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Based on observation, review of records, and interview, the hospital did not ensure the confidentiality of patient medical records, in that, (A) 7 of 7 "closed" records for current inpatients, and (B) a total of 1873 "closed" Emergency Department (ED) records were stored in an unsecured public area.

Findings:

(A) On a tour the morning of 03/16/10, the surveyor observed 3 unlocked cabinets located in the public waiting area of the second floor, separate from the nurses station, and directly across from the public elevators. On opening these cabinets, the surveyor, accompanied by the Chief Operating Officer (COO), (Personnel #2), observed 7 original and complete, "closed" patient medical records (Patient Records # 32, 33, 34, 35, 36, 37 & 38) that had not been secured.

In an interview with the Medical/Surgical charge nurse (Personnel #17), when asked if she knew that these "closed" patient medical records were stored in a public area and unsecured, she said "yes." She also said that these records were kept there so that the physicians had 24 hour access to their inpatient's "closed" records, as they did not have access to them at night.
In an interview the morning of 03/16/10 with the COO (Personnel # 2), when asked if the above medical records were properly secured to ensure confidentiality of patient information, she said "no."


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B) During a tour the morning of 03/15/10 with the Director of Nursing, a four drawer filing cabinet was observed in the ED lounge room. The filing cabinet did not have a locking mechanism. The first 3 drawers contained copies of patient ED medical records from December 16, 2009 to March 15, 2010. There were 324 patient records in December 2009, 653 in January 2010, 580 in February 2010, and 316 in March 2010.

In an interview the morning of 03/15/10, the Director of Nursing (Personnel #3) was asked why there were patient records in the lounge area. She stated that the ED physician wanted access to these medical records when patients revisit the ED at night time since the Medical Records Section was closed at night.

In an interview the morning of 03/17/10, the Director of Medical Records (Personnel #6) was asked if she knew about the unsecured patient records in the ED lounge area. She replied yes and agreed that they were not secured.

The hospital "Confidentiality" policy, undated, noted that:
-"Information in any form, verbal or written, concerning a...hospital patient's medical care is to be safeguarded. Additionally, staff must insure that records are not left unattended..."
-"Storage: All primary health records of the ...hospital shall be housed in the designated Medical Records Department under the immediate control of the Director of the Medical Records Department."

Based on review of records and interview, the Director of Medical Records did not report 5 of 5 identified delinquent ED medical records (Emergency Department) to QAPI (Quality Assessment and Performance Improvement) as required.

Findings:

~Patient #25 presented in the ED on 01/28/10 for possible gall stone problem. He was treated and transferred to another facility. The physician did not sign the ED record.

~Patient #26 presented in the ED on 01/27/10 for chest pain and cough. She was treated and discharged to home. The physician did not sign the ED record.

~Patient #27 presented in the ED on 02/10/10 for possible stroke. The patient was treated and transferred to another facility. The physician did not sign the physician's orders.

~Patient #18 presented in the ED on 02/14/10 for blood pressure check. She was treated and discharged to home. The physician did not sign the ED record.

~Patient #19 presented in the ED for fever and sore throat. The patient was treated and discharged to home. The physician did not sign the ED record.

QAPI meetings held on February 2010 did not include discussions of delinquent ED medical records.

In an interview the morning of 03/17/10, the Director of Medical Records (Personnel #6) was asked about the above delinquent medical records. She stated that she called these physicians to complete the records. She stated that these contracted ED physicians rotate their schedules. She stated that she was waiting for them to come back to the facility so she could personally ask them to sign the records. The Director of Medical Records was asked if she participates in the QAPI. She replied yes. She was asked if she reported the delinquent medical records to QAPI. She replied no. The Director of Medical Records was asked to provide a written protocol on resolution of delinquent medical records. She stated that there was none.

"2009 Quality Assurance Performance Improvement Plan (QAPI) dated 07/29/08 required "Departments will continue to report problems, as well as potential problems, to QAPI..."

Based on review of records and interview, the RN (registered nurse) did not supervise and evaluate the nursing care for 2 of 2 patients (Patient #8 & 12) who were confined for 5 or more days.

Findings:
~ Patient #8 was admitted on 09/28/09 for "Transient Ischemia Attack." The nurse noted on 09/28/09, 09/30/09, and 10/02/09, the patient complained of pain and was medicated with Norco 10/325 mg as ordered by the physician. There were no reassessments performed to evaluate patient response to therapy or nursing interventions.

~ Patient #12 was admitted on 01/04/10 for "Cellulitis/ Hematoma bilateral feet." The nurse noted from 01/04/10 to 01/10/10 that the patient was complaining of pain and itching. As ordered by the physician, oral Norco 10/325 (for pain), oral Benadryl (for itching), and Vistaril injection (for itching) were administered. There were no reassessments performed to evaluate patient response to therapy or nursing interventions.

In an interview the morning of 03/17/10, the Director of Nursing (Personnel #3) was asked why the nurses did not reassess patients after the administration of pain medications or other PRN medications (as needed). She replied that the nurses reassess but did not document it. No evidence of reassessment was provided.

Policy: "Patient Assessment by Registered Nurse" revised 06/15/09 required "The RN will assess each patient...to evaluate any change in patient's condition."

Policy: "24 Hour Nursing Record" reviewed 07/2007 required "All licensed personnel are required to document patient responses to therapies, nursing intervention, and education."

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Based on review of records and interview, the facility did not keep current nursing care plans to address the patient's needs for A) 2 of 2 patients (Patient #8 & 12) who were confined for 5 or more days; and B) 1 of 4 open records (Patient #20).

Findings:

A) Patient #8 was admitted on 09/28/09 for "Transient Ischemia Attack." The "Initial Patient Assessment" identified one patient problem, "Alteration in mobility..." The nurse noted on 09/28/09, 09/30/09, and 10/02/09, the patient complained of pain. As ordered by the physician, Norco 10/325 mg was administered. The nurse did not update the nursing care plan to address the patient's needs. The patient was discharged on 10/02/09.

Patient #12 was admitted on 01/04/10 for "Cellulitis/ Hematoma bilateral feet." The "Initial Patient Assessment" identified one problem, "Alteration in skin integrity." The nurses noted from 01/04/10 to 01/10/10 that the patient was complaining of pain and itching. As ordered by the physician, oral Norco 10/325 (for pain), oral Benadryl (for itching), and Vistaril injection (for itching) were administered. The nurse did not update the nursing care plan to address the patient's needs. The patient was discharged on 01/11/10.

In an interview the morning of 03/17/10, the Director of Nursing (Personnel #3) was asked why the nurses did not update the nursing care plan to address patient needs. She replied that she did not know.

B) Patient # 35 was admitted on 03/11/2010 for "Pneumonia, Chronic Obstructive Pulmonary Disease (COPD) and Dyspnea." The "Initial Patient Assessment" identified that this patient had a nutritional score of "6", where the scoring system of equal or greater than a "5" was "Moderate Risk" for nutritional deficits, including the fact that the patient had dentures. The diet ordered was an American Heart Association diet, which did not require changing the consistency of the patient's food. The nursing care plan had only identified one patient problem, "Impaired gas exchange," and had not addressed the patient's nutritional needs.

In an interview with Patient # 35, she was asked if she had her dentures at the hospital, and she said "no." When asked if she was able to chew her food, she stated that she only ate the "soft foods that came on her tray."

In an interview the afternoon of 03/15/10 with the RN in charge (Personnel # 17), when asked on review of this record, if the nutritional needs of the patient had been addressed or initiated on the nursing care plan, she said "no."

Policy and Procedure: "Care Planning, Nursing" revised 09/2009, required "3. Care Plans are initiated, reviewed and/ or updated by nursing every 24 hours. 4. The nurse evaluates if the care plan identifies health problems pertinent to the patient's needs..."

Based on review of records and interviews, the facility did not prepare drugs according to accepted standards of practice in 1 of 4 patients (Patient #8) diagnosed with Transient Ischemia Attack.

Findings:

Patient #8 was admitted on 09/28/09. Physician's orders included "Nifedipine XL 30 mg PO (per oral) daily" and "KCL SR 10 mEq PO BID (twice daily)."

On 09/28/09 at 1920, the nurse noted that the patient stated "he can't take pills very well unless they are crushed." The nurse administered KCL SR that was crushed.

On 09/29/09 at 2100, the nurse noted "HS meds (bedtime medications) given crushed in jelly..." The evening medications included KCL SR.

On 10/01/09 at 0700, the nurse noted "all meds crushed except Minipress and KCL." The morning medications included Nifedipine XL.

Patient #8 was discharged on 10/02/09.

In an interview the morning of 03/17/10, the Pharmacist (Personnel #5) was asked if Nifedipine XL 30 mg and KCL SR 10 mEq were medications that can be crushed. The Pharmacist replied that these medications can not be broken or crushed since they were slow release or extended release medications. The Pharmacist added that he had made a "list of medications that can not be crushed" and placed it at the nurse's station. The nurses were asked if they had seen such a list and if they could provide the list. Two of 3 nurses (Personnel #15 & 16) stated that they saw the list but could not provide the list.

Based on observation, review of records, and interviews, the hospital failed to ensure that supplies were safely maintained, in that, expired supplies were available for patient use.

On a tour of the inpatient nursing unit the afternoon of 03/15/10, the surveyor observed the following expired supplies available for patient use:

Medical/Surgical Unit, 2nd Floor:
1) Medication Room- 39 of 68 total number of 18 gauge angiocath needles stored here for immediate patient use were expired for dates ranging from 10/04 through 07/09.

2) Crash Cart - supplies locked inside, and available for patient use in emergencies included:
4 - 18 gauge angiocath needles, expired 06/04.
2 - 18 gauge angiocath needles, expired 06/05.
1 - 18 gauge angiocath needles, expired 11/05..

3) Nurse's Station Ante-room - Nutritional supplements stored here and available for patient use, included the following expired supplies:
10 - Arginaid drink mix, expired 12/09.
10 - Fibersource HN, expired 12/09.
10 - Glucerna shakes, 8 ounce bottles, expired 02/01/10.
1 - Jevity 1.5 Cal, 1 liter bottle, expired 02/10.
5 - Jevity 1.0 Cal, 8 ounce cans, expired 03/01/10.

The hospital "Infection Control Policy, General Guidelines," undated, noted that:
"When shelf life expires, the item is removed and returned to Sterile Supply or Central Supply for replacement."

In interviews the afternoon of 03/15/10, a Medical/Surgical Registered Nurse (RN), (Personnel # 18), verified the expired angiocath needles in the medication room; the Medical/Surgical Charge Nurse (Personnel #17) verified the expired angiocath needles on the crash cart and the expired nutritional supplements located on this unit. Both nurses agreed that these supplies had been available for patient use, and that the unit nurses were responsible for checking these prior to use.