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Based on interview, observation and record review, the facility failed to protect patient rights by not ensuring patient records were maintained to ensure confidentiality and privacy prior to destruction (see A-0142). The cumulative effect resulted in a failure to protect the patients' rights.

Based on observation, interview and record review, the facility failed to ensure patient health care records were secured form unauthorized access at all times, in all locations. Specifically, the facility failed to safeguard protected healthcare information prior to its destruction, at all times in all locations of the facility.

During an observation on 12/8/16 at 1:45 p.m., in the photo copier room in the administrative offices, was a blue plastic waste basket with a white recycling logo on the front. The wastepaper basket was open at the top, and was not covered or locked. The wastepaper basket contained patients' protected health information.

During an observation on 12/8/16 at 1:45 p.m., on the inpatient unit located in the large nurses station, was a tall plastic gray bin. The bin was open at the top, did not have a lid, and was not locked. The bin was one quarter filled with patients' protected health information.

During an observation on 12/8/16 at 2:00 p.m., on the PACU at the nurses station farthest from the entrance of the unit, were two blue plastic waste baskets with a white recycling logo on the front. The wastepaper baskets were open at the top, and were not covered or locked. The wastepaper basket contained protected patient health information. A nurse was not observed at the nurses station during this time.

During an observation on 12/8/16 at 2:10 p.m., located in the nurses station in the emergency department, were two blue plastic waste baskets with a white recycling logo on the front. The wastepaper baskets were open at the top, and were not covered or locked. The wastepaper baskets contained patients' protected health information.

During an observation on 12/8/16 at 2:11 p.m., located in the back nurses station of the emergency department, were two blue plastic waste baskets with a white recycling logo on the front. The wastepaper baskets were open at the top, and were not covered or locked. The wastepaper baskets contained patients' protected health information.

During an observation on 12/8/16 at 2:12 p.m., at the nurses station in the X-ray department, there was a blue plastic waste basket with a white recycling logo on the front. The wastepaper basket was open at the top, and was not covered or locked. The wastepaper basket contained patients' protected health information that was half full. There was no one at the nurses station.

During an observation on 12/8/16 at 2:20 p.m., located at the front desk of the infusion center, were three blue plastic waste baskets with a white recycling logo on the front. Two of the baskets had a wood cover with a slit cut in the top, but were not secured or locked to the top of the bin. The other wastepaper basket was open at the top, and was not covered or locked. The wastepaper baskets contained patients' protected health information.

During an interview on 12/8/16 at 12:45 p.m., staff member A stated the facility did not have the locked shred bins in place yet. Staff member A stated the facility had ordered the shred bins but they have not arrived at the facility. The staff member stated the facility originally ordered the shred bins through their current vendor. When they ordered the bins the vendor was going to charge the facility a monthly charge per bin. The facility canceled the original order and attempted to get the lockable shred bins through through an independent company. Staff member A stated the facility was not able to get the lockable shred bins through another company, so they had to re-order the lockable shred bins through their current vendor. The staff member stated the bins were expected to be delivered to the facility by the end of December.

During an interview on 12/8/16 at 12:45 p.m., staff member A stated she understood the facility would not be back in compliance without replacing the shred bins which are not secured with the secured shred bins.

A review of an email dated 12/8/16 at 11:48 a.m., from the President and CEO from the company which provided the secured shred bins to the facility showed the following:
"I just wanted to confirm your order for 15 lockable bin container have been ordered and the hospital will receive them by the end of the month."

A review of an email dated 11/1/16 at 2:21 p.m., showed the following areas would receive lockable bins and how many per area :
"- Inpatient Unit -4 bins
- Special Care Nurse Station - 1 bin
- PACU/OBS/Recovery - 3 bins
- ER Nurses Station - 1 bin
- ER Dictation - 1 bin
- Registration/ER Radiology Station - 1 bin
- Administration Work Area - 1 bin
- Check-in/Lab/Radiology/Specialty - 1 bin
- Infusion Center - 1 bin
- Clinic Cancer Care Check In - (locked doors)"

During an interview on 12/8/16 at 12:45 p.m., staff member A stated the facility had not completed the audit tool identified in their plan of correction. The staff member stated the facility would need to wait to complete the audit tool and quality measures until the lockable shred bins were in place.

Based on observation, interview and record review, the facility failed to ensure the daily management of established policies and procedures regarding safe practices for food handling were followed. This negative finding had the potential to affect all patients utilizing the food services from the facility's kitchen. Findings included:

1. During an observation on 10/17/16 at 4:40 p.m., in the kitchen's walk in cooler the following items were stored covered, with no date of use, and/or a use by date:

- Coleslaw
- The salad bar contents, including deli meats, vegetables and cheeses.

During an interview on 10/17/16 at 4:42 p.m., staff member B stated the items not dated in the refrigerator were from "today's salad bar." He stated that he would not be able to tell for sure if they were from that day's salad bar or not, since there was not a label with a use by date and/or a date of use. Staff member B stated all items used in the salad bar should be dated.

2. During an observation on 10/17/16 at 4:44 p.m., in the kitchen's walk in freezer, two frozen raw chicken breasts were uncovered, unwrapped, and sitting on top of a card board box that contained raw pork.

During an interview on 10/17/16 at 4:44 p.m., staff member B stated all items in the freezer, especially raw food should be wrapped, labeled and dated.

3. During an observation on 10/17/16 at 4:50 p.m., in the kitchen's refrigerator located on the kitchen's salad bar/food prep line were the following items:

- Yellow cheese slices not dated with a date of use and/or a use by date.
- White cheese slices not dated with a date of use and/or a use by date.

4. During an observation on 10/17/16 at 4:50 p.m., in the kitchen's freezer located in the kitchen's cooking range were unlabeled, undated, frozen breaded fish fillets and potato wedges.

During an interview on 10/17/16 at 4:50 p.m., staff member B stated any used or open items in the refrigerator or the freezer in the cooking range needed to be labeled and dated.

5. During an observation on 10/17/16 at 4:50 p.m., the kitchen did not have a temperature log for either the freezer or for the refrigerator located in the kitchen's grill/food prep line.

During an interview on 10/17/16 at 4:50 p.m., staff member A stated she did not know why they did not keep a temperature log for the small freezer and refrigerator located in the cooking island. Staff member A stated there was a temperature log for the walk in refrigerator and freezer.

During an in interview on 10/17/16 at 4:52 p.m., staff member B stated he was not aware of a need to keep a log for the freezer and refrigerator located in the kitchen's grill.

6. During in observation on 10/17/16 at 4:50 p.m., the grease trap located in kitchen's flat top grill had a thick hardened layer of black grease around the circular disposal in the grill. The grease trap itself had a large amount of dark black and yellow grease with a thick layer of sediment on the bottom of the trap filled to the max line in the grease trap.

During an interview on 10/17/16 at 4:50 p.m., staff member A stated the grease trap was cleaned out when it reached the line on the grease trap. She stated the grease trap was cleaned out approximately 2-3 times per week. Staff member A stated the grease trap was not cleaned daily or per use. Staff member stated the grease trap can fill up to the line after one meal prep on the flat top grill. Staff member A stated the grease trap was last emptied on Friday prior to the survey.

During a review of the facility's policy and procedure titled, "Refrigerator and Freezer Temperatures", showed:

"Policy: To ensure that foods are maintained in proper environment, the temperatures must be checked daily. Procedure: Nutritional Services will check and record the temps of the refrigerator and freezer temperature daily. A thermometer is located in each refrigerator/freezer and outside the door where it can be easily read...All temperatures must be recorded on the Refrigerator Temperature Log."

During a review of the facility's policy and procedure titled, "Objectives and Goals of Nutritional Services", showed:

- Policy: Receives and stores food items to maintain the highest degrees of freshness and free of any Contamination.
- Meets all standard as set by federal state and local agencies."