HospitalInspections.org

Based on interviews and record review the hospital failed to ensure that safeguards were in place to ensure that confidential patient information was not placed on the personal flash drives of hospital supervisors. Findings:

A telephone interview was held with S8, RN Night Shift Supervisor on 12/30/09 at 8:10 am. S8, RN indicated that as shift supervisor, he completes house reports of patients at the end of each shift. He added that he had some patient information on his flash drive after a patient is admitted. He further indicated he gathers this information from all of the units in the hospital which allows him to complete this report. S8, RN added that after his report is completed at the end of the shift, this information is deleted from his flash drive. He further indicated this information is strictly used that night and been deleted. S8, RN added that no one ever has access to his confidential flash drive. He indicated all employees are trained on the importance of patient confidentiality. S8, RN indicated that he is the house supervisor for two weeks per month. He added that the other two weeks in the month, S10, RN is the house supervisor.
A telephone interview was held with S10, RN House Supervisor on 12/30/09 at 8:45 am. S10, RN indicated that as the night time supervisor it is his responsibility to complete reports at the end of the shift. He indicated that he keeps empty forms on his flash drive that are always kept only in his possession. He added this is confidential information that remains at the hospital. S10, RN reported that his flash drive is kept at the hospital and never leaves the hospital. He reported that he did not bring his personal laptop to the hospital.
An interview was held with S12, ADON on 1/8/10 at 1:15 pm. He indicated Nurse Managers are to complete a House Manager Report which is a 24 hour report of the events from that day; ie, patient care, new medications, PRN medications, problems, or of new admissions. S12 further indicated these reports are generated by information gathered by the managers on each unit of the hospital. He added at the end of the day; he receives a copy of the report, and a copy of the report also goes to the main campus. When asked by this surveyor, if he was aware that Nurse Managers were using flash drives to gather information to complete this report, S12, indicated he was not aware this was practice was occurring. He further indicated that he had never looked at the flash drive of the 2 Nurse Managers to ensure that the information on the flash drives had been deleted. S12, ADON indicated that flash drives should not be used by employees if they were not issued by the hospital. S12, ADON further indicated there was no policy or procedure for managers using flash drives in the hospital.

Based on observation and interview the hospital failed to ensure:
1. A loose toilet did not leak around the base when the toilet was flushed.
2. Unlabeled toothbrushes were not laying next to each other on the counter next to the lavatory in patient room.
3.Torn/ ripped mattresses were removed from patient use. Findings:


1.An observation made in room six on the south wing on 12/29/09 at 1:40 pm, revealed a loose toilet that leaked around the base when the toilet was flushed. Further observation revealed water leaked on the floor and pooled around the base of the toilet when the toilet was flushed.

An interview was held wit S3, RN at this time. S3, RN verified that the toilet was loose and that water pooled on the floor when the toilet was flushed. She indicated this problem and needed to be fixed.
2. An observation was made on the north wing of the hospital on 12/29/09 at 1:15 pm. Further observations made in room nine, which is a four patient ward and in the presence of S3, RN, revealed three unlabeled toothbrushes laying next to each other on the counter next to the lavatory. An observation made in room ten at 1:25 pm on 12/29/09, which is a four patient ward and in the presence of S3, RN, revealed an unlabeled toothbrush laying on the sink next to the lavatory.
3. An additional observation was made on 12/29/09 at 1:00 pm that revealed rips/tears in the mattress pad on the stretcher located in the examination room/emergency clinic near the North Wing. An additional observation was made of a ripped mattress in room eleven on 12/29/09 at 1:30 pm.
An interview was held with S3, RN at 1:35 pm. She verified the above findings. S3, RN further indicated all toothbrushes on the unit should be labeled with the patient's name and added that torn/ripped mattresses should be replaced.
An interview was held with S14, RN on 1/4/10 at 2:00 pm. S14, RN indicated toothbrushes should always be labeled and placed in the patient's bedside table after they have been used by the patient. She further indicated that it is the staff's responsibility to check to ensure patient's toothbrushes are placed in their bedside tables after use, and not left on the counter next to the lavatory. S14, RN indicated it was not acceptable to have torn/ripped mattresses in the hospital. She further indicated when staff observe torn/ ripped mattresses, they should complete a work order and the mattress would be replaced.

Based on record review and interview, the hospital failed to ensure that a psychiatric evaluation was completed within 60 hours of admission for 2 of 12 sampled patients.(#3,#8) Findings:

The medical record of Patient #3 was reviewed on 12/29/09 at 2:30 p.m. This review revealed that the patient was admitted to the hospital on 12/24/09 at 11:00 a.m. This review revealed that the psychiatric evaluation was not complete and available for review as of the date and time of this record review (12/29/09 at 2:30 p.m.) which was 123.5 hours after admission to the hospital. In an interview with S14 (Registered Nurse) on 12/29/09 at 2:30 p.m., S14 reported that the psychiatric evaluation had not been received from dictation and confirmed that the psychiatric evaluation was not available for review at the time of this interview on 12/29/09 at 2:30 p.m.

The medical record of Patient #8 was reviewed on 12/30/09 at 9:50 a.m. This review revealed that the patient was admitted to the hospital on 12/23/09 at 8:45 p.m. This review revealed that the psychiatric evaluation was not complete and available for review as of the date and time of this record review (12/30/09 at 9:50 a.m.) which was greater than 157 hours after admission to the hospital. In an interview with S12 (Assistant Director of Nursing) on 12/30/09 at 9:50 a.m., S12 confirmed that the psychiatric evaluation was not available for review at the time of this interview on 12/30/09 at 9:50 a.m.

Based on record review and interview, the hospital failed to ensure that the patient's comprehensive treatment plan included short-term and/or long-term goals for 2 of 12 sampled patients (Patient #3 and Patient #8). Findings:

The medical record of Patient #3 was reviewed on 12/29/09 at 2:30 p.m. This review revealed that the patient was admitted to the hospital on 12/24/09 at 11:00 a.m. Review of the comprehensive treatment plan revealed no documentation to indicate that the comprehensive treatment plan included short term goals and/or long term goals as of the date and time of this record review.

The medical record of Patient #8 was reviewed on 12/30/09 at 10:40 a.m. This review revealed that the patient was admitted to the hospital on 12/23/09 at 8:45 p.m. Review of the comprehensive treatment plan revealed no documentation to indicate that the comprehensive treatment plan included short term goals and/or long term goals as of the date and time of this record review.

S14 (Registered Nurse) was interviewed on 12/30/09 at 11:15 a.m. S14 confirmed that the comprehensive treatment plans for Patient #3 & Patient #8 did not included short term or long term goals as of the date and time of this interview.