The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SSM HEALTH ST MARY'S HOSPITAL JEFFERSON CITY 2505 MISSION DRIVE JEFFERSON CITY, MO 65109 July 11, 2012
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on interview the facility failed to provide privacy for patients on two of two halls of the Behavioral Health Unit. The census on the Behavioral Health Unit was 19. The facility census was 82.

Findings included:

1. During an interview on 07/11/12 at 1:00 PM Staff G, Manager Behavioral Health stated that:
-The unit had two halls with patient rooms called 4 North (N) and 4 Central (C)
-Women only were on 4C and men and an overflow area for women were on 4N.
-A unisex bathroom with a shower was located on 4N.
-A woman's bathroom with a shower was located on 4N that is in an alcove. The door to this bathroom did not directly open into the hall.
-A woman's bathroom without a shower is located on 4N.
-The bathroom doors were all open unless in use.
-A small desk was in the hall to encourage staff to document and view the hall at the same time.
-The staff documented the location, activity, and mood of each patient every 15 minutes.

2. During an interview on 07/10/12 at 1:20 PM Staff H, Registered Nurse (RN) stated that:
-Staff checked bathrooms when a patient was in the bathroom for an unusual amount of time.
-The bathrooms on 4N were open all the time, unless in use.
-Hall ways have cameras which can be seen at the nurse's desk, but patient rooms and bathrooms are not visible on the cameras.

3. During an interview on 07/20/12 at 8:15 AM Staff C, Risk Manager stated that
cameras in the Behavioral Health Unit were not taped or seen by security.

4. During an interview 07/20/12 at 8:18 AM Staff G, Manager Behavioral Health stated that:
-The hall view of the camera on 4N showed the hall between the game room and the group/dining room.
-Staff could not view any of the entries into bathrooms on the cameras.
-Staff can only visualize the unisex bathroom entry from mounted mirrors in the corners across from the nurse's station.
-The 4C hall has individual bathrooms in each room and one shower that was located off the main hall and down an approximately four foot long hallway.
-The hall camera view on 4C showed only the entry area into the hallway.
-Employees were not assigned on 4C to observe patient activity in the halls or the monitors in the nurse's station.
-Employees were assigned on 4N to observe patient activity in the hall, but not the monitors in the nurse's station.
-The nurse on 4C stayed at the nurse's station and notified the charge nurse if the nurse was going to have to leave the nurse's station for a patient emergency that required being away for a long period. The nurse did not notify the charge nurse when gone for short periods of time.
-The entry into the hall shower on 4C was not visualized at all times.
-Employees were not instructed to stay at the patient door, while a patient uses the unlocked bathroom door, to ensure another patient does not enter.
-There is a unit secretary at the 4N nurse's station who periodically leaves 4N to work on 4C during the shift.
-The unit secretary does not visualize the bathroom doors at all times.

5. During an interview on 07/10/12 at 1:45 PM Staff I, Mental Health Tech (MHT)/Clerical Assistant (CA) stated that
-He assisted patients to obtain the supplies to use the shower and then pulled the door shut.
-Patients let him know when their shower was completed.
-He checked on patients every 15 minutes unless they had a higher level of supervision.
-He witnessed patients accidentally walk in on another patient, but come right back out.

6. During an interview on 07/10/12 at 2:07 PM Staff J, RN stated that:
-Staff stayed in the nurse's station at all times on 4N, unless there was a bad emergency.
-Employees that were by themselves were encouraged to use the front desk area.
-The facility did not have a policy regarding staff staying at the nurse's station.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
Based on observation, interview, and policy review the facility failed to ensure patient records, which contained protected patient information were secured for four of four out-patient areas. The facility census was 82.

Findings included:

1. Record review of the facility's policy titled, "Privacy Safeguards," reviewed 03/12 showed:
-Outside of normal work hours, all employees should clean their desks and work areas such that all sensitive and confidential data is properly secured.
-Medical record storage areas should be locked when not attended by employees or when the area cannot be monitored by line of sight.
-Limit unauthorized protected health information (PHI) access by patients, visitors and also staff members without need-to-know.

Record review of the facility's policy titled, "Confidential Information," revised 11/10 showed:
-Confidential patient information included face sheets, consent forms, test results, physician orders, nursing and other services documentation.
-Those with a right and a need to know confidential patient information include the patient, direct care providers, and other hospital personnel that need the information in order to do their job.
-All records of care, treatment, or examinations will be accessible only to those parties involved in direct patient care, or who have a right and a need to know, or who have either a primary or consulting relationship with the patient.

2. Observation on 07/11/12 at 9:45 AM in the Infusion Center (an out-patient unit where patients are treated with blood, intravenous infusions, and injections) showed:
-An unlocked file cabinet with two drawers of patient medical records with approximately 60 records in each drawer;
- Approximately seven patient charts were left in a container on the counter. The records included patient face sheets, which included demographic information such as, patients' date of birth and social security number. The unsecured records also included physician orders, treatments given, care plans, and lab results.

During an interview at the time of the observation Staff M, Registered Nurse (RN) stated that:
-The patient records were not locked in the cabinet when the clinical staff left for the day.
-Housekeeping cleaned after the Infusion Center staff left for the day.

3. During an interview on 07/11/12 at 11:00 AM Staff O, Director of Environmental Services and Linens stated that:
-One housekeeping employee cleaned the Infusion Center after the Center closed for the day and all clinical employees exited the area.
-Housekeeping cleaned the Comprehensive Wound Healing Center (a unit that specializes in complicated wounds) after the Clinic closed for the day and clinical employees exited the area.

4. During an interview on 07/11/12 at 12:15 PM Staff P, Information Processor for the Comprehensive Wound Center stated that she left two to three patient charts on her desk and unsecured each night after the Wound Center closed and the clinical employees left the area.

5. Observation on 07/11/12 at 12:27 PM in the Cardiac Rehab Clinic (a customized program of exercise, education to assist a patient to recover from a heart attack, heart disease, and heart surgery) showed:
-The door to the Cardiac Rehab Clinic was open and no employees were in the area.
-There was an unlocked file cabinet, which contained approximately 24 patient charts.

During an interview at the time of the observation, Staff C, Risk Manager verified the cabinet with patient records was left unlocked and unmonitored by staff.

6. During an interview on 07/11/12 at 12:40 PM Staff T, Supervisor of Women's Imaging stated that:
-Approximately 28-30 patient records were kept in an open hanging file unsecured, behind the counter in the patient waiting area, each night after Women's Imaging closed and the employees left the area.
-The patient packets contained a patient face sheet and prior test reports.
-Housekeeping cleaned the patient waiting area and behind the counter after the Women's Imaging closed and employees exited the area.