HospitalInspections.org

Based on interviews and a review of selected documents supplied by the hospital on 7/6/10, the hospital failed to ensure that three of four applicants to the medical staff had received appropriate review in order to document their clinical experience prior to appointment to the medical staff (CRNA X, Y, and Z). This could lead to the appointment of unqualified staff to the hospital.

Findings:

The hospital's "Clinical Privileges Delineation" form requires the "applicant to demonstrate activity of 350 cases per year for the previous two year period."

1. The credentials file for CRNA X revealed that a number of documented cases had been provided as documentation for clinical activity. However, the credentials file for CRNA X failed to reveal that the cases had been reviewed and tallied to ensure the appropriate number of cases met the privileging requirements of the medical staff prior to receiving a medical staff appointment by the governing body.

2. The credentials file for CRNA Y revealed that a number of documented cases had been provided as documentation for clinical activity. However, the credentials file for CRNA Y failed to reveal that the cases had been reviewed and tallied to ensure the appropriate number of cases met the privileging requirements of the medical staff prior to receiving a medical staff appointment by the governing body.

3. The credentials file for CRNA Z revealed that a number of documented cases had been provided as documentation for clinical activity. However, the credentials file for CRNA Z failed to reveal that the cases had been reviewed and tallied to ensure the appropriate number of cases met the privileging requirements of the medical staff prior to receiving a medical staff appointment by the governing body.

When interviewed on 7/6/10, at approximately 1130 hours, the Director of Medical Staff Services agreed that the bylaws of the medical staff had not been met and the requisite number of clinical cases had not been verified by tally, prior to appointment by the governing body.

Based on observation, interview, and record review the hospital failed to ensure services performed under a contract were provided in a safe and effective manner. A contracted mobile MRI unit was inspected and found to have a fire pull station that was inoperable. Additionally, review of fire drill documentation showed no fire drill activity had been performed since 2008. Without training and competency determination of staff in emergency fire response measures, the health and safety of patients receiving treatment are at risk for injury or death.

Findings:

On 7/8/10, a review of the hospital's policy and procedure titled: Fire Safety Management, showed fire drills are conducted in all hospital and ambulatory healthcare facilities on each occupied shift each quarter, and evaluated on a randomly selected basis to assure that all elements of the drill activity are exercised in all occupied areas during each alarm activation not announced as a bell test. The document showed fire drills are conducted in all other areas (e.g. clinics) in which patient care takes place at least once a year, with full evacuation of the affected area during the drill.

On 7/8/10, an inspection of the mobile MRI unit was conducted. The mobile MRI unit was located to the rear of the hospital (south) approximately 180 feet from the back hospital entrance. Contact was made with the Supervisor of Radiology who accompanied the tour and inspection. To the right of entry door to the MRI, inside, on a wall approximately four feet from the floor was a Fire Pull Station. The Director was asked about fire drills and what takes place during a fire drill. The Supervisor stated drills were performed on a regular basis. A hospital employee assigned to the MRI stated she would pull the alarm on the pull station. The Supervisor stated that this was not what the procedure was for notification of a fire. He stated the pull station was not operational as it was not connected.

The Supervisor was asked for fire drill documentation. Review of documentation of fire drills performed at the MRI mobile unit showed the last fire drill covering the MRI location was completed 6/5/08. A form titled: Fire Drill Report, showed there was a poor response to the drill and those staff members responding to the drill failed to bring a fire extinguisher. He was asked if there was any additional documentation relating to fire drills performed in the MRI location and he stated, "No."

Based on observation, interview and record review, the hospital failed to provide MRI (magnetic imaging services) free from hazards for patients and personnel. A fire pull station was observed in the mobile MRI scanner which was inoperable. Additionally, staff had no recent drills or training for management of emergency situations such as fire or a patient with a medical emergency.

Findings:

1. On 7/8/10, a review of the hospital's policy and procedure titled: Fire Safety Management, showed fire drills were conducted in all hospital and ambulatory healthcare facilities on each occupied shift each quarter, and evaluated on a randomly selected basis to assure that all elements of the drill activity were exercised in all occupied areas during each alarm activation not announced as a bell test. The document showed fire drills were conducted in all other areas (e.g. clinics) in which patient care takes place at least once a year, with full evacuation of the affected area during the drill.

On 7/8/10, an inspection of the mobile MRI unit was conducted. The mobile MRI unit was located to the rear of the hospital (south) approximately 180 feet from the back hospital entrance. Contact was made with the Supervisor of Radiology who accompanied the tour and inspection. To the right of entry door to the MRI, inside, on a wall approximately four feet from the floor was a Fire Pull Station. The Supervisor was asked about fire drills and what takes place during a fire drill. The Supervisor stated drills were performed on a regular basis. A staff member assigned to the mobile MRI unit stated she would pull the alarm located at the fire alarm pull station. However, the Supervisor stated the pull station was not operational as it was not connected.

On 7/8/10, the Supervisor of Radiology was asked for fire drill documentation. Review of documentation dated 6/5/08, showed a fire drill was conducted at that time. Review of a form titled: Fire Drill Report, showed there was a poor response to the drill and staff members responding to the drill failed to bring a fire extinguisher. He was asked if there was any additional documentation relating to fire drills performed in the MRI location and he stated, "No."

2. On 7/8/10 review of a policy and procedure titled: Code Blue Policy - MRI Truck, showed all MRI personnel involved in direct patient care were CPR certified (Cardio-Pulmonary Resuscitation). The mobile van staff will provide resuscitation efforts to any patient experiencing a cardiac/or respiratory arrest while undergoing an MRI procedure.

On 7/8/10, the Supervisor of Radiology was asked about emergency procedures and medical management for patients at the MRI. He stated there was no crash cart (a cart with emergency medical equipment/medications) in the MRI mobile unit. He stated the procedure was to call the hospital's emergency number and announce a 'Code Blue' (emergency response to a medical condition) and the location. He stated once a 'Code Blue' was activated, his staff would perform CPR if necessary. Observed in the MRI mobile unit was a oxygen cylinder. He was asked if he had oxygen tubing . The Supervisor looked on the shelf of a cabinet above the desk and retrieved extension tubing. He could not produce oxygen tubing specific for administering oxygen to patients. He stated all MRI staff were trained in CPR and were certified annually. The supervisor was asked about mock drills for emergency medical management for patients having an MRI. He stated no mock drills had been done.

On 7/8/10 an interview with the Chief Nursing Officer (CNO) was conducted. The CNO was asked if there had been any mock codes to demonstrate effective response for medical emergencies patients may experience while having an MRI procedure. She stated the crash cart would be brought from the intensive care unit which was the closest unit in proximity to the MRI mobile unit (approximately 180 feet away). She stated there had been no mock code blue drills specifically for the MRI mobile unit. She stated once the 'Code Blue' was activated the rapid response team would be called to the location.

Based on interviews and a review of selected documents supplied by the hospital on 7/6/10, the hospital failed to ensure that three of four applicants (CRNAs X, Y , and Z) to the medical staff had received appropriate review to document clinical experience prior to appointment to the medical staff. This could lead to the appointment of unqualified staff to the hospital.

Findings:

The hospital's "Clinical Privileges Delineation" form requires the "applicant to demonstrate activity of 350 cases per year for the previous two year period".

1. The credential file for CRNA X revealed that a number of documented cases had been provided as documentation for clinical activity. However, the credential file for CRNA X failed to reveal that the cases had been reviewed and tallied to ensure the appropriate number of cases met the privileging requirements of the medical staff prior to receiving a medical staff appointment by the governing body.

2. The credential file for CRNA Y revealed that a number of documented cases had been provided as documentation for clinical activity. However, the credential file for CRNA Y failed to reveal that the cases had been reviewed and tallied to ensure the appropriate number of cases met the privileging requirements of the medical staff prior to receiving a medical staff appointment by the governing body.

3. The credential file for CRNA Z revealed that a number of documented cases had been provided as documentation for clinical activity. However, the credential file for CRNA Z failed to reveal that the cases had been reviewed and tallied to ensure the appropriate number of cases met the privileging requirements of the medical staff prior to receiving a medical staff appointment by the governing body.

When interviewed on 7/6/10, at 1130 hours, the Director of Medical Staff Services verified that the bylaws of the medical staff had not been met and the requisite number of clinical cases had not been verified by tally, prior to appointment to the staff of the hospital by the governing body.

Based on interview and medical record review, the hospital failed to ensure the physician on call for OB (obstetric) emergencies in the ED (Emergency Department) responded by phone within the timeframe dictated by the General Medical Staff Rules and Regulations for one of 31 sampled patients (Patient 12). This resulted in the potential for a delay in treatment to prevent a premature birth and potential maternal complications.

Findings:

Review of the hospital's General Medical Staff Rules and Regulations, ED On-Call Panel Requirements, #4, showed a physician scheduled to take ED call must respond to all calls from the ED by telephone or in person within 30 minutes of a call or page from the ED.

The medical record for Patient 12 was reviewed on 7/7/10. The patient presented to the hospital's ED on 6/24/10 at 1913 hours. The patient, who stated she was six months pregnant, was complaining of severe left lower abdominal pain and vaginal bleeding.

The physician's dictated report of Patient 12's ED visit, dated 6/25/10, showed MD F examined the patient on 6/24/10, and ordered an OB ultrasound. MD F received the results of the ultrasound at 2100 hours. The ultrasound showed the the patient was pregnant with a 26 week fetus (full term is 38-40 weeks) in the breech position (feet presenting first) and the placenta was abrupting (tearing away from the uterine wall). MD F documented he ordered the on call OB physician, MD G, be called immediately. At 2107, not having received a return call from MD G, MD F documented he was able to contact another OB physician on the call panel at 2125 hours, and began the arrangements to transfer the patient to another hospital with an OB service. MD F documented Patient 12's pain continued and the patient began to deliver the infant at 2200 hours. The infant was delivered stillborn at 2206 hours. MD F documented MD G returned his call during the delivery of the infant.

During an interview with the Medical Director of the ED, MD E, on 7/8/10 at 0900 hours, the MD stated the hospital had a problem with getting it's on call physicians for the ED to return calls.

Based on observation, interview and document review, the hospital failed to ensure nursing staff was able to demonstrate the use of emergency equipment. This could potentially result in the staff's failure to intervene in a patient emergency.

Findings:

1. On 7/6/10 at 0845 hours, RN J was asked to demonstrate the ICU's defibrillator/external pacemaker machine. This type of machine was used for patients with cardiac emergencies. The defibrillator function of the machine gives patients electrical shocks to change heart rhythms and the pacemaker functions sends electrical impulses through the patient's chest to stimulate the heart to beat.

During RN J's demonstration of the defibrillator/external pacemaker machine, the RN was asked to demonstrate the pacemaker function of the machine. RN J stated she did not do the pacemaker function.

On 7/8/10, RN J's competency file was reviewed which included a form titled "ICU RN Competency Validation." RN J was signed off as competent with pacemakers on 10/17/09.

2. On 7/6/10 at 0900 hours, RN K was asked to demonstrate the use of the internal pacemaker system. An internal pacemaker system is used in cardiac emergencies and consists of a wire inserted through the patient's vein into the patient's heart; this wire is then connected to a cable which is then inserted into a pacing box. The pacing box generates an electrical impulse that goes through the cable, then the wire, and then into the heart to stimulate the heart to beat. During the internal pacemaker demonstration, RN K did know how to connect the pacing cable to the pacing box.

On 7/8/10, RN K's competency file was reviewed. RN K was signed off as competent with pacemakers on 10/13/09.

Based on observation, interview and medical record review, the hospital failed to ensure medications were administered to two of 31 sampled patients (Patients 4 and 5) per the hospital's P&Ps. This resulted in the potential for injury to a patient with a GT and a delay in treatment for a patient with an infection.

Findings:

1. RN M was observed during a medication pass observation on 7/7/10 at 1035 hours. The RN entered Patient 4's room with eight medications to be administered via GT (a gastrostomy tube is a feeding tube inserted into the stomach through the wall of the abdomen). The RN drew up approximately 30 ml of water from a cup into a 50 ml syringe. After removing the plug from the GT, the RN inserted the 50 ml syringe into the tube and withdrew a few ml of clear fluid. RN M stated she was checking the placement of the GT by withdrawing residual stomach contents. The RN stated the patient's formula feedings had been held that morning for a diagnostic test so she did not expect the patient to have much residual formula in his stomach. The RN then drew up approximately 30 ml of water from the cup into a 50 ml syringe. With the plunger of the syringe still inserted in the syringe, the RN inserted the syringe tip into the GT. The RN stated the water should flow by gravity into the GT, but since it did not, she stated she had to push on the plunger to instill the water into the GT. The RN then proceeded to administer medications to the patient. For the first three medications the RN mixed each crushed medication with water, drew the medication up into the syringe, and with the plunger of the syringe still intact, inserted the syringe into the GT. The RN held up the tubing trying to attempt a gravity flow. When there was no gravity flow, the RN pushed the medication into the tubing with the plunger of the syringe. 30 ml of water was used to irrigate the tubing in between medications and was pushed into the GT in the same manner. Before administering the next medication, the RN inserted the syringe into the tubing without the plunger and poured the medication mixed with water into the syringe. As the medication mixed with water flowed easily by gravity into the tubing, the RN stated she realized leaving the plunger in the syringe was a mistake.

During an interview with RN M on 7/7/10 at 1130 hours, she stated she ensured the correct placement of the GT by checking for residual stomach contents. When asked the hospital's P&P on irrigating the GT for patency, the RN stated there should be a gravity flow when water was instilled. The RN stated the plunger of the syringe kept the medications and water from flowing by gravity during the medication pass described above.

During an interview with the CNO and RN O on 7/7/10 at 1510 hours, the CNO stated the hospital did not have a specific P&P to address the administration of medications via a GT. The CNO stated they have educated staff to use the Lippincott Manual of Nursing Practice as a reference in the instances where there was no P&P developed as a guide for a procedure.

Review of the Lippincott Manual of Nursing Practice provided for review showed on page 297, a reference to the administration of medications through a GT. The nurse was directed to remove the plug on the end of the GT, attach a syringe or funnel to the tip and instill 10 ml of water into the tube through the syringe to check for patency. If the water flowed in easily from the syringe the tube was patent. If the water did not flow in easily the procedure should be stopped and the physician was to be notified. Medication was to be added to the syringe and allowed to flow into the tubing by gravity drainage.

2. The P&P entitled Drug Distribution and Dispensing; revised date 10/09, was reviewed on 7/7/10 at 0920 hours. The area addressing time of delivery showed all STAT doses shall be delivered within 15 minutes of receipt of the physician's order.

During an interview with the Director of the Pharmacy on 7/6/10 at 0915 hours, he stated the turn around time for stat medications has been studied in the hospital and averaged 15 minutes.

The pharmacy log book listing the medications removed by the nursing supervisor from the night pharmacy locker was reviewed with the Director of the Pharmacy on 7/6/10 at 1045 hours. An entry in the log book showed Vancomycin (an antibiotic) 1 gm was removed by the nursing supervisor on 7/3/10 at 0114 hours for Patient 5. A copy of the physician's order attached to the log showed the physician wrote the order for Vancomycin 1 gm to be administered to Patient 5 "now." on 7/2/10 at 2210 hours. When asked, the Director of the Pharmacy stated he did not know why the medication administration was delayed for three hours after the order was written.

The medical record for Patient 5 was reviewed with the CNO during an interview on 7/6/10 at 1130 hours. Documentation showed the patient was admitted to hospital's ICU on 7/2/10 at 2300 hours from the ED. The ED physician admitted the patient to the hospital with diagnoses which included pneumonia, UTI (urinary tract infection) and sepsis (infection in the bloodstream). Review of the Medication Administration Record showed Vancomycin 1 gm was administered to Patient 5 on 7/3/10 at 0115 hours. The CNO stated she did not know why the medication was delayed.

During an interview with RN P in the ICU unit on 7/7/10 at 0840 hours, the RN stated if a physician wrote an order to be give a medication "now," she would interpret the order as STAT and would administer it as soon as possible, within 30 minutes.

During an interview with LVN B on the medical/surgical unit on 7/7/10 at 0915 hours, the LVN stated if a physician's order was written for a medication to be given "now" she would be give it as soon as possible within one hour.

Based on open and closed medical record review and interview, the hospital failed to ensure that three of 31 records reviewed had medication entries that were legible and complete, consistent with hospital policies and procedures (Patients 2, 7 and 13).

Findings:

Review of the hospital's P&P "Medication Orders" dated 12/09 showed that medication orders should include the name of the drug, strength, route, frequency and any specific instructions.

1. The open medical record for Patient 2 was reviewed on 7/7/10. The record contained a "Physician Orders Renewal Report" dated 7/3/10. The report was a list of medications and procedures printed by the pharmacy which required the physician to indicate whether he wished the medications or procedures to be discontinued or renewed. The physician instructions required that he mark a box for "Renew" or "Discontinue" and sign, date and time the form. The instruction boxes provided were directly above each other. The boxes for the Vanomycin and normal saline flush had the physician's mark between the two boxes. The boxes for the Vitamin C, Zinc Sulfate and Norco tablets had a slash beginning on the discontinue and ending on the renew. From the marks on the form it could not be positively ascertained what the physician was ordering.

RN B was interviewed on 7/8/10 and shown the Physician Orders Renewal Report for Patient 2. He stated that he knew from caring for the patient that the physician did not wish to discontinue the procedures or medications, but he admitted that the order as marked by the physician was not clear and if he had been reviewing the record after discharge he would have been unsure of what the physician's instructions were.

2. The closed medical record for Patient 7 was reviewed on 7/8/10. The "Physician Orders Renewal Report" dated 7/4/10, indicated that Tylenol Suppository 1000 mg needed renew or discontinue instructions. The physician had a check mark that was in between the two instruction boxes making it unclear what the instruction was.

3. The closed medical record for Patient 13 was reviewed on 7/8/10. The "Physician Orders Renewal Report" dated 6/3/10 was reviewed. The medications Buspar Tab 15 mg. twice daily, and Atrovent Inhaler every 4 hours, needed instructions to renew or discontinue. The physician had placed the check mark in between the two boxes on each medication and it was not possible to ascertain what the instructions were.

Based on observation, interview and record review, the hospital failed to properly store human tissue specimens found in a cabinet. The cabinet was not labeled and along with the tissue samples were boxes of laboratory supplies, gloves, trays, and electronic equipment. Each specimen container had a patient identification label with a date. Lost or misplaced human tissue specimens have the potential to impact or delay clinical diagnosis and treatment for patients.

Findings:

Review of the policy and procedure titled: DISPOSAL OF TISSUE, GLASS SLIDES, PARAPHIN BLOCKS showed the policy was developed to ensure the proper disposal of tissue, used glass slides, and used paraphin blocks. The document showed tissue was retained for one month from the date of the procedure and then disposed.

On 7/6/10, a tour of the hospital laboratory was conducted. The Laboratory Director was in accompaniment. A room with signage that showed PATHOLOGY, was entered and inspected. The room had a counter top with a row of cabinets below. Inspection of one cabinet showed laboratory supplies, materials, gloves, boxes of gloves, laboratory equipment, and 13 specimen containers containing human tissue samples. The Laboratory Director was asked about the storage of these specimens and he stated, "I don't know why they are stored down there." The Laboratory Director was asked about the handwritten date on the specimen containers. He stated the date was the date of the procedure.

Each specimen container was labeled with a patient identification label and a date was hand written on the label. Six specimen containers had a handwritten date for the following: 3/3/10, 3/11/10, 3/17/10, 3/20/10, 3/29/10 and 3/30/10. Five specimen containers had a handwritten date for the following: 4/1/10, 4/10/10, 4/12/10, 4/23/10 and 4/30/10. Two specimen containers had a handwritten date for the following: 5/3/10 and 5/29/10.

On 7/8/10 at 1400 hours, an interview with the Business Manager of the Pathology Department was conducted. She was asked about the specimen containers found in the cabinet. She stated the samples were not stored properly as they should have been stored in a one-gallon plastic jug container. She stated she did not know who put the specimens in the lower cabinet.

Based on interview and document review, the hospital failed to have a director of food and dietetic services to ensure the cool down system was implemented as stated in the department policy and procedure with the potential of service of patient food that caused food borne illness.

Findings:

On 7/7/10 at 1300 hours the cool down log was reviewed with the RD1. The cool down log showed an entry dated 7/4/10 for "Beef" started cooling at 1115 hours at 170 degrees Fahrenheit (F). The cool down log directions specify "start time (for temperature) when food is 135 degrees F." Review of the policy titled "Rapid Cooling Process" confirmed the food product was to be "cooled from 135 degrees to 70 degrees within 2 hours..." The policy also referenced the Hazard Analysis Critical Control Point program (HACCP) manual for food service operations.

On 7/7/10 at 1300 hours duirng an interview, RD1, who had responsibility for the management of the food and dietetic department, stated that the cook had not followed the cool down log directions. He stated that the form did not reflect the rapid cooling he had the staff do before the 135 degree F temperature was reached. He acknowledged the form should be modified to reflect the addition to the procedure.

The Hazard Analysis Critical Control Point Program ,which includes the procedure for cool down for food that will be served the next day, is a system used to ensure food safety and prevent food borne illness.

Based on document review and interview, the hospital failed to ensure the diet manual approved by the dietitian and medical staff had a publication date or revision date not more than 5 years old, with the potential of patients not receiving therapeutic and medical nutrition therapy in accordance with current national standards.

Findings:

On 7/6/10 at 1144 hours the current diet manual was reviewed on the ICU unit. The Clinical Diet Manual, 13th edition was revised 2002. The Clinical Diet Manual was reviewed and approved by the medical staff and dietitian with documents dated 2002 and 2005. The publication was more than 5 years old.

Based on interview and record review, the hospital failed to ensure orientation and competency documentation was completed according to the hospital's requirements for one of 25 employee files reviewed. This could potentially result in the physical plant not being maintained in a safe manner.

Findings:

1. On 7/8/10 at 1100 hours, the Plant Operations Director's personnel file was reviewed. The Director's hire date was listed as 8/11/09. One form in the file was an "Initial Hospital/Department Orientation" form with the notation that the form should be completed during the first working shift. The form included, among other topics, the employee's role in fire safety, emergency situations, locations of medical gas valves and the procedures to shut them off and responsibility during disruption of services of critical utilities. Each topic had a section for initials and a date. They were documented as completed on 8/10 through 8/12 (no year was listed). Below this section, the form had a signature section for the employee (the Plant Operations Director), a date section, and an evaluator's signature section with the statement "My signature below indicates I have been oriented to the information listed above." The signature and date sections were blank. The Director of HR, who was present during the review, verified that the signatures and date sections should have been completed.

2. Review of the hospital's policy and procedure "Competency Based Assessment Program" showed the competencies were essential interventions or activities for a given role/title.

During additional review of the Plant Operations Director's personnel file on 7/8/10, a form titled "Competency Assessment" dated 8/14/09, was noted. The form had twenty areas of competency including one specific for plant operations. For example, the competency form listed: demonstrate how to use electrical leakage testing equipment; how to do maintenance and testing of boilers; and to demonstrate the operation, preventative maintenance, and back up systems for medical air compressors.

The competency assessment form had sections for a self assessment of competency and a supervisor trainer validation of competency section. The Supervisor/Validator section was blank for all twenty areas. The Director of HR, who was present during the file review, stated the form should have been completed during the first six months of employment.

Based on observation and record review, the hospital failed to ensure staff members used PPE according to the hospital's P&P. This could potentially result in the spread of infection.

Findings:

1. Review of the hospital's P&P "Infection Control" dated 11/2007, showed when removing PPE, gloves should be removed first.

On 7/7/10 at 0900 hours, EVS A was asked to demonstrate entering and leaving a droplet isolation room. Droplet isolation requires anyone entering the room to wear a mask, gown and gloves. During the demonstration of PPE removal, EVS A removed the mask and gown, before removing the gloves.



07127

2. The hospital's P&P "Personal Protective Clothing and Equipment" dated 6/2008 documented that when putting on a protective gown it should be put on with opening at the back and the edges at the back should overlap one another to cover clothing,

On 7/7/10 at 0945 hours, CNA Q was observed entering the ICU. He stated that he had been asked to come in to assist ICU staff to pull a patient up in bed. The door to the patient's room was observed marked with an alert sign indicating that the patient was in contact isolation and anyone entering needed to put on a gown and gloves. The CNA put on a gown with the opening at the back, but failed to secure the edges to protect his clothing. The entire back of his uniform was exposed.

Based on observation, interview, and record review, the hospital failed to provide security for medical records and to prevent individuals from unauthorized access to such records. Information obtained from medical records may result in access to names of patients, their diagnosis, social security numbers, addresses, account numbers to insurance carriers, and other confidential information.

Findings:

On 7/8/10, during a tour of the hospital medical records location, six grey storage bins were observed outside of the hospital, lined up at the top of the loading ramp. Each bin had a slit for disposal of documents inside the bin. The bin had a locking mechanism requiring a key. Five of the six grey bins were empty and one was full. The Plant Manager was asked what was stored in the gray bins. He stated they were for medical records to be given to their contracted service for destruction. The Plan Manager was asked about security in the immediate area. He stated there was no fence around the hospital and there was no video surveillance of the area in question. The Plant Manager was asked who was in charge of the bins to ensure the security of the contents of the bins. The Plant Manager stated the Environmental Services Supervisor was in charge of the bins.

An interview with the Environmental Services Supervisor was conducted on 7/8/10. He was informed about the full bin on the loading ramp and asked whether it was secure or not. He stated he did not know the bin was full with medical records. He stated the bins were usually picked up by the company, but could not say when the company would be there to pick up the full bin. He stated the bins were kept in the individual departments of the hospital. When the bins were full the department contacted him to retrieve the full bin and replace it with an empty one.

On 7/7/10, an inspection of the Medical Records Office showed a grey bin in the middle of the room. Staff were asked what the procedure was when the bins were full of medical record documents. They stated they called the Environmental Services Supervisor to have the bin removed and replaced with a empty one.

On 7/8/10, review of the contracted agreement between the hospital and the document destruction company showed the service provided 64 gallon bins that were capable of holding 150-200 pounds of paper. Documentation on an invoice form dated 6/29/10, showed the next scheduled pick up for the bins was 7/27/10.