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Based on observations, facility document review, and staff interviews, the facility failed to ensure that facility practices were performed in a manner that would prevent communicable diseases.

This failure contributed to patients and staff being exposed to potentially infectious agents.

FINDINGS:

1. The facility did not ensure that cleaning solutions were properly diluted to ensure effective cleaning and disinfection of equipment used during patient procedures.

a) On 06/11/13 at 2:00 p.m., the facility's sterile instrument cleaning area was viewed and an interview was conducted with an Operating Room (OR) staff nurse. The OR staff nurse stated s/he cleaned the surgical instruments in a cleaning solution that s/he mixed prior to putting them in the washer. The OR staff nurse stated that s/he mixed "one squirt" of an enzymatic cleaning solution, in an unknown amount of water that s/he estimated was the right amount of water, as it fully covered the instruments. S/he stated there was no marking on the sink to indicate how many gallons it could hold. The OR Manager then read the manufacturer's instructions on the enzymatic cleaning solution bottle to the surveyor, which stated,"to add 1/2 ounce of enzymatic cleaner to 1 gallon of water". The facility's OR staff nurse was unable to verbalize how s/he was able comply with the manufacturer's instructions without knowing the exact amount of water contained in the sink.

b) POLICY

2. The facility performed dry dusting and sweeping in patient care areas.

a) On 06/10/13 at 1:00 p.m., the facility's inpatient unit janitor's closet was viewed with the facility's Vice President of Patient Services. The closet contained a broom, which the facility's Vice President of Patient Services stated that housekeeping used to sweep the vents in the hallways of the inpatient unit.

b) On 06/10/13 at 2:00 p.m., the facility's Emergency Department (ED)janitor's closet was viewed with the facility's Vice President of Patient Services. The closet contained a broom and featherduster. The Vice President of Patient Services stated s/he was unsure where housekeeping cleaned with these items.

c) POLICY

Based on observations, interviews, and review of facility policies/procedures, the facility failed to ensure the confidentiality of medical record information by providing safeguards against loss and unauthorized use.

This failure had the potential to lead to unauthorized individuals accessing confidential medical records or for medical records to be lost.

FINDINGS:

1. The facility did not restrict access to medical records to only those individuals with a need for access to medical records.

a) On 06/10/13 at 3:00 p.m., a tour of the facility's Radiology Department was conducted with the facility's Radiology Manager. The Radiology Department was not locked and did not restrict patient or staff access to the area.

The mammography room in the Radiology Department contained a large desk with unlocked drawers that contained numerous mammography patient medical records. The desk drawers were unable to be locked per the Radiology Manager, who verified these patient medical records were not secure.

During the same tour, the Radiology Department's nursing station was viewed. The nursing station contained several unlocked drawers, which contained numerous patient medical records and radiology results. The Radiology Manager stated that these drawers were unable to be locked, were left unattended at times, and were not secure.

b) On 06/12/13 at 10:30 a.m., the facility's policy, "Record Management", was reviewed. The policy stated,"Records containing confidential and proprietary information shall be securely maintained, controlled, and protected to prevent unauthorized access". The facility's Health Information Manager verified this was the current policy.