HospitalInspections.org

Based on observations, records reviewed and interviews the Hospital failed to consistently adhere to their policies, procedures and acceptable standards of care for safe medication management, handling of biohazard materials, performing high-level disinfection and disposal of expired medical supplies.

1.) The Surveyor interviewed RN #3 at 2:30 P.M. on 8/4/2020 in the Step-Down Unit. RN #3 said the only multi-dose vial the unit consistently used was insulin. RN #3 showed the Surveyor how the insulin was stored in the medication room. RN#3 said the vials were labeled by pharmacy services, however while each of the multi-dose vials was labeled, the date did not indicate whether it was the date the vial was dispensed, opened or the expiration date which could create confusion for staff using the multi-dose vial.

2.) According to the Hospital's Exposure Control Plan (ECP), revised June 2020, items that (biohazard) are labeled or color coded include containers used to ship blood or other infectious material. Also, regulated waste is discarded into containers that are red in color or labeled with the appropriate biohazard warning label.

The Surveyor toured the Surgical Intensive Care Unit (SICU) at 9:40 A.M. on 8/4/2020 and interviewed the Assistant Chief Nursing Officer (ACNO). The Surveyor observed a cream-colored container labeled with two biohazard stickers. This container had signage indicating that this was a receptacle for N95 respirators. The ACNO said that the Hospital collected previously worn N95's from the staff and that the Hospital had the ability to recycle and reprocess these masks as needed but recognized they were not biohazardous waste material as labeled.

The Surveyor toured a vacant patient room in the SICU and observed the biohazard container set up. The covered red container, which meets the Hospital designation for biohazardous waste, was lined with a red bag.

The Surveyor observed the same covered red container in the corridor that was lined with a clear bag. According to the Exposure Control Plan this container also met the definition of biohazard waste. The ACNO said the container in the hall was a wastebasket.

The Surveyor toured the Step-Down Unit at 2:30 P.M. on 8/4/2020 and interviewed the ACNO. The Hospital used a pneumatic tube system that propelled a cylindrical container through a network of tubes as a means of transporting items throughout the Hospital. The ACNO said the tube system was also used to transport blood and other specimens to the laboratory. The ACNO showed the Surveyor the clear zip-lock back that would be used to hold the laboratory sample. Neither the zip-lock bag nor the transport cylinder was labeled with a biohazard warning as required.

3.) High-Level Disinfection (HLD) is a process that is used on some medical devices to eliminate all microorganisms except for a small number of spores. HLD can be accomplished by using an automated device or by hand (manual) reprocessing.

The Surveyor toured the Central Processing Department at 1:30 P.M. on 8/5/2020 and interviewed CPD Technician #1. CPD Technician #1 said there was only one instrument in the Hospital that required manual High-Level Disinfection. CPD Technician #1 began to demonstrate the multi-step process to achieve manual high-level disinfection. Each step in the process was done correctly except the dip sticks to test the concentration of the disinfectant had expired.

4.) The Surveyor toured the Surgical Intensive Care Unit at 9:40 A.M. on 8/4/2020. During the tour the Surveyor opened a procedure cart that was in the corridor but could be wheeled outside of a patient's room to provide additional supplies needed for a procedure. The Surveyor observed 3 surgical foam dressings, 6 packages of sutures, 1 package of electrodes and a package of vascular felt that had all passed their expiration dates.