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Based on observation, interview, and record review, the hospital failed to ensure that patient medical information was kept confidential when the Respiratory Services Room door was left propped open with a trash can, and patients' ABG (a blood test that measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery) results were available to anyone who walked into the room. This failure had the potential for patient medical information to be disclosed without the patient's authorization.

Findings:

On 11/3/14 at 11:50 am, the door for the Respiratory Services area, in which arterial blood gases were analyzed, was observed to be propped open with a trash can with no one present. The door had a lock mechanism directly on the door which required a code to enter the room. A binder was present in the room that contained patient names, dates of ABG testing, and test results.

On 11/5/14, the hospital's policy, titled, "Medical Records and PHI (personal health information) Access and Retrieval," last reviewed 10/24/14, indicated that access to PHI, such as ABG results, was to be kept secure and access was restricted to authorized users.

In a concurrent interview, Nurse Manager J acknowledged that the Respiratory Services door should remain locked if no one was present, and that patients' PHI was not kept secure from access by unauthorized users when the door was propped open with no hospital staff present.

Based on observation, interview, and record review, the hospital failed to ensure that medications were kept secure when the Respiratory Services door was left propped open with a trash can, without any hospital personnel in attendance, and medications were available to anyone who walked into the room. This failure had the potential for medications to go to unintended recipients and cause infection or harm.

Findings:

On 11/3/14 at 11:50 am, the door for the Respiratory Services area, in which arterial blood gases were analyzed, was observed to be propped open with a trash can with no one present. The door had a lock mechanism directly on the door which required a code to enter the room. Medications used by respiratory therapists were available on the shelves and in the unlocked refrigerator.

On 11/5/14, the hospital policy, titled, "Medication Storage Areas," dated 1/16/08, read, "Drugs and pharmaceutical supplies will be stored in locked cabinets, rooms, or carts, inaccessible to unauthorized individuals."

In a concurrent interview, Nurse Manager D acknowledged that the medications in the Respiratory Services room should be secured from access by unauthorized personnel.

Based on interview and record review, the anesthesia provider for one of three sampled surgical cases failed to document the amount and times of anesthetic agents given during a colonoscopy (a surgical procedure to view the inner lining of the rectum and intestines). (Patient 13).

This failure had the potential for unsafe medication practices to go unnoticed and potentially cause patient harm.

Findings:

On 11/5/14, Patient 13's record was reviewed. Patient 13 was admitted for a colonoscopy on 10/21/14. Patient 13's record contained an anesthesia record that listed two medications given, Propofol (an anesthetic) and Lidocaine (to ease the pain of administering Propofol) that showed a line across four columns (one hour ' s time interval) and then listed total amounts that was administered for each medication. There was no evidence in Patient 13's record of the amounts of medication give during each 15 minute interval nor the times of administration.

On 11/5/14, the hospital policy, titled, "Intraoperative Care," read, "Accurate and careful recording of the physiological status of the patient and the main events which occur during anesthesia shall be documented in the anesthesia record...Documentation of drug and agents used shall be done."

On 11/5/14 at 10:15 am, Certified Registered Nurse Anesthetist (CRNA) M stated he was continuously giving the above medications to maintain Patient 2's sedation level and did not document each administration of medication. When asked which standards he used for anesthesia, CRNA M replied, "American Association of Nurse Anesthetists (AANA)."

AANA standards, titled, "Documenting the Standard of Care," were provided by CRNA M and read, "Anesthesia care normally is documented in a graphic anesthesia record, which includes a sequence of entries reflecting the anesthesia care given, the drugs and fluids administered, and the patient's responses to the care. The design of the anesthesia record should allow for a sequential recording of information and serve as a reminder of the items to be recorded. The graphic charting area of the record should be composed of a grid on which ...drugs and fluids administered are recorded. Information to be contained in the Anesthesia Record:...Medications Administered ... Names,.. Amounts/concentrations, Tines - use of graphic or continuous flow charting most desirable for anesthetic drugs, Totals, when indicated..."

CRNA M confirmed Patient 13's record did not demonstrate the amounts and times of the Propofol and Lidocaine administrations. CRNA M acknowledged that the AANA standards were not reflected in his documentation.