HospitalInspections.org

Based on record review, observation, and interview, the facility failed to prevent unauthorized disclosure of patients' name, age, and other protected health information for 3 (P (patient)11, P12, and P13) of 13 (P1-P13) patients. This failed practice would likely lead to unauthorized disclosure of all patients' name, age, and other protected health information in this facility.

The findings are:

A. Record review of the facility's policy "RISK MANAGEMENT-Patient Rights & Responsibilities" "Effective Date: 08/10/2015":

1. "2.8 The organization respects the needs of patients for confidentiality, privacy and security."

2. "AS A PATIENT YOU HAVE THE RIGHT TO: ...The following in regards to your medical records and health information." "The right to confidentiality ..."

B. During observation on 11/16/23 at 4:09 am of 5th Floor Unit, a portable computer workstation was unlocked and open to P11's medical chart. There was no staff present. P11's name, age, medical record number, diagnoses, medical orders, and nursing flow sheets were visible.

C. During interview on 11/16/23 at 4:12 am with Staff (S)14, Registered Nurse (RN), was asked what is the expectation for the nurses if they need to leave the workstation when patient information is on the screen? RN stated, "We're supposed to lock the computers [block access to the computer desktop and any patient information until a security measure has been completed to gain access], when we get up and leave them..."

D. During observation on 11/16/23 at 4:20 am of 4th Floor Unit, a portable computer workstation was in hall unlocked and open to P12's medical chart. There was no staff present. P12's name, age, medical record number, diagnoses, medical orders, and nursing flow sheets were visible. At 4:28 am, a portable computer workstation was in hall unlocked and open to P13's medical chart. There was no staff present. P13's name, age, medical record number, diagnoses, medical orders, and
nursing flow sheets were visible.

E. During observation on 11/16/23 at 4:28 am, a portable computer workstation was in hall unlocked and open to P13's medical chart. There was no staff present. P13's name, age, medical record number, diagnoses, medical orders, and nursing flow sheets were visible.

F. During interview on 11/16/23 at 2:37 pm with S8 Assistant Chief Nursing Officer, was asked "What should staff do when leaving a workstation that has patient information on the screen?" S8 responded "Staff are trained not to leave workstations without badging out [blocks access to the computer desktop and any patient information until a security measure has been completed to gain access]."

Based on record review, observation and interview, the facility failed to meet the Condition of Participation for the prevention and control of HAIs (Hospital Acquired Infections) and other infectious diseases for all patients. This failed practice is likely to lead to infections, poor outcomes, and death for all patients of this facility.

The findings are:

A. The facility failed to ensure that all staff members and contract employees adhere to proper hand hygiene practices during patient care. Refer to Tag A-0749.

Based on record review, observation, and interview, the facility failed to ensure all staff members and contract employees adhere to proper hand hygiene practices. This failed practice is likely to lead to infections, poor outcomes, and death for all patients of this facility.

The findings are:

A. Record review of the facility's policy "IC [infection control] Hand Hygiene-IC-Corp" "Effective Date: 08/11/2017":

1. "Policy: 4) Definitions: a) Hand hygiene is a general term that applies to hand washing, antiseptic hand wash, antiseptic hand rub [or hand sanitizer], or surgical hand asepsis [removal of all microorganisms]"

2. "Procedure: 1) Indications for hand hygiene include inpatient ... settings:

a) Before contact with patient or items in the immediate vicinity ...d) When leaving a patient's room or at the end of caring for a patient-gel in and gel out [to use hand sanitizing gel before going into a patient room and to use hand sanitizing gel on leaving a patient room] ...f) Before donning [putting on] gloves and after removing gloves. Always."

B. During observation on 11/16/23 at 3:45 am on 5th Floor Unit an unidentified contract Phlebotomist (blood drawer) Staff (S)17, put on gloves without performing hand hygiene, entered room, exited room with gloves on, took gloves off, did not perform hand hygiene, and handled items on the cart.

C. During observation on 11/16/23 at 4:09 am on 5th Floor Unit, an unidentified contract Phlebotomist S18 put on gloves and entered patient room without performing hand hygiene.

D. During interview on 11/16/23 at 4:12 am with 5th Floor S14 Charge RN, it was asked, "When do you perform hand hygiene?" S14 stated "When we go into a room ...we always use gel [hand sanitizer] before we put on gloves and after we take them off and when we are done with the room."

E. During observation on 11/16/23 at 4:25 am on 4th Floor Unit, S21 Registered Nurse (RN) exited a patient room without performing hand hygiene.

F. During observation on 11/16/23 at 10:04 am on 9th Floor Unit S15 RN exited a patient room with gloves on, did not remove gloves or perform hand hygiene, retrieved supplies, re-entered patient room with same gloves on and did not perform hand hygiene.

G. During interview on 11/16/23 at 10:12 am with S9 Director for the 7th and 9th Floors, S9 confirmed all staff has training on hand hygiene every year. It was asked "What is the process for performing hand hygiene?" S9 stated ..."we gel in [use hand sanitizer], put on gloves, after we're done with a room we take off gloves and gel out."

H. During interview on 11/16/23 at 2:37 pm with S8 Assistant Chief Nursing Officer, confirmed hand hygiene should be performed before entering a patient's room, after contact with a patient, on exiting a patient room, before and after patient care.

I. During interview on 11/16/23 at 3:45 pm with S22 [Name of Laboratory] Onsite Manager for contract phlebotomists, S22 confirmed that phlebotomists are expected to follow the facility's protocol for hand hygiene.