HospitalInspections.org

Based on record review and interview, the facility staff failed to provide documented education related to cleaning procedures for blood and body fluids of patients for the 4 of 4 Emergency Department Registrations staff ( Registrars E, F, G and H) in a total 11.

Findings include:

Review of facility policy titled, "Infection Prevention- Exposure Control Plan" IP-008 (not dated) revealed, "I. Policy: A comprehensive infection prevention and control plan regarding bloodborne pathogen exposure is followed. II. Purpose: To reduce risk for colleagues exposure to bloodborne pathogens. III. Guidelines/Procedures: A. Exposure Determination. The following job classifications are those where, as a result of performing their job duties, colleagues could "reasonably anticipate" exposure to blood/body fluids of patients. 2. Ancillary Services: a. Case Management b. Sterile Processing Clinical Engineering d. Environmental Services e. Guest Services...(Registration Staff is not listed). 9. Education/Training a. New colleagues receive a training program regarding components of the exposure control plan upon hire. b. The specific training regarding use and location of protective devices and the procedures to minimize exposure to bloodborne pathogens are further covered in each specific department orientation. d. Additional training is provided to colleagues when there are any changes of tasks, procedures or products that affect their risk of occupational exposure. e. Educational records are maintained in the hospital computer program for 3 years. f. Educational offerings and content are revised to meet regulatory requirements and to address most current colleague needs."

During an interview on 06/15/2021 at 2:46 PM, Manager of Environmental Services B stated, Environmental Services was asked to complete a 30% reduction of staff. Due to the reduction in staff, cleaning services at the hospital were no longer offered by Environmental Services between the hours of 11:30 PM and 6:00 AM. Staff who completed registration in the Emergency Department was then expected to clean blood/body fluids in the emergency department waiting areas during the hours that environmental services were not scheduled to work. Manager of Environmental Services B was asked if the registrations staff were provided any documented education regarding clean up of blood/body fluids and Manager of Environmental Services B stated, there was no documented education, the education was sent out in an email.

During an interview on 06/15/2021 at 4:14 PM, Registrar E stated would not know the first thing about how to clean up blood/body fluids. Stated had not been trained but knew there was a binder with directions and the code to get into the housekeeping closet.

During an interview on 06/15/2021 at 4:17 PM, Registrar F stated had not received any training on cleaning up blood/body fluids. Stated would place a towel over area and call environmental services during the day to clean the area.

During an interview on 06/15/2021 at 5:27 PM, Registrar G stated had not received any formal training on cleaning up blood/body fluids. Stated would put on proper personal protective equipment and would refer to guidance which was sent out in an email.

During an interview on 06/15/2021 at 5:38 PM, Registrar H stated there was no hands on training provided to the staff to clean up blood/body fluids, but has a nursing background and felt would be able to clean it up safely until housekeeping would be able to do the official cleaning.