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Based on observation, interview, and policy review, the facility failed to ensure medical information was protected from public view for six (#12, #13, #14, #15, #16 and #17) patients in the outpatient clinic. This had the potential to affect any patients in the outpatient clinic by revealing to the public personal patient information. The facility census was 11.

Findings included:

1. Record review of the facility's "Patient Rights", date 03/08, showed that the patient and/or patient representative have the right to every consideration of privacy concerning the patient's medical care program.

2. Observation on 03/07/12 at 8:50 AM, showed a Picture Archiving and Communication System (PACS - monitor similar to/used like a computer screen, which can also show x-rays) located in the patient hallway of the Outpatient Clinic. The monitor displayed Patient #12, #13, #14, #15, #16 and #17's full first and last names, patient identification numbers and the type of x-ray (listed as procedure type) performed on the patient (example: Foot - two views). Patients' and family members were seen in the hallway and used the hallway to get to patient examination rooms located in the clinic hall. The information on the screen was readable by anyone standing or walking through the hall, in the vicinity of the monitor.

During an interview on 03/07/12 at 9:08 AM, Staff W, Nurse Practitioner, stated that patient information remained on the PACS monitor throughout the day as several staff and physicians' used the monitor to look up patient information. Staff W added that there was no way to minimize (removes the patient information from visibility on the screen) the screen when staff were finished viewing, without completely signing out of the system.

Observation on 03/07/12 at 9:13 AM showed a (approximate) two foot wide by one and one-half foot tall monitor in the main hall of the Outpatient Clinic. The monitor displayed an x-ray of the lower half of Patient #16's body. The x-ray included the patient's full first, middle, and last name, age, date of birth, sex and patient identification number, which was readable from over eight feet away in the main hallway of the Outpatient Clinic. This observation was verified by Staff D, Director of Patient Care Services.

During an interview on 03/07/12 at 9:15 AM, Staff V, Outpatient Clinic Charge Nurse stated that the PACS monitors had been in place for approximately two years, and that there were concerns about the patient's privacy before the monitors were installed in the main hallways of the clinic, so the corporate office was contacted regarding those concerns. Staff V stated that she was not involved in the discussions with the corporate office.

During an interview on 03/07/12 at 9:20 AM, Staff U, Radiology Director stated that prior to the PACS monitors being installed in the clinic, there were discussions about placing the monitors inside the patient examination rooms because of concerns with patient privacy and confidentiality of information. Staff U added that the monitors were placed in the hallway to minimize cost and because of "push" by the physicians.

During an interview on 03/07/12 at 9:25 AM, Staff T, Privacy Officer stated that he was not involved in the discussions about the PACS monitor instillation with the corporate office.

Based on observation, interview, record review and policy review, the facility failed to ensure controlled substances (medications that are high risk for personal use and abuse) were secured and managed in a way to prevent diversion (to take a patient's medication for personal use) for one (#4) of one current patient and two (#18 and #19) of eight discharged patients. This had the ability to affect all patients in the facility. The census was 11.

Findings included:

1. Record review of the facility's policy titled "Omnicell" (a brand of medication dispensary) reviewed on 11/02/11, showed that controlled substances should be wasted (dispose of unused medication with a second nurse for verification) at the time the medication is pulled from the medication dispensary or after administration to the patient.

2. Observation on 03/06/12 at 12:15 AM showed Staff C, Registered Nurse (RN), broke a Percocet (narcotic pain medication) tablet in half and left the remaining half of the tablet in the original pill package lying on the counter in the medication room. Staff C then shut the door, which cannot be opened without a code, and went to administer the medication to Patient #4.

Observation on 03/06/12 at 12:27 AM showed Staff B, RN, entered the medication room where the Percocet tablet half remained in the package on the counter. Staff B retrieved medications for Patient #5, exited the medication room, and left the door to the medication room open with the Percocet tablet half still on the counter. The door opened into the main hall of the nursing unit, where staff, patients, and visitors move throughout the unit.

Observation on 03/06/12 at 12:40 AM showed the medication room door still stood open, with the Percocet tablet half in the package on the counter, and four staff members (three RN's and a unit clerk) in the department.

During a conversation on 03/06/12 at 12:40 AM, Staff D, Director of Patient Care Services informed Staff C that the remaining Percocet tablet should have been wasted immediately and not left in the medication room. Staff C responded that she left the medication so that it could be wasted at a later time (indicating that leaving the narcotic unsecured for an extended amount of time was a standard practice for wasting narcotics).

3. Record review of a medication dispensary report showed the following unused medications were not wasted when they were dispensed or soon after they were administered:
-Patient #18's liquid Percocet was removed from the medication dispensary on 03/01/12 at 3:56 AM, and three milliliters (ml - unit of measure) was wasted at 7:05 AM;
-Patient #19's Morphine (narcotic pain medication) 10 milligrams (mgs - unit of measure) injectable was removed from the medication dispensary on 03/01/12 at 3:59 PM, and five mgs was wasted at 5:56 PM;
-Patient #4's two Percocet tablets were removed from the dispensary on 03/01/12 at 8:21 PM, on 03/02/12 at 4:02 AM, and again at 6:11 AM, which equalled a total of six tablets removed.Of the six tablets removed, one and ? tablets (three ? tablets wastes) were wasted together on 03/02/12 at 6:11 AM;
-Patient #4's Percocet tablet was removed from the medication dispensary on 03/04/12 at 6:01 AM, and ? tablet was wasted at 9:19 AM.

During an interview on 03/07/12 at 2:00 PM, Staff S, Director of Pharmacy stated that he was aware of the nurses practice to hold on to narcotic wastes until a time later in their shift when it was convenient for another nurse to witness the waste or to waste several narcotics at one time. Staff S added that he reviewed narcotic wastes daily and that "rarely" are narcotic wastes missing. When he does find a missing waste, Staff S stated he contacts the nurse manager with the information, but states he doesn't keep a record of them.

During a conversation on 03/07/12 at 2:20 PM, and while reviewing the medication dispensary report, Staff D informed Staff S, that if he knew nursing staff were holding on to narcotic wastes and wasting them several hours later, he should have contacted the nursing manager with that information so that she could address it with the staff.

During an interview on 03/12/12 at 2:04 PM, Staff S, stated that the facility realized during the survey that there was an issue with the timeliness of wasting narcotics and that "a waste sitting there for hours is unacceptable".

Based on record review and policy review, the facility failed to ensure an accurate process was used during the reconciliation (process to monitor the loss of medication) of controlled substances (medications with a high risk for misuse or abuse). The census was 11.

Findings included:

1. Record review of the facility's policy titled "Perpetual Inventory Narcotic Procedure" dated 11/03/11, showed that controlled substances in the medication dispensary would be monitored by pharmacy on a daily basis.

Record review of the facility's policy titled "Omnicell" (a brand of medication dispensary) dated 11/02/11, showed that when discrepancies (when the amount of a controlled substance is different than the amount expected) occur:
-a report will print out;
-the discrepancy should be resolved immediately;
-two users will count the drug in question;
-the discrepancy resolution will be entered and signed by the two users;
-pharmacy will receive the discrepancy report and conduct an investigation.

Record review of a medication dispensary report showed that two Percocet (narcotic pain medication/controlled substance) tablets were pulled from the dispensary on 03/02/12 at 6:55 PM for administration to Patient #4. On 03/02/12 at 7:29 PM, the report showed two Percocet tablets for Patient #4 were returned to the medication dispensary.

2. Record review of the medication administration record for Patient #4 showed that on 03/02/12 at 7:00 PM, two Percocet tablets were administered to the patient by Staff R, Registered Nurse (RN).

During an interview on 03/07/12 at 3:30 PM, Staff R stated that she accidentally pulled four Percocet tablets (instead of two as documented in the dispensary report) on 03/02/12 at 6:55 PM, because she was distracted, which created a discrepancy. Staff R stated that she returned two of the four Percocet tablets to a "non-returnable bin" (a separate bin that secures medications inside) and administered the remaining two Percocet tablets to the patient.

During an interview on 03/07/12 at 3:35 PM, Staff Q, Pharmacy Technician stated that she corrected the Percocet discrepancy with Staff R on 03/05/12, based on the information Staff R told her, but didn't verify if the Percocet were actually present in the return bin.

During an interview on 03/12/12 at 2:04 PM, Staff S, Director of Pharmacy stated that prior to the survey, pharmacy staff didn't check the return bin for the presence of returned narcotics before correcting a narcotic discrepancy. Staff S stated that when pharmacy staff would ask nursing staff what occurred to create the discrepancy, "we just took their word for it".

Based on observation, interview, and policy review, the facility failed to adhere to approved facility infection control policies to prevent the spread of infection to patients and employees by failing to ensure staff followed hand hygiene policies to prevent potential contamination of patient medication during medication administration for two (#1 and #2) of five patient medication passes observed. The facility census was 11.

Findings included:

1.Record review of the facility's policy titled, "Hand Hygiene", reviewed 02/05/12, provided by the Infection Control Practitioner on 03/06/12 showed the following direction:
- Nail polish may be worn in patient care areas if it is of neutral color with no chips, cracks, or peeling areas.

2. Observation for Patient #2 on 03/05/12 at 11:55 PM showed Staff C, Registered Nurse (RN) administer an intravenous medication (IV). Staff C's fingernails had chipped dark nail polish on them, this places patient at risk for contamination from the chipped nail polish.

Observation for Patient #1 on 03/05/12 at midnight showed Staff C, RN administer an IV medication with chipped dark nail polish.

3. During an interview on 03/06/12 at 1:00 AM Staff C stated that she didn't think there was a policy on nail polish. Staff C was shown the facility policy, Staff C stated, "guess nail polish could chip off and infect the patient".

During an interview on 03/07/12 at 9:30 AM Staff M, RN, nurse manager stated that nail polish could be worn, but nail polish should not be chipped. Staff M stated, "nail polish that is chipped increases the risk of bacterial presence and contamination".

During in interview on 03/07/12 at 10:57 AM, Staff G, Infection Control Nurse stated that the facility follows the Centers for Disease Control (CDC) guidelines for infection control and that staff who provide patient care are allowed to wear fingernail polish as long as it's not chipped.



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