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Based on observations, interview, and review of the hospital's policies and procedures, the hospital failed to ensure the privacy of patient medical records was maintained in the Endoscopy preoperative area and the infusion center.

The findings are:

Observations in the infusion center on 12/12/18 at 9:40 AM revealed there were multiple patients and family members in a large area. A computer screen with the patient's name and medical information was visible, with no staff member positioned at the computer station. In an interview on 12/13/18 at 11:45 AM, the Risk Manager, who was present in the infusion center when the unattended computer screen with patient information was observed, confirmed the computer screen was open and unattended with patient information visible on the computer's screen.

Review of hospital policy 8350205, titled, "Legal Health Records", revealed privacy for records would be maintained using password protected access to the secure electronic records. In an interview on 12/13/18 at 11:46 AM, the Nursing Director stated computer screens that were left open would not time out or log out for 10 minutes and computer screens which were not logged out would not protect patient privacy.


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On 12/12/18 at 10:05 a.m., random observations in the Endoscopy Preoperative area revealed a lap top computer located on a cart that was left signed on and unattended that revealed the patient's information on the computer's screen. On 12/12/18 at 10:05 a.m., Director 3 verified the finding.

Based on direct observations, interview, and review of the hospital's policy and procedures, the hospital's staff failed to follow aseptic techniques when preparing Intravenous (IV) medications.

The findings are:

On 12/12/18 at 10:35 a.m., direct observations during Patient 9's Esophagogastroduodenoscopy (EGD) procedure revealed Certified Registered Nurse Anesthetist (CRNA) 1 opened a syringe, opened a vial of Lidocaine, and withdrew the Lidocaine from the vial without cleaning the rubber septum on the vial. CRNA 1 opened another syringe, opened a vial of Propofol and withdrew the Propofol without cleaning the rubber septum on the vial. On 12/12/18 at 10:35 a.m., CRNA 1 verified the finding and stated, "Normally, I disinfect."

Hospital policy and procedure, titled, "IV Medications - Continuous, IV Push and Piggyback" reads "....D. Aseptic technique should be used when preparing and administering IV medications, flush/locking solutions and other parenteral solutions administered by direct IV injection. Aseptic technique includes: Hand hygiene prior to and after preparation and administration of the solution as well as disinfection of the medication access diaphragm on a vial or the neck of an ampule prior to accessing the medication or solution. - Disinfection of the IV access port, needless connector, or other vascular device should be performed prior to administration of the medication or solution. The use of personal protective equipment should be used if contact or exposure to blood or body fluids when administering the medication or solution is anticipated."




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On 12/12/2018, observations of the medication administration for Patient 3's medication from 9:51 a.m. to 10:00 a.m., (Registered Nurse) RN 6 split a tablet (Atenolol twenty-five milligrams) in half without donning gloves. The finding was verified by RN 6 at 10:00 a.m. on 12/12/2018.

Based on record reviews, interview, and review of the hospital's policy and procedure, the hospital staff failed to obtain appropriate authentication of witnesses for health consents with no legal signature for 4 of 14 inpatient charts reviewed for care and services. (Patient 1, 2, 3, and 7)

The findings are:

Patient 1
On 12/12/2018 at 2:36 p.m., review of Patient 1's chart revealed Patient 1 with an admission date of 12/10/2018 was admitted with an Ileus. Review of the patient's chart revealed the patient's consent for treatment witness authentication was not completed with a legal signature. The finding was verified by Admitting Supervisor 1 and Admitting Supervisor 2 at 3:46 p.m. on 12/12/2018.

Patient 2
On 12/12/2018 at 11:30 a.m., review of Patient 2's chart revealed Patient 2 with an admission date of 12/11/2018 was admitted with Pneumonia. Review of the patient's chart revealed the consent for treatment witness authentication was not completed with a legal signature. The finding was verified by Admitting Supervisor 1 and Admitting Supervisor 2 at 3:46 p.m. on 12/12/2018.

Patient 3
On 12/12/2018 at 10:15 a.m., review of Patient 3's chart revealed Patient 3 with an admission date of 12/8/2018 was admitted with Hematuria and Urinary Tract Infection. Review of the patient's medical record revealed the consent for treatment witness authentication was not completed with a legal signature. The finding was verified by Admitting Supervisor 1 and Admitting Supervisor 2 at 3:46 p.m. on 12/12/2018.

Patient 7
On 12/12/2018 at 2:46 p.m., review of Patient 7's chart revealed Patient 7 with an admission date of 12/11/2018 was admitted with Left Sided Paresthesia. Review of the patient's chart revealed the consent for treatment witness authentication was not completed with a legal signature. The finding was verified by Admitting Supervisor 1 and Admitting Supervisor 2 at 3:46 p.m. on 12/12/2018.

On 12/12/2018 at 3:46 p.m., review of the hospital's policy and procedure for consents revealed, "Witnesses are to use their legal signature when signing a consent and date and time their signature". The findings were verified by Admitting Supervisor 1 and Admitting Supervisor 2 at 3:46 p.m. on 12/12/2018.

Based on observations, interview, and review of the hospital's medical management plan, the hospital failed to ensure the patient call light system and emergency system worked effectively in a patient care over flow area when observed.


The findings are:


On 12/11/18 at 4:00 p.m., observations in the emergency department overflow patient unit located on the second floor of the hospital revealed the patient call lights and the emergency system were not working for patient rooms 203-220. In an interview with the Director of Emergency Services, the Director stated, "I didn't know they weren't functional. We are putting a work order in now." On 12/11/18 at 4:30 p.m., Facility Technician 3 came to the emergency department's overflow unit and stated, "We will work on it now."

Hospital policy and procedure, titled, "Medical Equipment Management Plan", reads, "....The scope of medical equipment management plan defines the processes that ..... provides for the safe and proper use of medical equipment used in the patient care setting....The goals of ..... medical equipment management plan include the following: to minimize the clinical and physical risks of equipment through inspection, testing and regular maintenance....".

Based on review of the hospital's infection control program, quality program, governing body data, and interview, the hospital failed to show evidence of the appointment of its Infection Control Officer. (ICO).

The findings are:

On 12/12/18 at 3:30 p.m., review of the hospital's governing body minutes revealed there was no documentation of the appointment for the Infection Control Officer. On 12/12/18 at 4:00 p.m., the Chief Operating Officer (COO) revealed, "I am not sure where the appointment may be, but we will look for it." On 12/13/18 at 2:30 p.m., the Infection Control Officer stated, "I have been in this position since 1997, and I'm not sure if it was done or where it would be located. The only thing I have is where my salary was increased when I took the position." On 12/13/18 at 4:30 p.m., the Regulatory Manager, the COO, and the Chief Nursing Officer revealed there was no evidence of the written appointment for the Infection Control Officer.

Based on observations, interview, and review of the hospital's policies and procedures, the hospital failed to ensure its staff adhered to accepted principles of infection control to prevent the potential cross contamination of infectious agents in the hospital setting for 1 of 1 Registered Respiratory Therapists(RTT 1)

The findings are:

On 12/12/18 at 11:15 a.m., observations on the 5 South Medical-Surgical Unit revealed RRT 1 entered Patient room 540, which was a contact isolation room, without donning personal protective equipment (PPE). Observations showed RRT 1 administered care to the patient who was sitting in a reclining chair. When RRT 1 exited Patient room 540, RRT 1 went to the computer on wheels located outside the door to Patient room 540. When RRT 1 was asked about the PPE requirement for a contact isolation room, RRT 1 stated, "We should wear gloves and a gown. Well, she(patient) has a history of MRSA (Methicillin-Resistant Staphylococcus Aureus), but I saw the second screening result was negative for her(patient) this morning. Therefore, I don't have to wear the PPE." On 12/12/2018 at 11:15 a.m., the finding was verified by the Director of Emergency Services and the Nurse Manager of 5 South during the observations. The Manager stated, "No matter if the results have come back yet or not, until it has been made official and the isolation cart has been removed from the door, staff are expected to follow the policy and wear the required PPE."


Hospital policy # 5.3, titled, "Isolation", reads, "....d. Contact Precautions....In addition to Standard precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact....Wear gloves when entering the room. Wear a gown when entering the room....remove the gown before leaving the patient's room...".

Based on observations, interview, and review of the hospital procedures and current quality assurance and performance improvement plans, the hospital failed to ensure infection control in the dialysis clinic was incorporated into the hospital wide quality assurance and performance improvement plan.

The findings are:

Review of the hospital's current quality assurance and performance improvement (QAPI) plans on 12/13/18 at 3:10 PM revealed there were no plans in place to address infection control in the dialysis clinic. Review of the hospital's QAPI plan goal statement revealed the QAPI plan was to "Incorporate quality planning throughout the system." In an interview on 12/13/18 at 3:35 PM, the hospital's Chief Operating Officer confirmed the hospital did not currently have a program addressing infection control in the dialysis clinic incorporated into the hospitals system wide QAPI plan.



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On 12/13/18 at 3:30 p.m., the Infection Control Officer revealed, "I do not physically do observations on the dialysis unit. The information I receive from that unit comes from the corporation that owns the unit. I should have more documented time there, but I don't. I know they draw cultures every month, and I try to make contact with the Nephrologist monthly. Otherwise I do not contribute anything else for the unit."