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Based on record review, staff interview and observation, the facility failed to ensure 3 of 3 patient medical records were protected and kept confidential from unauthorized persons.

Findings include:

During an interview with the Release of Information Clerk on 3/4/14, in the main reception area of the Medical Records department, it was noted a bookshelf contained three patient records. One of the records contained, a Magnetic Resonance Imaging (MRI) report attached to a large envelope. The MRI report was wedged between two shelves and was face up, making the patient information and medical findings of the patient visible to anyone walking by the bookshelf. Two other records were stored on the shelf and contained confidential patient medical information.

The Release of Information Clerk indicated two of the records were awaiting pick up and the other record was pending a pre-payment for a release of the record. The clerk indicated all records were kept behind closed doors which could only be accessed with a key by staff members. The clerk revealed the door to the main reception area (where the bookshelf was located) remained unlocked during business hours and would at times remain unattended by staff.

The Medical Records Supervisor revealed to prevent unauthorized access to medical records in the hospital, all doors leading into the Medical Records department required a staff key.

Both the Release of Information Clerk and Medical Records Supervisor acknowledged files were susceptible to unauthorized access.

The facility's "Release of Patient Health Care Information" policy last reviewed on 12/24/13 revealed "Patient health records will be maintained in such a manner as to ensure maximum confidentiality. Health care records are the property of the health care system and must be protected against unauthorized disclosure. The information contained in the record belongs to the patient, and as such, will only be released with the consent of the patient (or legal guardian)."

Based on record review, interview and observation, the facility failed to ensure patient record confidentiality and protect medical records from unauthorized access for 3 of 3 patient records.

Findings include:

During an interview with the Release of Information Clerk on 3/4/14, in the main reception area of the Medical Records department, it was noted a bookshelf contained three patient records. One of the records contained, a Magnetic Resonance Imaging (MRI) report attached to a large envelope. The MRI report was wedged between two shelves and was face up, making the patient information and medical findings of the patient visible to anyone walking by the bookshelf. Two other records were stored on the shelf and contained confidential patient medical information.

The Release of Information Clerk indicated two of the records were awaiting pick up and the other record was pending a pre-payment for a release of the record. The clerk indicated all records were kept behind closed doors which could only be accessed with a key by staff members. The clerk revealed the door to the main reception area (where the bookshelf was located) remained unlocked during business hours and would at times remain unattended by staff.

The Medical Records Supervisor revealed to prevent unauthorized access to medical records in the hospital, all doors leading into the Medical Records department required a staff key.

Both the Release of Information Clerk and Medical Records Supervisor acknowledged files were susceptible to unauthorized access.

The facility's "Release of Patient Health Care Information" policy reviewed on 12/24/13 revealed "Patient health records will be maintained in such a manner as to ensure maximum confidentiality. Health care records are the property of the health care system and must be protected against unauthorized disclosure. The information contained in the record belongs to the patient, and as such, will only be released with the consent of the patient (or legal guardian)."

Based on observation, policy review and staff interview, the facility failed to secure medication rooms and crash carts containing medications.

Findings include:

On 3/3/14, the following observations were made on the facility's inpatient units:

Telemetry Unit - The medication room was found unlocked. An unlocked refrigerator in the medication room was found to contain an open vial of Novolog. Unsecured medications were found in the room outside of the Pyxis.

Medical Oncology Unit - The door to the medication room was unlocked and unsecured medications were found in the room. The unsecured medications included intravenous solutions and antibiotics awaiting admixture. On 3/3/14, a unit clerk was interviewed and reported all staff was authorized to enter the medication room.

Pediatric Unit - The door to the medication room was found to be unlocked. A nurse from the unit was interviewed on 3/3/14, and reported the door should have been locked. The nurse was observed to store the key to the medication room in a desk drawer.

Surgical Intensive Unit - The door to the medication room was found to be unlocked.

On 3/4/14, the following observations were made:

Orthopedic Unit - A large unlocked metal box labeled"Compartmental Syndrome Test" was observed at the nurses station. The box contained five expired saline syringes.

Critical Care Areas - The medication rooms and medication refrigerators containing drugs were found to be unlocked. An interview conducted with nursing staff on 3/4/14, revealed all staff, including housekeepers, were able to enter the medication rooms.

Crash Carts

On 3/3/14 and 3/4/14, the following observations were made regarding crash cart medication security:

Crash carts containing medications in the Emergency Department were found to be unlocked. Break-away locks were not used. Medications within the crash cart were in an easily removable box. The box was covered with a see through plastic cover that could be easily pierced allowing drugs to be removed.

The Emergency Department crash carts contained Adenosine, Amiodarone, Atropine, Calcium Chloride, Dextrose, Dopamine, Epinephrine, Lidocaine, Magnesium Sulfate, Naloxone, Procainamide, Sodium Bicarbonate, Vasopressin and Verapamil.

During an interview with the Pharmacy Manager 3/4/14 at 10:00 AM, the manager confirmed the crash carts were stored in patient rooms #1 through #4 and indicated it was up to the nurses judgement whether a patient could be left in a room with an unsecured crash cart.

Observations made on the remaining hospital inpatient areas revealed all crash carts were left unlocked and contained medications.

Observations made on 3/4/14 , at an off-campus urgent /emergent care revealed there were two crash carts stored in the trauma room. Both crash carts were unlocked and contained medications. At the time of observation, a patient was in the trauma room.

During an interview with the Chief Nursing Officer (CNO), Employee #5, she confirmed there was no policy addressing medication room and crash cart security. The CNO confirmed there was no list of personnel authorized to enter the medication rooms.

Review of the facility's policy entitled "Security of Staff and Drugs", Policy #20-01, effective date 6/1/05, revealed the policy did not address medication room security, crash cart security or staff access to drug storage areas outside the pharmacy.

Based on observation and staff interview, the facility failed to remove expired drugs from the drug supply for patient use and failed to date multidose vials upon opening.

Expired Drugs

On 3/4/14, the Orthopedic Surgery Unit on the second floor was observed. There was a large metal box affixed to the wall at the nurses station with the words "Compartmental Syndrome Test Kit" written on it. The metal box was unlocked and was found to contain five "Stryker Instruments" syringes filled with 3 cc of sterile saline. The syringe's labels indicated they expired on 6/1/13.

The charge nurse was interviewed on 3/4/14, and reported staff did not routinely look in the metal cabinet. The nurse confirmed the drugs were expired and disposed of the syringes.



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Observation at off campus urgent/emergent care

On 3/5/14 at approximately 10:30 AM, an observation was done at an off campus urgent/emergent care. A 50 milliliter (ml) vial of Bupivicaine and a 30 ml vial of Xylocaine were observed on the counter. The vials were opened and undated. The registered nurse reported they were thrown away at the end of the shift.

Observation at an off campus physical therapy site

On 3/5/14 at approximately 12:30 PM, an observation was done at an off campus physical therapy location. An opened vial of Dexamethasone was observed. The vial was not dated. The physical therapist reported the Dexamethasone was used for the iontophoresis therapy. The physical therapist reported they rarely used it and had no idea of when the Dexamethasone was opened.

Review of the facility policy, Multiple Use Sterile Drugs, with an effective date of 12/15/13, revealed the following under length of use of multiple-use sterile drugs:

"Multiple-use containers of sterile drugs shall be dated and initialed or signed when first opened or entered.

After inital entry, mulitple-use sterile durgs may be used up to 28 days after the date first opened or entered provided they are in date, contain a preservative, and show no evidence of contamination."

On 3/5/14, the Director of Infection Control was interviewed and reported that all vials were considered single use and were to be disposed after opening.

Based on observation, review of laboratory temperature logs and confirmation with laboratory personnel, room temperature records were not consistently documented in laboratory locations to ensure that manufacturer's temperature requirements for the performance of laboratory tests and the storage of laboratory supplies were met.

Findings include:

1. A temperature log reviewed for January 2014 at Carson Tahoe Urgent Care, Carson City showed 11 of 31 room temperature records missing.
2. A temperature log reviewed for March 2014 at the Clinic at Walmart at 3770 US 395 South, Carson City, showed 6 of 6 room temperature records missing.
3. The log sheets at all clinic locations did not have a column to record room temperatures and there was no acceptable range documented for room temperatures to ensure the proper storage and testing conditions for the laboratory.

Based on observation, interview, and policy review, the facility failed to ensure preventive maintenance was performed as required for autoclaves, hand washing was performed as required, and general infection control practices were consistent throughout the healthcare system.

Findings include:

Surgical Observations

On 3/3/14 from 9:30 AM to 1:30 PM, observations were made during a surgical procedure. The circulating nurse was observed to crawl on the floor to adjust the connections for the sequential compression device (SCD). The circulating nurse was observed to perform hand hygiene before moving on to the next task. The circulating nurse had to get on the floor a second time to make another adjustment to the connection for the SCD. The circulating nurse was not observed to perform hand hygiene. The surgeon had a needle needing disposal, and he dropped the needle on the foot stool. The circulating nurse put on a glove, picked up the needle with a glove, and then take the glove off, trapping the needle inside the glove. The circulating nurse was not observed to perform hand hygiene after removing the glove. The circulating nurse dropped a pack of sutures on the floor. The circulating nurse was not observed to perform hand hygiene after picking up the pack of sutures.

The anesthesiologist was observed to take her gloves off and make adjustments to the equipment throughout the surgical procedure. The anesthesiologist was observed to put on a new pair of gloves without performing hand hygiene.

On 3/4/14, an endoscopic procedure was observed. Registered Nurse (RN-Employee #17) was observed giving medication through an intravenous saline port. The RN cleansed the port with an alcohol wipe before administering the first medication. The RN was not observed to consistently clean the port with alcohol before administering subsequent doses of medication.

During the endoscopic procedure a registered nurse assisted with the positioning of the patient. The first procedure was completed, and the patient was positioned for the second procedure. The RN was not observed to perform hand hygiene.

On 3/4/14, the Director of Infection Control was interviewed. The surgery and endoscopy observations were discussed. The Director of Infection Control reported the expectation was to perform hand hygiene each time gloves were removed and before moving to another task or putting on a pair of new gloves. The Director of Infection Control reported the saline port should be cleansed with an alcohol wipe before each injection.

Physical Therapy Observation

On 3/5/14 at approximately 12:30 PM, an observation was done at an off campus physical therapy location. A jar of massage cream was on the counter. A physical therapist was interviewed regarding the application of the massage cream to a patient. The physical therapist reported he used his hands to remove the cream to apply to a patient. The physical therapist reported he washed his hands thoroughly and frequently.

On 3/5/14 at approximately 2:30 PM, the Director of Infection Control was interviewed regarding the observation at the physical therapy site. The Director of Infection Control reported the therapists should use a tongue blade to remove the cream to apply to a patient.

Review of the facility policy, Infection Control: Central Services, with an effective date of 5/1/13 revealed the following under handwashing facilities are available within the department:

"Hands will be washed with hospital approved soap using friction:
After handling contaminated items,
after removing gloves or other personal protective equipment..."


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Sterilizing Equipment:

On 3/4/14 in the morning, the steam sterilizer located on the third floor Labor & Delivery Operating Room (OR) had an inspection tag which indicated the next inspection was due by February 2014.

On 3/4/14, the Lead OR Technician and the Patient Safety Director verified the unit had not been inspected and tagged by the contracted agency to perform preventative maintenance (PM) by the due date of February 2014.

On 3/5/14 in the morning, the Patient Safety Director further indicated all of the facility's steam sterilizers were not inspected and PM not performed timely by the end of February 2014 (including 3 located in the OR's, 3 located in Central Supply, 1 in the Labor & Delivery OR, and 2 located in the Outpatient Surgery Center).

On 3/5/14 in the afternoon, the contracted Biomed Manager indicated all steam sterilizers should be inspected and PM service provided in accordance with the manufacturer's guidelines. The Biomed Manager verbalized the units should have been inspected and PM performed by the end of February 2014; however, there was a scheduling delay due to re-negotiation of contracts between the facility and the contracted agency.

The Operator Manual - Routine Maintenance, Section 7.1 indicated the preventative maintenance (preparation for preventative maintenance, door assembly, valves, miscellaneous piping components, control, safety testing, final checkout and tests), must be performed regularly.



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Instruments

On 3/4/14, the Orthopedic Surgery Unit on the second floor was observed. A cart containing instruments was opened and found to contain an aspiration needle and a pair of forceps in need of reprocessing. The sterile supply technician was interviewed on 3/4/14, in the presence of the unit clerk and confirmed the indicators within the instrument packages were very old and reprocessing was necessary.

On 3/4/14, a "Quick Pressure Monitor Set" by Stryker Instruments was found in a large metal cabinet affixed to a wall within the nurses station. The monitor set had expired on 6/1/2013. In addition, five "Stryker Instruments" syringes filled with 3 cc of sterile saline were found. All of the syringes expired on 6/1/13.

During an interview with the unit charge nurse on 3/4/13, she confirmed the syringes and the device had expired.

Urgent Care

During an inspection at Urgent Care, the technician reported she scrubbed soiled instruments after soaking the instruments in an enzymatic cleaner. The instruments were then put in a biohazard container and sent to the hospital for processing. The instruments were scrubbed in the procedure room of the facility.

On 3/3/14 at approximately 3:30 PM, the Director of Sterile Processing was interviewed and reported all off campus locations followed the same procedure for dirty instruments. The off campus locations were to spray the instruments with an enzymatic cleaner and place them in a plastic container. The containers were then put in a red bag for transport to the main hospital.

Review of the facility policy, Infection Control: Central Services, with an effective date of 5/1/13, revealed the following under Returning Used Items to Central Services for Processing:

"All contaminated reusable instruments returned to the decontamination room must be in a bio-hazard leak-proof container or clear plastic bag labeled with a bio-hazard sticker."




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Intensive Care Unit

An open cup of coffee and a thermos dispenser for coffee was found in ICU located next to the glucometer kit labeled ICU #2 where testing supplies were stored.


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Kitchen

- During a tour of the kitchen on 3/3/14, the kitchen steamer was observed to be excessively leaking water.

- Outside dumpster area had accumulation of debris (pallets, leaves and unnecessary articles).