HospitalInspections.org

Based on facility policy review, infectious waste service agreement review, observation, and interview, the facility failed to follow its policy on storage of hazardous waste; failed to ensure hazardous waste material was properly stored; and failed to ensure equipment for patient use was sanitary.

The findings included:

Review of the facility policy entitled "Hazardous Waste" #HAZ-00-000 and dated May 2009; revealed "...(named hospital) has contracted with (named collection agency) to remove all hazardous waste from the premises. Waste is stored in a screened, locked area attached to the facility located beside the back entrance to the Maintenance Shop. Waste are stored in red, bio-hazard bags..." Continued review of the policy revealed "...Trained environmental services personnel will remove full, rigid storage containers from the user department to the designated labeled accumulation area in the rear of the hospital..." Further review of the policy revealed "...Only bio-hazardous/bio-medical waste shall be transported in the designated rigid containers. Any waste placed into a red bag and subsequently the rigid container shall then be considered to be bio-hazardous/bio-medical waste..."

Review of the contract with the collection agency dated 11/20/13, revealed the statement "...all packages of regulated medical waste be prepared for transport in containers meeting the following requirements:
1. rigid
2. leak resistant
3. impervious to moisture
4. of sufficient strength to prevent tearing or bursting under normal conditions of use and handling
5. sealed to prevent leakage during transport
6. puncture resistant for sharps..."

Observation of the holding area for hazardous materials on 6/17/15, at 9:40 AM, revealed the area was located behind the hospital near Plant Operations. Continued observation revealed the area was partially screened and partially closed in. Further observation revealed the door was locked.

Observation of the inside of the holding area revealed:
1. 52 locked sharps containers
2. 14 locked big bins containing sharps
3. many (30+) red biohazard bags of infectious waste
4. red bags in a rolling collection cart
5. red bags lying on top of locked bins of sharps
6. red bags lying in and on top of a large bin
7. 8 red bags lying on the floor

A request was made for the invoices from the collection agency for the last 6 months. Review of the invoices revealed:
1. 1 dated 1/30/2015, for collection of waste, for a sum of $74.00.
2. 1 dated 4/11/15, for pick up of "...aggressive amount of medical waste..."
3. 1 dated 4/13/15, for "...medical waste services on 4/11/15 per agreement..." for an amount of $1900.00.
4. 1 dated 4/30/15 for pick up of 4 - 30 gallon square tubs for amount of $74.00

Observation during a facility tour on 6/17/15, at 9:45 AM, of a portable x-ray machine, sitting in the main hall across from the dining room, revealed a layer of dust on the arm, instrument panel, and flat plate attached to the arm.

Interview with the CCO on 6/17/15 at 9:45 AM, beside the machine, confirmed there was a layer of dust on the machine which should have been cleaned by Environmental Services and the machine was available for patient use.

Interview with the Environmental Services Director on 6/17/15, at 10:30 AM in the hall near Administration, revealed the red bags contained used wound dressings, anatomical organs and tissues removed during surgical procedures, as well as isolation disposals.

Interview with the Chief Compliance Officer (CCO) on 6/17/15, at 11:15 AM, in the administrative offices, confirmed there were no other invoices for collection of hazardous waste. In continued interview, the CCO confirmed "...there was a gap for awhile when waste pick up did not service them..." Further interview with the CCO confirmed the red bags in the storage area were not in rigid containers as the facility policy stated.