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Based on document review and interview, the person designated as infection control officer failed to ensure established policy/procedure for aseptic technique was followed for 1 emergency department.

Findings include:

1. Review of policy/procedure Aseptic Technique indicated the following:
"5. At any time the aseptic technique is broken all involved care givers are responsible to stop the procedure, re-implement the aseptic techniques."
This policy/procedure was last reviewed/revised on March 2011.

2. Review of facility documentation dated 08-22-12 at 0935 hours indicated the following:
"Staff #43 described that he/she was holding the child's head still so the physician could suture the laceration to the face. Staff #43 heard a click or a pop which was when the needle left the needle holder at which time the ED physician stated it does appear to have broken the skin; as the needle did hit the back of staff #43's hand to where staff #43 responded with an ouch. Physician continued to suture with contaminated needle."

3. On 09-10-12 at 1130 hours, staff #40 confirmed that he/she spoke with staff #43 and staff #43 understood that aseptic technique was broken and he/she should have spoken up to the physician.