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Based on observations, interviews, and review of the Hospital's policies and procedures, the Hospital failed to consistently ensure an acceptable level of infection prevention practice.
Findings include:


1. The hospital failed to consistently adhere to OSHA's Bloodborne Pathogens Standard and the hospital's Bloodborne Pathogen Exposure Control Plan.

According to CFR 1910.1030(c)(1)(iv), employers are required to conduct an annual review and update of the Exposure Control Plan to reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens and document annually their consideration and implementation of appropriate commercially available and effective safer medical devices.

During the tour of the Operating Rooms on the East campus on 12-3-12, accompanied by the Nurse Director of Surgical Services and the Nurse manager of the East campus, at approximately 9:30 A.M., supply carts stocked with #22, 25, 27 and 30 gauge non-safety needles readily available for use were observed.

Interview with the Chairperson of the Sharps Committee Chairperson on 12-4-12 at 3:30 P.M. and review of the hospital's Exposure Control Plan, indicated that a sharps waiver process had been established as described in the hospital's Exposure Control Plan. However, the process of sharps review and waiver was initiated only after a device was involved in an employee injury. There was no documentation in the hospital's waivers to support the continued use of #22, 25, 27 and 30 gauge non-safety needles in the Operating Room.

Therefore, the hospital failed to consistently specify the circumstances in which sharps injury prevention technology may be excluded and non-safety sharps allowed (e.g., a device that may compromise patient safety).

2. Observations in the "Parent Walkway" on the Neonatal Intensive Care Unit on 12-4-2012 at approximately 10:15 A.M., included two sinks used by the mothers to clean their dedicated breast milk pump equipment. The Nurse Manager of the Neonatal Intensive Care Unit (NICU) was interviewed during the observation and corroborated that this was the practice.

Two mothers were observed washing their breast pump equipment directly in the sinks. There was no sanitation of the sinks at the completion of the equipment cleaning process to clean the sink for the next mother.

According to the directions posted above the sinks and interview with the Nurse Manager of the NICU, the mothers were instructed to wash their hands prior to cleaning the breast pump equipment. However, other than the utility sinks used to clean the breast pump equipment, there were no hand washing sinks in the "Parent Walkway". Hand washing sinks were located in the NICU patient rooms, however, the "Parent Walkway" was an enclosed area with doors that would need to be opened to enter into the "Parent Walkway", therefore hand washing would be required upon entry to this area.

Adjacent to one of the utility sinks was the potable ice machine dispenser. The ice machine was located approximately 8-10 inches from the sink where mothers were directed to clean their breast pump equipment, allowing for potential contamination from splashing resulting from the cleaning of the breast milk equipment.


3. Observation of a circumcision in the procedure room in the Feldberg 6 nursery at 8:15 A.M., included Staff RN #3 cleaning the area after the circumcision for Newborn #1 was completed and the area was prepared for another procedure. Staff RN #1 was observed cleaning the soiled infant restraint board in the sink in the procedure room. The procedure room sink is a dedicated hand washing sink and is not to be used for cleaning soiled equipment.