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Based on observations and staff interviews, the facility failed to ensure that medications available for patient use were appropriately stored.

This failure created the potential for the administration of unsafe medications.

Findings:

A position paper from the Association of Professionals in Infection Control and Epidemiology (APIC) titled, "Safe Injection, Infusion and Medication Vial Practices in Healthcare" published July 30th, 2009 stated the transmission of bloodborne viruses and other microbial pathogens to patients during routine healthcare procedures continues to occur due to unsafe and improper injection, infusion and medication vial practices being used by healthcare professionals within various clinical settings throughout the United States. APIC strongly supports adherence to the following safe injection, infusion and medication vial practices. Dispose of opened multidose medication vials 28 days after opening.

1. The facility failed to write the date on multidose medication vials indicting when they were opened.

a) On 02/19/14 at 9:30 a.m., a tour of the facility's clinic was conducted with the facility's Administrator. There were multiple opened multidose medication vials located throughout the clinic. None of the vials had a date written on them indicating when they had been opened.

b) On 02/20/14 at 12:55 p.m., an interview with Staff #13 was conducted. When asked how long a multidose vial could be used after it was opened, Staff #13 stated 28 days and the vials should have been dated as to the date opened.

c) On 02/20/14 at 1:10 p.m., an interview with Staff #14 was conducted. When asked how long a multidose vial could be used after it was opened, s/he stated 28 days. Staff #14 also stated the medication vials should have been dated as this was the only way to ensure the medications would not be used after 28 days.

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

This failure did not restrict access to medical records to authorized individuals accessing confidential records.

Findings:

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

a) On 02/19/14 at 9:30 a.m., a tour of the medical records department was conducted with the facility's Administrator. There were two areas where medical records were stored with a wall separating the two areas. One side was where medical records for a clinic were stored, and one side was where medical records for the hospital were stored. When asked who had access to the areas, the facility's Administer stated Registered Nurses, medical records staff, and housekeeping.

b) On 02/20/14 at 9:10 a.m., an interview with the Medical Records Director was conducted. S/he stated that housekeeping cleans the area where the clinic medical records are stored in the morning and that there are no medical records staff present. The Medical Records Director also stated that the area where the hospital medical records were stored was cleaned in the evening after medical records staff has left. S/he confirmed there was no other staff present when housekeeping cleaned the two areas.

c) On 02/19/14 at 11:10 a.m., a tour of the facility's preoperative area was conducted with the Surgical Services Supervisor. At the nurses station there were five medical records on the desk. When asked about the medical records, the Supervisor stated they were patients that were coming in the next day. S/he also stated that they would remain there until the following day and would not be secured over night.