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Based on observation and record review, this facility failed to ensure there is an effective infection control surveillance program for preventing and controlling potential infections in 2 of 2 observations.

03/02/2015 at 11:00 AM, observation of Lab Technician G performing a routine lab draw on a patient located in the ED (emergency department), Lab Tech G failed to prevent cross contamination of clean supplies and used/contaminated supplies. While performing lab draw, Lab Tech G placed all tubing and products selected to perform the lab draw on the white sheet of patient's gurney next to patient's left leg. Then cleaned the targeted area of patient's arm and placed used/contaminated products in a small section in the supply carrier rather than throwing used products in the garbage. Once 3 full tubes of blood were drawn, Lab Tech G removed gloves, handled and labeled tubes without gloves and placed blood filled tubes in with clean vacutainers (another section of the supply carrier) and transported the tubes back to the lab. Upon return to the lab, Lab Tech G then threw away the used/contaminated cleaning products in the garbage and without cleaning the small section from where the used/contaminated products were, placed multiple clean tourniquets in that space. Requested facility provide a policy and procedure for aseptic technique, Assistant Admin B forwarded on 03/04/2015 at 12:26 PM an Infection Control: Asepsis-No touch technique policy #GL-9700. Policy reviewed 03/04/2015 at 12:30 PM. Assistant Administrator Patient Care B stated, "They have not yet implemented this policy into the facility, but plan on using it in the future". No other policy was provided regarding aseptic technique in this facility.

03/02/2015 at 09:30 AM, observation of RN (registered nurse) F administering medications to patient in room #117 found that RN F was unable to answer as to when the IV (intravenous) tubing was scheduled to be replaced as it was not labeled identifying the tubings expiration date. RN then retrieved a new IV tubing set and proceeded to replace the current tubing with the new tubing and placed a sticker with date of expiration. While changing out the tubing, it was observed that RN F spiked the old and half empty IV bag of 0.9% normal saline, rather than spiking a new fluid bag with new tubing which now contaminated the new tubing. Reviewed 03/02/2015 at 01:15 PM, facility Policy and Procedure #12-41 IV Therapy Administration/Insertion & Maintenance, dated 04/04/92 last reviewed and revised 03/29/07, section E: Changing IV Tubing, #3 obtain new administration set and IV solution, #9 adjust fresh solution flow rate to the rate ordered by the physician, #11 chart tubing change and condition of site on IV flow sheet. Policy received and verified by Assistant Administrator Patient Care B.