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Based on observation, documentation review, and staff interview, the hospital failed to ensure the biohazard waste are disposed of and maintained in a secured environment.

Findings included:

1. At 11:50 AM on 2/5/2014, the temporary receiving dock was toured and the overhead garage door to the Hazardous Waste Sorting room was observed open to the Receiving Dock. The Hazardous Waste Sorting Room was not secured as required per policy and state rules.

2. At 12:05 PM on 2/5/2014, after entering the Hazardous Waste Sorting Room; there were two large containers for the storage of red biohazard bags. The red bags were observed overflowing and lying on the floor approximately 10 feet in front of the containers. There were approximately 100 red biohazard bags observed loose on the floor. On the backside of the red biohazard bag storage containers was the location where the assorted sizes of closed sharp containers were stored obstructing maintenance and construction equipment. The sharp containers were observed spilling over a storage container onto the floor covering approximately 10-foot by 20-foot floor surface area. There were approximately 150 to 250 assorted closed sharp containers observed. The hazardous waste area was not secured, and separated from maintenance and contractor equipment.

3. At 12:25 PM on 2/5/2014, staff member #9 was observed lining hazardous waste storage containers with red bags. Staff member #9 was observed throwing red biohazard bags that were lying on the floor out of his/her way to get to the working area adjacent to the Steam Sterilizer; to finish repairing the sterilizer. The staff member was observed not wearing any apron, bunny suit, shoe covers, rubber gloves, or face shield.

4. Good Samaritan Hospital (GSH) Handling and Disposal of Hospital Waste (last revised April, 2013) states, " GSH will provide guidelines regarding medical waste within the hospital departments. Waste will be properly and safely segregated and disposed of according to all applicable Federal and State regulations. This policy has been developed not only for the safe management of medical waste, but to reduce the potential incidence of injury and disease among healthcare workers in this facility. All healthcare workers working in this facility and those who have contact with this facility are responsible and accountable for adhering to this Hospital Waste Policy. "

5. Indiana State Department of Health Rule 3 Infectious Waste 410 IAC 1-3-24 states, " All persons and facilities subject to this rule shall ensure that infectious waste is at all times contained in a manner that will reasonably protect waste handlers and the public from contracting dangerous communicable disease that may result from exposure to the infectious waste. If infectious waste is stored prior to final disposal, all persons subject to this rule shall store infectious waste in a secured area."

6. Good Samaritan Hospital Infection Control Policy for Medical Waste Disposal Operator (Last revised August 2012) states, " Procedure: Always wear rubber gloves, shoe covers and face mask when handling red bags: and take a shower before clocking out and leaving the hospital. "

7. At 12:45 PM on 2/5/2014, staff member #9 indicated he/she works for the Maintenance Department. The Maintenance staff had been trained in the Hazardous Waste Sorting Room. The staff member indicated the personnel protective equipment (PPE) was on the desk. The staff member indicated he/she was supposed to wear a bunny suit while sorting the waste, however, it gets too cold from the temporary receiving dock. The staff member indicated he/she does not wear the bunny suit. Staff member #9 also indicated the Laundry Department and the Dietary Department store items they receive through the temporary receiving dock in the Hazardous Waste Sorting Room. Those items are assorted chemicals. The staff member indicated the sorting room is utilized as a multipurpose room.

8. At 1:00 PM on 2/5/2014, staff member #2 indicated the steam sterilizer has been broken and the hospital has a contingency plan. Company A would collect all red biohazard bags and sharp containers that have not been processed to keep the room orderly and clean; however, the contingency plan was not followed. The staff member #2 indicated the maintenance staff was to take showers after working in the sorting room; however, this was not being done.

9. At 1:50 PM on 2/5/2014, staff member #4 indicated the door separating the temporary dock and the sorting room should remain closed for security and safe handling and processing of hazardous waste.