HospitalInspections.org

The Critical Access Hospital (CAH) reported an average daily census of 6.3 patients with a current census of six patients, three acute patients and three skilled swing bed patients. Based on observation, staff interview and policy review, the CAH failed to ensure equipment and supplies commonly used in life-saving procedures were readily available to staff in one of three Emergency Department (ED) rooms, three of four crash carts (locked cart with emergency medications and supplies), the Intensive Care Unit (Room #131) and two of two Broselow bags (pediatric emergency kit). The CAH's failure to ensure emergency supplies were available to patients has the potential to cause harm and delay emergency care to patients.

Findings include:

The CAH's policy titled "STOCK ROTATION" reviewed on 7/8/15 at 10:00am directed staff, "...Items whose packaging has been damaged or which have exceeded their expiration date shall be forwarded to the Nurse Manager who will discard the expired supply..."

- Emergency Department (ED) Room #2 observed on 7/6/15 at 12:05pm revealed the top shelf of the locked crash cart containing one blue vacutainer tube (used to draw blood for lab testing), with expiration date 01/15 and one yellow vacutainer tube (used to draw blood for lab testing) with expiration date 06/15. The CAH's failure to ensure proper lab drawing equipment is available has the potential for incorrect lab testing and poor patient outcomes.

Registered Nurse Staff M and Registered Nurse Staff N interviewed on 7/6/15 at 12:35pm acknowledged that two vacutainer tubes were expired.

- Emergency Department Room #3 observed on 7/6/15 at 12:45pm in the upper cabinet revealed the following:
1. Plastic specimen cup with 50 ml (milliliters) of clear liquid labeled "Formalin" (solution used to preserve tissue for pathology) with no date.
2. "A.C.T. II Collection & Transport System" (swab and medium used to culture for infection) kit with an expiration date of 2/6/08.
3. "Sure Path Preservation Fluid" (used for pap smears) with an expiration date of 7/07.
4. "UTM-RT Medium Transport-Viruses, Chlamydia, Mycoplasma and Urea Plasma", 3.0ml (used to culture for infection) with an expiration date of 1/2007.
5. "Remel Amies Charcoal with Bacti Swab " (used to culture for infection) with an expiration date of 12/31/06.
6. " Gen probe Urine Specimen", 2ml (used to culture for infection) with an expiration date of 12/31/06.
7. "Bacti Swab NPG Collection and Transport System", (used to culture for infection) with an expiration date of 3/3/07.
8. "Bacti Swab II Collection and Transport System", (used to culture for infection) with an expiration date of 5/4/08.
9. "Gen Probe Aptima Swab Specimen Transport Tube", (used to culture for infection) with an expiration date of 2/28/07.

Administrative Staff A interviewed on 7/6/15 acknowledged the Formalin did not have a date and the seven expired specimen swabs. Administrative Staff A states the expired swabs are used to teach staff what to use.

- The Intensive Care Unit (ICU) Room #131 observed on 7/7/15 between 8:35am to 9:45am revealed the following outdated emergency supplies:

1. One Multilumen Central Venous Catheterization kit (catheter inserted via the subclavian, jugular or femoral veins for administration of fluid, medication, or blood products) with an expiration date of 6/2015.
2. Two 15gauge intraosseous needle (a needle used to access into the bone marrow to provide a rapid and effective route for fluid resuscitation and medication) sets with an expiration date of 10/14

- The Intensive Care Unit (ICU) Room #131 observed on 7/7/15 between 8:35am to 9:45am revealed the following outdated emergency supplies in a Broselow Bag (a pediatric emergency kit):
1. Five intraosseous modules with an expiration date of 4/15
2. One intraosseous module with an expiration date of 2/15
3. One intraosseous module with an expiration date of 1/15
4. Two intubation modules (used to maintain an airway) with expiration dates 10/14
5. Two intubation modules with an expiration date of 10/13
Registered Nurse Staff F interviewed on 7/7/15 at 9:45am acknowledged the outdated unusable emergency supplies in the Broselow Bag in the ICU room.

- The Infusion Clinic office observed on 7/7/15 at 11:50am revealed a crash cart with an Emergency Cricothyrotomy Catheter set (used to start an emergency airway) with an expiration date of 2/2015.

Staff Registered Nurse O interviewed on 7/7/15 at 11:55am acknowledged the expired Cricothyrotomy Catheter set.

- Surgery Center observed on 7/8/15 at 1:00pm revealed a crash cart with the following:
1. One King LT-D Laryngeal Tube Size 3, (used to establish an airway in an emergency), with an expiration date of 6/15.
2. One King LT-D Laryngeal Tube Size 5, (used to establish an airway in an emergency), with an expiration date of 5/15.

- Surgery Center observed 7/8/15 at 1:00pm revealed one Broselow bag (pediatric emergency kit) with the following:
1. One pediatric pink/red Intraosseous kit (a needle used to access into the bone marrow to provide a rapid and effective route for fluid resuscitation and medication) with an expiration date of 11/14.
2. One pediatric White kit Intubation tube with an outdate 11/14.

Staff Registered Nurse L interviewed on 7/8/15 at 1:10pm acknowledged the expired supplies from the crash cart and Broselow Bag.

The Critical Access Hospital reported an average daily census of 6.3 patients with a current census of six patients, three acute patients and three swing-bed patients. Based on observation, policy review, document review and interview the hospital failed to provide for the safety of patients and or staff in one of one oxygen storage room with portable oxygen tanks. This deficient practice has the potential to cause harm to patients and staff members.

Findings include:


- The CAH's policy "use of Flammables and Oxygen Safety" reviewed on 7/7/15 at 2:00pm directed, "...To ensure a safe environment for the patient, staff and visitors ...Oxygen Cylinder storage should occur on secure carts or secured to a stationary object..."


- The oxygen storage room observed on 7/7/15 at 12:25pm revealed two E oxygen tanks and seven D oxygen tanks sitting on the cement floor. The oxygen tanks failed to be secured in a cylinder stand or to a stationary object.


Administrative Maintenance staff D interviewed on 7/7/15 at 12:25pm in the oxygen storage room, acknowledged the unsecured oxygen tanks.

The Critical Access Hospital (CAH) reported an average daily census of 6.3 patients with a current census of six patients, three acute patient and three skilled swing bed patients. Based on observation, staff interview, and policy review the CAH failed to provide a clean and orderly environment in the Physical Therapy department and in the Infusion Clinic.

Findings include:

- The Critical Access Hospital (CAH) policy "Cleaning Paraffin Bath" reviewed on 7/7/15 at 10:40am directed, "...Cleaning of the unit is to be done once a month, or as needed when used excessively for that month..."

- The Physical Therapy treatment room #1 observed on 7/7/15 between 10:10am and 10:35am revealed a paraffin bath used for treatment for pain. The paraffin bath cleaning schedule reviewed on 7/7/15 at 10:15 lacked evidence of cleaning in 2015.

Physical therapy Staff J interviewed on 7/7/15 at 10:30am acknowledged facility staff failed to clean the paraffin bath per CAH policy.

- The CAH's policy "Cleaning Hydrocollator" (a machine to warm packs in warm water) reviewed on 7/7/15 at 10:40am directed, "...the hydrocollator will be cleaned once a month..."

- The Physical Therapy gym observed on 7/7/15 between 10:10am and 10:35am revealed a hydrocollator. Review of the hydrocollator cleaning schedule revealed staff last cleaned the hydrocollator May 2015.

Physical therapy Staff J interviewed on 7/7/15 at 10:30am acknowledged facility staff failed to document cleaning of the hydrocollator in June per CAH policy.

- The Infusion Clinic observed on 7/7/15 at 11:40am revealed two computers with white sticky debris along edges.

Registered Nurse Staff O interviewed on 7/7/15 at 11:40am indicated they did not have enough workspace and they place patient stickers on the computer. The white debris came from the back of patient stickers.

The Critical Access Hospital (CAH) reported an average daily census of 6.3 patients with a current census of six patients, three acute patients and three swing-bed patients. Based on observation, staff interview, and document review the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control program for staff practices which could contribute to healthcare acquired infections of patients and personnel. Observations included one of one observed wound dressing change (patient #19), one of seventeen observed patient rooms with wall suction (Room #128), one of two observed soiled utility rooms (Medical-Surgical unit), two of two observed ice chests (Nourishment Room in the Medical-Surgical unit and Infusion Center), two of two observed patient refrigerators (Nourishment Room in the Medical-Surgical unit and Infusion Center), one of two infusion treatment rooms (Room #2) and one of three observed Emergency Treatment Rooms (Room #2). The CAH's failure to identify failures with infection control practices created the potential for healthcare acquired infections.


Findings include:


- The CAH's policy for outdated supplies reviewed on 7/8/15 at 10:00am directed, " ...Items whose packaging has been damaged or which have exceeded their expiration date shall be forwarded to the Nurse Manager..."


- Emergency Department (ED) Room #2 observed on 7/6/15 at 12:30pm revealed an open box of "Scrub Care Chlorhexidine Gluconate Solution 4%" (Surgical Hand Scrub brushes) almost full box (30 scrubs per box) with an expiration date of 05/2015.

Staff Registered Nurse M and Staff Registered Nurse N interviewed on 7/6/15 at 12:37pm acknowledged the expired hand scrub brushes and the brushes may not be effective.

- The CAH's policy "Exposure Control Plan" reviewed on 7/8/15 at 10:00am directed, "...Mask and eye protection (such as goggles, face, shields) are used whenever splashes or sprays may generate droplets of infectious materials...Protective clothing (such as gowns and aprons) is worn whenever potential exposure to the body is anticipated..."

- Registered Nurse Staff F observed on 7/7/15 at 9:05am provided a dressing change to patient #19's leg wound using normal saline(a salt liquid solution). Staff F failed to wear protective clothing such as a gown or apron to protect their uniform from potential exposure of microorganisms from patient #19's wound.

Registered Nurse Staff F interviewed on 7/7/15 at 9:45am acknowledged they failed to wear a protective gown while providing wound care to Patient #19.

- The CAH's policy "Exposure Control Plan" reviewed on 7/8/15 at 10:00pm directed, "...Employee food is not stored in refrigerators used for patient care..."

- Nourishment Room in the Med-Surg area observed on 7/7/15 between 10:45am revealed a patient refrigerator with the following:
1. One plastic container with a red lid with unidentified brown food without a label
2. One 32 ounce Clover Valley French Vanilla Non Dairy Creamer without a label
3. One 24 ounce White Corn Black Bean Salsa glass jar without a label
4. Two plastic containers filled with potato salad from the Dietary Department for patient use which lacked a date when prepared
5. One 16 ounce Rock Star Lime Freeze Energy Drink without a label
6. One ice chest with standing water and an ice scoop in the bottom.

Nurse Aide Staff P interviewed on 7/7/15 at 11:00am acknowledged staff food in the patient refrigerator. Staff P indicated they did not know how long the food had been in the refrigerator or whose food was in the patient refrigerator. Staff Nurse Aide P acknowledged food from the Dietary Department intended for patients did not have dates.

- The soiled utility room on the Med-Surg Unit observed on 7/7/15 at 11:08am revealed a flush rim sink and sprayer. Observation in the room revealed the lack of cover gowns (personal protective equipment (PPE) available to protect staff and their clothing from splash and the spread of germs while using the flush-rim sink and sprayer.

Maintenance Staff D interviewed on 7/7/15 at 11:08am acknowledged lack of accessible PPE.

- Infusion Clinic Treatment Room #2 observed on 7/7/15 at 11:30am revealed one container of Super Sani-Cloth with an expiration date of 04/2015.

Administrative Staff A interviewed on 7/7/15 acknowledged the expired Super Sani-Cloth and should not be available.

- The CAH's policy "Single Use Package Items" reviewed on 7/7/15 at 2:45pm directed, "...Opened but unused single use medical devices must be discarded and not left opened or connected for emergent usage..."

- Patient room #128 observed on 7/7/15 at 11:10am revealed a Yankauer suction (plastic tube to suction secretions from a person's mouth) connected to a wall suction canister.

Registered Nurse Staff E interviewed 7/7/15 at 11:15am and acknowledges the open Yankauer suction tip connected to wall suction and indicated the tip should not be opened.

- The Infusion Clinic observed on 7/7/15 at 11:40am revealed a frozen Chicken Enchilada Suiza dinner and an open, partially filled water bottle in the patient refrigerator. The counter on the south wall contained a small ice chest with standing water.

Registered Nurse Staff O interviewed on 7/7/15 at 11:40am indicated the dinner probable belonged to a staff member and the water bottle probable had been drunk from and belonged to a staff member. Staff O acknowledged staff should not place personnel food in the patient refrigerator and the contaminated water bottle exposed patient food to contaminate. Staff O indicated the ice chest is used for patients and did not know how long the water had been sitting in the ice chest.

The Critical Access Hospital (CAH) reported an average daily census of 6.3 patients with a current census of 6 patients, three acute patient and three skilled swing bed patients. Based on observation, staff interview, and policy review the CAH failed to ensure compliance with outdated supplies in the Laboratory Department.

Findings include:

- The CAH's policy "Hospital Stock Rotation" for all hospital departments reviewed on 7/9/15 at 9:30am directed, "...items which have exceeded their expiration date shall be discarded..."

- The Laboratory observed on 7/6/15 at 12:15pm revealed a cabinet which contained three boxes of ABG (Arterial Blood Gas (test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery) control cartridges. One box of controls which expired 6/23/15 and two boxes of controls which expired 6/30/15. A cabinet on the north side of the lab contained eighteen HCG (pregnancy tests) which expired 6/30/15.

Laboratory Director Staff I interviewed on 7/6/15 at 12:15pm acknowledged outdated supplies in the cabinet.

Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) failed to follow written policies for medical records storage (refer to C-0301), failed to maintain medical record storage in an organized and accessible manner (refer to C-0302), failed to ensure medical records contained a pertinent medical history and physical completed in a timely manner and ensure a complete medical record within thirty days (refer to C-0304), and failed to safeguard confidential patient information from possible destruction or unauthorized use (refer to C-0308).

The cumulative effect of the systematic failure to follow written policies for medical records storage, failure to maintain medical record storage in an organized and accessible manner, failure to ensure medical records contained a pertinent medical history and physical completed in a timely manner and ensure a complete medical record within thirty days, and failure to safeguard confidential patient information from possible destruction or unauthorized use resulted in the CAH's inability to provide care in a safe and effective manner.

The Critical Access Hospital (CAH) reported an average daily census of 6.3 patients with a current census of six patients, three acute patients and three skilled swing bed patients. Based on observation, staff interview, and policy review the CAH failed to follow written policies for medical records stored in three of three medical record storage areas (old whirlpool room, the medical records office, and the basement storage area). This practice has the potential to affect the patient's records in these areas rendering them damaged, or unable to be retrieved or be accessed by unauthorized personnel.

Findings include:

- The CAH's policy "Secure Filing of Medical Records" reviewed on 7/8/15 at 3:00pm directed, "...Medical records housed within the hospital shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals...Medical records will be maintained in a manner that shelving will be secure to house and protect the records...The Health Information Management Department is responsible for safeguarding both the record and its informational content against loss, defacement and tampering. They are also responsible to safeguard the medical record against use by unauthorized individuals..."

- The Medical Records storage room in the old whirlpool room observed on 7/8/15 at 9:15am revealed a room with a whirlpool, double sink and wall water supply. The storage room contained sixteen banker boxes (cardboard boxes used to store medical records) with patients' medical records placed directly on the floor.

Medical Records Staff C interviewed on 7/8/15 at 9:15am acknowledged the boxes contained patients' medical records and the boxes sat directly on the floor with the potential for flooding and indicated they lacked knowledge the boxes should not sit on the floor.


- The Medical Records office observed on 7/8/15/15 at 9:25am revealed twenty banker boxes with patient records placed directly on the floor.

Medical Records Staff C interviewed on 7/8/15 at 9:25am acknowledged the boxes contained patients' medical records and the boxes sat directly on the floor with the potential for destruction.


- The Medical Records storage room in the basement of the CAH observed on 7/8/15 between 9:40am to 10:10am revealed a large room with boxes piled haphazardly in the east end with approximately 250 to 270 banker boxes containing medical records. The lack of arrangement prevented an accurate accounting of the records. Water pipes were visible above the boxes. Observation of the medical records banker boxes revealed approximately 22 boxes with evidence of water damage.


Medical Records Staff C interviewed on 7/8/15 at 10:10am acknowledged the boxes contained patients' medical records and the boxes were haphazard, damaged and some appeared destroyed.


- The dietary back hallway observed on 7/8/15 at 10:12am revealed a large red tote box overflowing with papers and books. Further observation revealed seven folders containing patient names and procedures, ten surgery schedule books with patient names and procedures, and nine surgery logbooks with patient names, types of surgeries, diagnoses and complications.


Medical Records Staff C interviewed on 7/8/15 at 10:30am called the OR staff to inquire about the red tote box with patient information and indicated the OR staff cleaned the office, gave housekeeping the records and housekeeping left them in the hallway to be placed in the storage room by someone with a key. Staff C indicated housekeeping placed the red tote in the hallway the evening of 7/7/15. Staff C confirmed unauthorized persons could access patients ' confidential health information.


The CAH failed to follow written policies for medical records storage.

The Critical Access Hospital (CAH) reported an average daily census of 6.3 patients with a current census of six patients, three acute patients and three skilled swing bed patients. Based on observation, staff interview, and policy review the CAH failed to maintained medical record storage in an organized and accessible manner. This practice has the potential to affect the patient's records in one of three medical record storage areas (basement storage area).

Findings include:

- The CAH's policy "Secure Filing of Medical Records" reviewed on 7/8/15 at 3:00pm directed, "...Medical records housed within the hospital shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals...Medical records will be maintained in a manner that shelving will be secure to house and protect the records...The Health Information Management Department is responsible for safeguarding both the record and its informational content against loss, defacement and tampering. They are also responsible to safeguard the medical record against use by unauthorized individuals..."

- The Medical Records storage room in the basement of the CAH observed on 7/8/15 between 9:40am to 10:10am revealed a large room with boxes piled haphazardly in the east end with approximately 250 to 270 banker boxes containing medical records. The lack of arrangement prevented an accurate accounting of the records. Above the medical records were water pipes. Observation of the medical records banker boxes revealed approximately 22 boxes evidenced water damage.

Medical Records Staff C interviewed on 7/8/15 at 10:10am acknowledged the boxes contained patients' medical records and the boxes were haphazard, damaged and some appeared destroyed.

Medical Records Staff C interviewed on 7/9/15 at 1:00pm indicated the CAH failed to have a policy for storage of medical records in an organized and accessible manner

The CAH failed to maintained medical record storage in an organized and accessible manner.

The Critical Access Hospital (CAH) reported an average daily census of 6.3 patients with a current census of six patients, three acute patients and three swing-bed patients. Based on medical record review, staff interview, policy review, and Medical Staff Rules and Regulation review the CAH failed to ensure four of thirty sampled medical records contained a pertinent medical history and physical (H & P) completed in a timely manner (Patient #'s 30, 36, 39, and 40) and failed to ensure a complete medical record within thirty days for two of twenty seven closed medical records reviewed (Patient #'s 30 and 42) The CAH's failure to ensure patients' medical history and physical are competed in a timely manner and complete a closed medical record timely has the potential for poor patient outcomes.

Findings include:

- The CAH's Medical Staff Rules and Regulations reviewed on 7/8/15 at 11:00am directed, "...A medical history and physical examination can be completed no more than 30 days before or 24 hours after admission for each patient..."

- The CAH's policy "History and Physical-Surgical Services" reviewed on 7/9/15 at 8:29am directed, "...a comprehensive history and physical (H&P) examination shall be completed within 24 hours of admission to inpatient services...though no more than 30 days prior to admission or readmission..."

- Patient #30's surgical medical record reviewed on 7/7/15 revealed an admission date of 5/22/15 for a surgical procedure. Patient #30's medical record revealed a history and physical completed 3/11/15 (65 days prior to surgery). The CAH failed to ensure Patient #30's medical record contained a history and physical completed within 30 days of surgery.

Medical records Staff C interviewed on 7/7/14 at 2:10pm acknowledged patient #30's history and physical failed to be completed within 30 days of surgery.

- Patient #36's medical record reviewed 7/7/15 revealed an admission date of 6/15/15 with a diagnosis of gastrointestinal bleed. Patient #36's medical record revealed a history and physical completed on 7/4/15 (19 days after admission). The CAH failed to ensure Patient #36's medical record contained a history and physical completed within 24 hours after admission.

Medical Records Staff C interviewed on 7/7/15 at 2:00pm acknowledged patient #36's history and physical failed to be completed within 24 hours.

- Patient #39's medical record reviewed on 7/7/15 revealed an admission date of 6/13/15 with a diagnosis of a fractured pelvis. Patient #39's medical record revealed a history and physical completed on 6/15/15 (48 hours after admission). The CAH failed to ensure Patient #39's medical record contained a history and physical completed within 24 hours after admission.

Electronic Medical Records Director Staff G interviewed on 7/7/15 at 1:50pm acknowledge patient #39's history and physical failed to be completed within 24 hours.

- Patient #40's medical record reviewed on 7/7/15 revealed an admission date of 6/25/15 with a diagnosis of weakness. Patient #40's medical record revealed a history and physical completed on 7/4/15 (nine days after admission). The CAH failed to ensure Patient #40's medical record contained a history and physical completed within 24 hours after admission.

Electronic Medical Records Director Staff G interviewed on 7/7/15 at 2:10pm acknowledge patient #40's history and physical failed to be completed within 24 hours.

- The CAH's policy "Completion of Medical Records" reviewed on 7/8/15 at 3:00pm directed, "...In accordance with Kansas Hospital Regulation, records of discharged patients are completed within 30 days of dismissal..."

- Patient #30's surgical medical record reviewed on 7/7/15 revealed an admission date of 5/22/15 for a surgical procedure and discharged on 5/25/15. Patient #30's operative report record lacked a signature by the physician (46 days after discharge).

Medical Records Director Staff C interviewed 7/8/15 at 4:00pm acknowledged patient #30's operative report lacked evidence of physician's signature.

- Patient #42's medical record review on 7/7/15 revealed an admission date of 12/22/14 and discharged on 1/8/15. The medical record contained a discharge summary dated 3/4/15 (56 days after discharge).

Administrative staff G interviewed on 7/7/15 at 2:48pm acknowledged Patient #42's medical record failed to be completed within the required 30 days.

The Critical Access Hospital (CAH) reported an average daily census of 6.3 patients with a current census of six patients, three acute patients and three skilled swing bed patients. Based on observation, staff interview, and policy review the CAH failed to safeguard confidential patient information from possible destruction or unauthorized use. This practice has the potential to affect the patient's records in three of three medical record storage areas (old whirlpool room, the medical records office, and the basement storage area).

Findings include:

- The CAH's policy "Secure Filing of Medical Records" reviewed on 7/8/15 at 3:00pm directed, "...Medical records housed within the hospital shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals...Medical records will be maintained in a manner that shelving will be secure to house and protect the records...The Health Information Management Department is responsible for safeguarding both the record and its informational content against loss, defacement and tampering. They are also responsible to safeguard the medical record against use by unauthorized individuals..."

- The Medical Records storage room in the old whirlpool room observed on 7/8/15/15 at 9:15am revealed a room with a whirlpool, double sink and wall water supply. The storage room contained sixteen banker boxes (cardboard boxes used to store medical records) with patients' medical records placed directly on the floor.


Medical Records Staff C interviewed on 7/8/15 at 9:15am acknowledged the boxes contained patients' medical records and the boxes sat directly on the floor with the potential for flooding and indicated they lacked knowledge the boxes should not sit on the floor. The CAH failed to assure protection of medical records from destruction.


- The Medical Records office observed on 7/8/15/15 at 9:25am revealed twenty banker boxes with patient records placed directly on the floor.

Medical Records Staff C interviewed on 7/8/15 at 9:25am acknowledged the boxes contained patients' medical records and the boxes sat directly on the floor with the potential for destruction.


- The Medical Records storage room in the basement of the CAH observed on 7/8/15 between 9:40am to 10:10am revealed a large room with boxes piled haphazardly in the east end with approximately 250 to 270 banker boxes containing medical records. The lack of arrangement prevented an accurate accounting of the records. Water pipes were visible above the boxes. Observation of the medical records banker boxes revealed approximately 22 boxes with evidence of water damage.


Medical Records Staff C interviewed on 7/8/15 at 10:10am acknowledged the boxes contained patients' medical records and the boxes were haphazard, damaged and some appeared destroyed.


- The dietary back hallway observed on 7/8/15 at 10:12am revealed a large red tote box overflowing with papers and books. Further observation revealed seven folders containing patient names and procedures, ten surgery schedule books with patient names and procedures, and nine surgery logbooks with patient names, types of surgeries, diagnoses and complications.


Medical Records Staff C interviewed on 7/8/15 at 10:30am called the OR staff to inquire about the red tote box with patient information and indicated the OR staff cleaned the office, gave housekeeping the records and housekeeping left them in the hallway to be placed in the storage room by someone with a key. Staff C indicated housekeeping placed the red tote in the hallway the evening of 7/7/15. Staff C confirmed unauthorized persons could access patients' confidential health information.


The CAH failed to safeguard confidential patient information from possible destruction and/or unauthorized use.