K062, and K069.)
2. Observation, interview, and record review, with the Maintenance Director at Woodridge Psychiatric Hospital (Building B), on May 27, 2015 between 9:00 a.m. and 3:00 p.m. it was confirmed the facility failed to ensure hazardous area's fire-rated construction was maintained, failed to ensure locked exit doors could be readily unlocked, failed to ensure sprinklers were not mis-matched with Quick response and standard response heads, failed to provide non-slip egress to a public way, and failed to ensure GFCI protected outlets were in wet areas. (Reference Life Safety Tags (Building 3): K029, K038, K051, K056, K130, and K147.)

Based on policy review, observations, interview, and review of the Association of Perioperative Registered Nurses (AORN) guidelines, the facility failed to implement policies and procedures for controlling infections in 3 patient care units (5200, 7500, and the Emergency Department/ED) of 42 units observed in Building A; 2 Cardiac Cath Labs (#3 and #4) (a procedure room in which an invasive procedure involving cardiac catheterization is performed) of 6 Cardiac Cath Labs observed in Building A; and 1 unit (Laurel) of 5 units observed in Building B.

The findings included:

Review of the facility's Isolation Precautions policy, number IC-600-003, effective date 2/20/15, revealed, "PPE (personal protective equipment) should be donned prior to entering the patient's room and removed upon exiting the patient's room...Contact/Droplet Precautions...shall wear gown, gloves, and surgical mask upon entering the room, which should be removed upon exiting the room..."

Observation of patient room number 5213 on 5/19/15 at 9:00 AM, revealed a sign stating "Contact/Droplet Isolation" on the door. Further observation of room 5213 revealed respiratory therapist (RT) #1 removed her gown, gloves and mask, placed these in a hazardous waste container on the opposite side of the room from the exit, and walked past the patient and bed to exit the room without any PPE.

Interview with RT #1 and the Patient Safety Officer (PSO) #2 on 5/19/15 at 9:00 AM, outside room number 5213, confirmed RT #1 removed her gown, gloves, and mask inside the room and, without PPE, walked past the patient to the exit. Further interview with PSO #2 confirmed the hazardous waste container should be next to the exit and not on the opposite side of the room from the exit.

Review of the facility's Infection Control policy number IC-700-019, effective date 1/9/2015, revealed, "...Glucometer...Must be disinfected between patient use..."

Review of the facility's undated Policy and Procedure for Cleaning Nova StatStrip Glucometer (a device used to measure the amount of sugar/glucose in the patient's blood) revealed, "...all glucometers will be thoroughly wiped with disinfectant and allowed to air dry after every use..."

Observation in Building B, of the medication room on the Laurel Unit, on 5/18/15 at 11:30 AM, revealed the glucometer was stored ready for use and was visibly soiled with dried brown stains.

Interview with the Nurse Manager on 5/18/15 at 11:30 AM, in the Laurel Unit medication room, confirmed the stored glucometer was soiled with dried brown stains.

Observation in Building A, of the medication room on the 7500 unit on 5/18/15 at 1:50 PM, revealed the glucometer was stored ready for use and was visibly soiled with dried brown stains.

Interview with PSO #2 on 5/18/15 at 1:50 PM, in the 7500 medication room, confirmed the stored glucometer was stored ready to use and was soiled with dried brown stains.

Observation on 5/19/15 at 10:30 AM, in the Emergency Department (ED) in Building A, revealed a blood glucose monitoring device with red dried dirty debris observed on the machine.

Interview with the ED Nurse Manager on 5/19/15 at 10:31 AM, in the ED hallway, confirmed the blood glucose monitor was dirty. Further interview revealed "...the nurses should clean the monitor after each use..."

Review of the facility's Surgical Attire - Perioperative policy effective date 7/7/14, revealed, "...if a reusable head covering is used, it must be covered with a disposable head covering...surgical mask must be worn in surgical environments where open sterile supplies or scrubbed persons are located...a mask should fully cover both nose and mouth and be secured to prevent venting..."

Review of AORN Guidelines for Surgical Attire for 2015 revealed, "...surgical attire and cover apparel should be laundered in a health care-accredited laundry facility after each use and when contaminated..."

Observations in Building A, of Cardiac Cath Lab #3 on 5/19/15 from 2:15 PM to 2:30 PM, revealed one Registered Nurse (RN) and two surgical scrub technicians (SST) preparing the room for a cardiac catheterization (a sterile procedure where a small plastic tube is inserted inside an artery and advanced inside the patient's heart) and were assisting with the procedure while wearing uncovered re-usable hats.

Observations in Building A, of Cardiac Cath Lab #4 on 5/19/15 from 2:15 PM to 2:30 PM, revealed two SSTs preparing the room for a cardiac catheterization and assisting with the procedure while wearing uncovered re-usable hats. Further observation revealed one SSTs mask was below her nose leaving her nose uncovered while she assisted in preparing the surgical instruments for the procedure.

Interview with Cardiac Cath Lab's nurse manager, in the control room between Cardiac Cath Lab #3 and #4, on 5/19/15 at 2:30 PM, confirmed the RN and 2 SSTs in #3, and the 2 SSTs in #4, were wearing uncovered re-usable fabric hats in the Cardiac Cath Labs before and during the procedures. Further interview revealed it is the facility's practice to allow surgical staff to wear re-usable hats in the Cardiac Cath Labs, and staff take the caps home to launder each day. Further interview confirmed the SST in Cardiac Cath Lab #4's surgical mask was not covering her nose during preparation for the procedure, and surgical masks were to completely cover the mouth and nose.

Interview with the Infection Prevention Manager on 5/20/15 at 10:30 AM, in the administration conference room, revealed it was facility policy that re-usable hats must be covered with a disposable hat when worn in the Cardiac Cath Labs. Further interview with the Infection Prevention Manager revealed surgical masks must cover the mouth and nose fully whenever surgical instruments are open in the Cardiac Cath Labs. Further interview revealed glucometers must be cleaned after each patient use. Further interview with the Infection Prevention Manager revealed the hazardous waste containers in an isolation room must be placed near the door to allow staff to exit the room immediately after removing their PPE.



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