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1200 JD ANDERSON DRIVE

MORGANTOWN, WV 26505

PATIENT RIGHTS: PRIVACY AND SAFETY

Tag No.: A0142

A. Based on observation, document review and staff interview it was determined the facility failed to secure clinical records for six (6) of six (6) patients admitted to the Intensive Care Unit (ICU) and the Critical Care Unit (CCU) (patients #3, 13, 36, 37, 38 and 39). This failure has the potential for all patients who are admitted to the hospital to have their personal medical information breached.

Findings include:

1. During a tour of the CCU and ICU with the Clinical Care Coordinator and the Unit Director on 10/30/18 at 10:00 a.m., clinical records belonging to patients #3, 13, 36, 37, 38 and 39 were unsecured in an open drawer outside of each patient's room.

2. Review of the policy titled "Compliance Standards," last reviewed 7/22/18, revealed it states in part: "When patient information is in your possession, you are responsible for safeguarding it. Do not leave protected health information unattended in an area where others can see it."

3. In an interview with the Clinical Care Coordinator and the Unit Director during the tour, they concurred with the above findings.

B. Based on observation, document review and staff interview it was determined the facility failed to secure clinical records for twenty-four (24) out of twenty-four (24) patients admitted to the surgery/orthopedic unit (patients #40-63). This failure has the potential for all patients who are admitted to the hospital to have their personal medical information breached.

Findings include:

1. During a tour of the surgery/orthopedic unit with the Unit Director on 10/30/18 at 12:30 p.m., clinical records belonging to patients #40-63 were unsecured in a cabinet outside of each patient's room.

2. Review of the policy titled "Compliance Standards," last reviewed 7/22/18, revealed it states in part: "When patient information is in your possession, you are responsible for safeguarding it. Do not leave protected health information unattended in an area where others can see it."

3. In an interview with the Unit Director during the tour, she concurred with the above findings.

C. Based on observation, document review and staff interview it was determined the facility failed to secure clinical records for eight (8) out of eight (8) patients being treated in the Emergency Department (ED) (patients #64, 65, 66, 67, 68, 69, 70 and 71). This failure has the potential for all patients who are being treated in the ED to have their medical information breached.

Findings include:

1. During a tour of the ED with the ED Registered Nurse and the Director of the ED on 10/30/18 at 12:50 p.m., clinical records belonging to patients #64, 65, 66, 67, 68, 69, 70 and 71 were unsecured at the nurse's station outside of line of sight of staff.

2. Review of the policy titled "Compliance Standards," last reviewed 7/22/18, revealed it states in part: "When patient information is in your possession, you are responsible for safeguarding it. Do not leave protected health information unattended in an area where others can see it."

3. In interviews with the ED Registered Nurse and the Director of the ED conducted during the tour, they concurred with the above findings.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

A. Based on observation and staff interview it was determined the facility failed to secure medical devices in the Critical Care Unit (CCU) and the Intensive Care Unit (ICU). This failure has the potential to place all patients in the CCU/ICU at risk for care in an unsafe setting.

Findings include:

1. A tour of the CCU and ICU conducted on 10/30/18 at 10:00 a.m. with the Clinical Coordinator and the CCU/ICU Unit Director revealed there were needles and sterile water unsecured in patients' rooms.

2. In an interview with the Outcomes Analyst on 10/31/18 at 1:00 p.m. she revealed the expectation is that sharps should be secured at all times.

3. In interviews with the Clinic Coordinator and the CCU/ICU Unit Director during the tour, they concurred with the above findings.

B. Based on observation and staff interviews it was determined the facility failed to secure medical devices and drugs in the Emergency Department (ED). This failure has the potential to place all patients in the ED at risk for care in an unsafe setting.

Findings include:

1. A tour of the ED conducted on 10/31/18 at 12:50 p.m. revealed seven (7) suture trays were unsecured and unattended.

2. A tour of the ED conducted on 10/31/18 at 12:50 p.m. revealed betadine solution and chlorhexadine solution was unsecured and unattended.

3. In an interview with the Director of Quality on 10/31/18 at 1:30 p.m., it was revealed betadine and chlorhexadine are considered drugs by the hospital and the expectation is that they will be secured.

4. In an interview with the Trauma Program Director on 10/31/18 at 1:00 p.m., he concurred with the above findings.

C. Based on observation and staff interview it was determined the facility failed to secure plastic laundry bags in the dedicated psychiatric care room. This failure has the potential to place all patients in the psychiatric care room at risk for care in an unsafe setting.

Findings include:

1. A tour of the ED on 12/30/18 at 12:50 p.m. with the Director of the ED revealed the room used for care of psychiatric patients had an unlocked cabinet in which plastic laundry bags were stored.

2. In an interview with the Director of the ED during the tour, he concurred with the above finding and stated the expectation was the cabinet in which the plastic bags were kept should be locked.

PROTECTING PATIENT RECORDS

Tag No.: A0441

A. Based on document review, observation and staff interview it was determined the facility failed to ensure protected health information was safeguarded and unable to be accessed by unauthorized personnel, in accordance with their own policy, for nineteen (19) out of nineteen (19) patients who presented to the facility's pre-/post-procedure areas of the Endoscope Surgical Outpatient Unit before and after their surgical procedures. This failure has the potential to negatively impact the confidentiality of all patients' medical records who present to the facility for outpatient procedures.

Findings include:

1. The policy, "Compliance Standards," last reviewed 7/26/18, was provided for review. Number eight (8), Maintain Confidentiality of Records and Information, states in part: "Do not disclose any patient specific information to unauthorized people or utilize any of this information for personal gain. When patient information is in your possession, you are responsible for safeguarding it. Do not leave protected health information unattended in an area where others can see it. Confidential information of any sort should not be discussed in any non-business situation with Health Systems or affiliate or non Health System staff. Health System or affiliate personnel with access to patient specific information shall abide by the HIPAA Privacy and Security policies, confidentiality policies related to patient care and medical record standards. Departmental and medical staff confidentiality policies shall also be adhered."

2. A tour of the Endoscope Surgical Outpatient Unit was conducted on 10/30/18 at 9:30 a.m. During the tour it was observed in the pre-/post-procedure areas of the unit that patient medical records were left unattended on the table in the patients' rooms with the patient and family members present.

3. An interview was conducted with the Nurse Manager of the Endoscope Surgical Outpatient Unit on 10/31/18 at 9:52 a.m. She stated: "We should be keeping the patients' medical records in the chart carousel at the nurse's station on the unit and away from unauthorized personnel." She concurred with the above findings.

B. Based on document review, observation and staff interview it was determined the facility failed to ensure protected health information was safeguarded and unable to be accessed by unauthorized personnel, in accordance with their own policy, for twenty-nine (29) out of twenty-nine (29) patients who presented to the facility's pre-/post-procedure areas of the Surgical Care North Outpatient Unit before and after their surgical procedures. This failure has the potential to negatively impact the confidentiality of all patient's medical records who present to the facility for outpatient procedures.

Findings include:

1. The policy, "Compliance Standards," last reviewed 7/26/18, was provided for review. Number eight (8), Maintain Confidentiality of Records and Information, states in part: "Do not disclose any patient specific information to unauthorized people or utilize any of this information for personal gain. When patient information is in your possession, you are responsible for safeguarding it. Do not leave protected health information unattended in an area where others can see it. Confidential information of any sort should not be discussed in any non-business situation with Health Systems or affiliate or non Health System staff. Health System or affiliate personnel with access to patient specific information shall abide by the HIPPA Privacy and Security policies, confidentiality policies related to patient care and medical record standards. Departmental and medical staff confidentiality policies shall also be adhered."

2. A tour of the Surgical Care North Outpatient Unit was conducted on 10/30/18 at 10:30 a.m. During the tour it was observed in the pre-/post-procedure areas of the unit that patient medical records were left unattended on the table in the patients' rooms with the patient and family members present.

3. An interview was conducted with the Nurse Manager of the Surgical Care North Outpatient Unit on 10/31/18 at 9:52 a.m. She stated: "We should be keeping the patients' medical records in the chart carousel at the nurse's station on the unit and away from unauthorized personnel." She concurred with the above findings.

C. Based on document review, observation and staff interview it was determined the facility failed to ensure protected health information was safeguarded and unable to be accessed by unauthorized personnel, in accordance with their own policy, for ten (10) out of ten (10) patients who presented to the facility's pre-/post-procedure areas of the Surgical Care South Outpatient Unit before and after their surgical procedures. This failure has the potential to negatively impact the confidentiality of all patients' medical records who present to the facility for outpatient procedures.

Findings include:

1. The policy, "Compliance Standards," last reviewed 7/26/18, was provided for review. Number eight (8), Maintain Confidentiality of Records and Information, states in part: "Do not disclose any patient specific information to unauthorized people or utilize any of this information for personal gain. When patient information is in your possession, you are responsible for safeguarding it. Do not leave protected health information unattended in an area where others can see it. Confidential information of any sort should not be discussed in any non-business situation with Health Systems or affiliate or non Health System staff. Health System or affiliate personnel with access to patient specific information shall abide by the HIPPA Privacy and Security policies, confidentiality policies related to patient care and medical record standards. Departmental and medical staff confidentiality policies shall also be adhered."

2. A tour of the Surgical Care South Outpatient Unit was conducted on 10/30/18 at 11:30 a.m. During the tour it was observed in the pre-/post-procedure areas of the unit that patient medical records were left unattended on the table in the patients' rooms with the patient and family members present.

3. An interview was conducted with the Nurse Manager of the Surgical Care South Outpatient Unit on 10/31/18 at 9:52 a.m. She stated: "We should be keeping the patient's medical records in the chart carousel at the nurse's station on the unit and away from unauthorized personnel." She concurred with the above findings.



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D. Based on observation, document review and staff interview it was determined the facility failed to secure patients' medical records in twenty-eight (28) out of twenty-eight (28) patients present on the 6 North Medical Unit. This failure has the potential to adversely impact all patients on the unit.

Findings include:

1. A tour of the 6 North Medical Unit on 10/30/18 at 10:30 a.m. revealed patients' paper medical record charts were kept in an unlocked cabinet outside of each patient's room on the unit.

2. A review of the policy titled "Compliance Standards," last reviewed 07/26/18, revealed it states in part: "When patient information is in your possession, you are responsible for safeguarding it. Do not leave protected health information unattended in an area where others can see it."

3. During an interview conducted on 10/30/18 at 10:40 a.m., the Director of the 6 North Medical Unit concurred patients' medical records were located in an unlocked cabinet outside of each patient's room.

E. Based on observation, document review and staff interview it was determined the facility failed to secure patients' medical records in forty five (45) out of forty five (45) patients present on the Observation Unit and Stepdown Unit. This failure has the potential to adversely impact all patients on both units.

Findings include:

1. A tour of the Observation Unit on 10/30/18 at 11:45 a.m. revealed patients' paper medical record charts were kept in an unlocked cabinet outside of each patient's room on the unit.

2. A tour of the Stepdown Unit on 10/30/18 at 12:00 p.m. revealed patients' paper medical record charts were kept in an unlocked cabinet outside of each patient's room on the unit.

3. A review of the policy titled "Compliance Standards," last reviewed 07/26/18, revealed it states in part: "When patient information is in your possession, you are responsible for safeguarding it. Do not leave protected health information unattended in an area where others can see it."

4. During an interview conducted on 10/30/18 at 12:10 p.m., the Director of the Observation Unit concurred patients' medical records were located in an unlocked cabinet outside of each patient room.

PHYSICAL ENVIRONMENT

Tag No.: A0700

Based on observation, record review and staff interview it was determined the facility failed to ensure building construction type and sprinklered stories were sprinklered throughout in accordance with National Fire Protection Association (NFPA) 101 (see Tag K161); failed to ensure that hazardous areas are protected and separated from other spaces in accordance with NFPA 101 (see Tag K321); failed to ensure that automatic sprinkler and standpipe systems were maintained in accordance with NFPA 25 (see Tag K353); failed to ensure that smoke and fire barriers were constructed and maintained to the appropriate fire resistance rating in accordance with NFPA 101 (see Tag K372); failed to maintain smoke and fire barrier doors in accordance with NFPA 101 (see Tag K374); failed to ensure that fire drills were held at least quarterly on each shift in accordance with NFPA 101 (see Tag K712); failed to ensure that electrical wiring and equipment shall be in accordance with NFPA 70 (see Tag K911); failed to maintain and test electrical receptacles at patient bed locations in accordance with NFPA 101 (see Tag K914); failed to ensure that maintenance and testing of the generator and transfer switches were performed in accordance with NFPA 110 (see Tag K918); failed to ensure that nonflammable medical gas cylinder and storage requirements were in accordance with NFPA 99 (see Tag K923); and, failed to ensure that personnel had received the appropriate medical gas equipment qualifications and training in accordance with NFPA 99 (see Tag K926).

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on document review, observation and staff interview it was determined the facility failed to ensure equipment was kept clean in accordance with their own policy. This practice has the potential for all patients who are admitted to the hospital to be placed at risk for infection.

Findings include:

1. Review of the policy titled "Management of Clean and Dirty Equipment," effective date 4/17/18, revealed it states in part: "Clean equipment in a terminally cleaned patient room shall be covered with a clear plastic bag or a large blue rubber band attached to the item in plain sight indicating the item is clean."

2. During a tour of the Critical Care Unit (CCU) and the Intensive Care Unit (ICU) on 10/30/18 at 10:00 a.m. with the Clinical Care Coordinator and the ICU/CCU Unit Director, pillows were noted in vacant patient room closets uncovered and without clear plastic bag coverings.

3. Interviews conducted with the Clinical Care Coordinator and the ICU/CCU Unit Directors during the tour revealed they concurred with the above findings.