HospitalInspections.org

Based on hospital policy review, observations during tour, and staff interviews the hospital's staff failed to ensure unauthorized individuals could not gain access to protected and confidential health information contained in patient medical records stored in the outpatient Wound Care department.

The findings include:

Review of current hospital policy "Storage and Security of Medical Records" (Revised 04/2011) revealed "GUIDELINES: Medical records housed within the hospital shall be kept in secure areas at all times under the direct supervision of the Health Information Management Director. Medical records shall not be left unattended in areas accessible to unauthorized individuals. The Health Information Management Department is responsible for safeguarding both the record and its information content against loss, defacement and tampering. They are also responsible to safeguard the medical record against use by unauthorized individuals. ...Paper charts that are temporarily maintained in any of the patient care outpatient areas, i.e., PT (physical therapy), WC (wound care), Sleep Study, etc. until scanned into the Horizon Patient Folder....are kept secured at all times...."

Observation during tour on 07/26/2012 at 1400 of the outpatient Wound Care department revealed a room adjacent to the nurses' station used as a staff break/conference room. Observation revealed one entry door into the room. Observation of the entry door revealed the door was secured by a key pad lock. Observation revealed the WC Director had to enter a code into the key pad lock to gain access to the room. Observation upon entry into the room revealed a male service repair technician wearing a "SYSTEL" uniform. Observation revealed the technician was working on the copier/printer machine located in the room. Observation revealed no other hospital staff member present in the room. Observation revealed the technician was alone and unsupervised. Observation revealed a metal multi-shelved file cabinet with doors stored less than 2 feet from the copy/printer machine. Observation of the opened shelves in the file cabinet revealed numerous blue jacketed file folders. Observation revealed the file folders were in clear line-of-site of the copy/printer machine and technician. Review of one of the file folders stored on the file cabinet shelf revealed the file folder contained the protected and confidential health information (medical records) of an active wound care patient. Observation revealed the file folders were easily accessible by the technician. Interview during tour with the WC Director revealed the multi-shelved file cabinet was used to store all active wound care patient medical records. Interview revealed the breakroom/conference room is used by all department staff to include housekeeping. Interview revealed a code is required to enter the room. Interview revealed only authorized staff have the access code. Interview revealed the technician had to be let into the room by a authorized staff member. Interview revealed the technician was not authorized to have access to patient medical records. Interview revealed the technician should have been supervised while in the room. Interview confirmed the technician was alone and unsupervised by authorized staff when the surveyor entered the room. Interview confirmed the technician had access to the protected and confidential health information contained in the medical records stored in the file cabinet.

Interview on 07/26/2012 at 1445 with the Director of Health Information Management (HIM) revealed patient medical records are stored in locations other than the main HIM department within the hospital. Interview revealed medical records are stored in the outpatient Physical Therapy and Wound Care departments. Interview revealed medical records should be stored in a secure location at all times and not left unattended. Interview revealed only authorized individuals should have access to medical records. Interview revealed the SYSTEL Technician is not authorized to have access to medical records. Interview revealed "the SYSTEL Technician should not have been left unattended." Further review revealed "it is clearly a violation." Interview revealed the HIM Director was unaware staff were allowing unauthorized individuals unsupervised access to areas where medical records were stored. Interview confirmed the hospital's staff failed to follow the hospital's policy for the storage and security of medical records.

Based on policy review, medical record review, observation, and staff interview, the hospital's Infection Control Officer failed to ensure the control of infections by failing to ensure staff utilized personal protective equipment (PPE) and handwashing techniques per policy for 1 of 4 sampled patients observed on isolation precautions (Patient #7).

The findings include:

Review of current hospital policy entitled "Guidelines for Isolation Precautions" dated 12/2011 revealed, "...PURPOSE: To provide epidemiologically sound principles for isolation precautions. To prevent transmission of pathogens....CONTACT, DROPLET, and AIRBORNE ISOLATION PRECAUTIONS (Tier II): Refer to Appendix I for transmission-based guidelines...." Review of the attached Appendix I revealed the following guidelines for the implementation and maintenance of contact isolation precautions: "WHEN TO IMPLEMENT: Known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the patient (hand or skin to skin) or indirect contact (touching) environmental surfaces or patient-care items in the environment...EXAMPLES: MRSA (Methicillin Resistant Staphylococcus Aureus)....GOWNS: Wear if contact with the patient, environmental surfaces, items in the room....GLOVES: Wear when entering the room, change after contact with infective materials. Remove before leaving room & discard in regular trash. HAND HYGIENE: Decontaminate/wash hands after: contact with patient's intact skin....after contact with inanimate objects in the environment (including medical equipment....after clean or sterile glove removal...."

Open medical record review on 07/25/2012 at 1000 for Patient #7 revealed a 53 year-old female that was admitted to ICU Room 8 on 07/24/2012 with narcotic overdose and acute respiratory failure. Record review revealed the patient had a past history of MRSA.

Observation of ICU Room 8 on 07/25/2012 at 1000 with the unit Charge Nurse revealed a "Contact Precautions" sign on the patient's door. Observation revealed a device that contained gloves and gowns (PPE) hung on the patient's door. Observation revealed the inside of the patient's room, including the patient's bed, was visible from the nursing station through the room's window and opened door. Observation revealed Registered Nurse (RN) #1 went into the room without donning gown or gloves. Observation revealed the nurse touched the IV (intravenous) machine located at the patient's bedside and then reached over the side rail and touched the patient in the bed. Observation revealed the nurse exited the patient's room without sanitizing his hands. Observation revealed the nurse then walked to the nursing station, touched surface areas within the nursing station, and then went into ICU Room 6, where another patient was located, without sanitizing his hands. Observation at 1005 revealed the nurse went back into Room 8, exited the room without sanitizing his hands, went into the nourishment room, and then to the nursing station.

Interview on 07/25/2012 at 1000 with the Charge Nurse during the observation confirmed the nurse touched the IV machine and patient without wearing gloves and did not sanitize his hands when he exited the patient's room.

Interview on 07/25/2012 at 1010 with RN #1 revealed Patient #7 (located in Room 8) was on contact precautions because she had a history of MRSA. Interview revealed when a patient was on contact precautions the nurse should wear a gown if he expected to get his clothes contaminated with body fluids and wear gloves whenever touching the patient. Interview revealed, "I do not touch her without gloves." Surveyor reported observations made of the nurse touching IV machine and patient without gloves. Interview revealed the nurse repeated, "I do not touch her without gloves."

Interview on 07/25/2012 at 1530 with the Director of Quality revealed the Infection Control Preventionist (ICP) was no available for interview. Interview revealed the Director of Quality oversees the hospital's infection control program. Interview revealed patient's with a history of MRSA must be placed on contact precautions. Interview revealed, "If you anticipate contact with the patient and your body, you should have on a gown. You definitely should have gloves on (for patient contact)."