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Based on observation, interview and record review, the facility failed to ensure the facility staff disposed of bodily fluids according to policy for one patient (P-15) of 24 patients sampled, resulting in the potential for adverse patient outcomes from improper handling of biohazardous fluids. Findings include:

During initial facility tour on 03/05/24 at 1048 medical surgical unit was observed with Staff P, Staff Q and Staff R. P-15 was observed lying in bed in his room. Two clear plastic bottles were noted sitting on a windowsill next to the patient's bed. One bottle was filled to the top with a red fluid. Second bottle had approximately 50 ml of red fluid in it. Both bottles were not covered and were visible form the hallway. Staff nurse in care of P-15, Staff S, was asked regarding the bottles. Nurse S stated that it was a bladder irrigation fluid that was collected by urology residents this morning and residents left it there, on the window. Staff S was not sure what has to be done with the fluid since he did not receive any instructions from the urology residents regarding collection of any specimens for laboratory analysis and he was not sure if it was ok to discard the fluid.
Staff nurses, Staff T and Staff U were called into the room to see if they had any knowledge of the bottles. Both nurses looked at the bottles and Staff T said that urology residents do that sometimes- they collect the bladder irrigation and leave the fluid behind so "nurses clean after them". Staff T and Staff U were asked if they educate residents on proper disposal of bloody bodily fluids. Nurses responded that they do it "all the time". Both nurses were asked what an appropriate place would be to discard the bloody fluid. Staff responded that they always do it into the patient's bathroom, into the toilet. During this conversation Staff S was observed collecting more irrigation fluid from P-15's catheter into a plastic container. He asked his peers where he should dispose it. Both nurses responded that it needs to be flushed down into the toilet in patient's bathroom. During collection of the bladder irrigation Staff R noted not to wear eye protection. Staff T and Staff U were asked if they do wear eye protection while collecting bladder irrigation. Staff T said that they usually don't, and they (staff) just look away, so it won't splash in the eyes.

Unit Nurse Manager, Staff R, who was present during the conversation with the staff, was asked if the bloody irrigation fluid should be removed from the window and discarded at this point. She stated yes. When asked where it should be discarded, Staff R responded that it should go "into the hopper in soiled utility room".
Infection Control Nurse, Staff P, was present during the conversation with nursing staff and unit manager. She was asked if medical staff, including residents, have a designated infection prevention educator. Staff P stated that she was not sure. When asked how residents can be educated on appropriate and timely bodily fluid disposal, Staff P said it would be communicated through medical leadership.

On 03/06/24 at 1026, during interview with Staff P and Staff B, facility's Infection control prevention practices and policies were discussed in detail. Staff P shared the description of her responsibilities as an Infection Control Nurse. Part of Staff P's role was clinical staff education on facility's infection prevention and control guidelines, policies, and procedures. She stated that clinical applications of the policies and guidelines are discussed in huddles with clinical staff regularly. When asked about bloody fluids sitting on the windowsill as being an appropriate practice, Staff P indicated "absolutely not", and reassured that all the clinical staff who was involved will be re-educated. When asked if staff needs to follow facility's policy for personal protective equipment when working with biohazard materials, Staff P stated "yes".

Facility's Infection control and prevention policies were requested and reviewed on 03/06/24. Medical Waste Plan Policy, effective date: 05/09/23, indicated the following:
Objective
To provide an effective medical waste management program for the (facility's name) to protect human health and the environment from exposure to the hazards posed by regulated medical waste.
2. Medical Waste Management-General
F. Medical waste is stored in such a manner that putrefaction will not occur and infectious agents will not come in contact with air or individuals. E. Human blood, blood products and body fluids shall be flushed into designated sanitary sewers located throughout each facility.
4. Protective Measures
A. Appropriate personal protective equipment (PPE) must be worn when handling, packaging, and transporting medical waste as well as for management of general waste.

Isolation Policy, effective and revised 11/01/2023, indicated the following:
Objective/Purpose:
To prevent the spread of communicable and other infectious diseases between patients, personnel, and visitors. To improve the safety of the (facility's name) healthcare delivery system by reducing the rates of healthcare associated infections.
A. Standard Precautions by the Centers for Disease Control and Prevention includes the practice of Universal Precautions for blood and body fluids in the care of all patients in accordance with the OSHA Bloodborne Pathogens rule.
I. Standard precautions
Standard Precautions presumes that all patients may be harboring an infectious agent, does not rely upon specific diagnosis or culture results for implementation and applies to all blood and bodily fluids.
3. Gloves are worn for anticipated contact with blood or body fluids, mucous membranes, or non-intact skin. Gloves are worn when handling items or surfaces soiled with blood or body fluids. Gloves are changed after each task and after contact with each patient; hand hygiene is performed between glove changes.
4. Masks and protective eyewear are used during procedures likely to generate splashes of blood or body fluids to prevent exposure to mucous membranes of the mouth, nose, and eyes.
6. Gowns are not routinely necessary. Gowns are used during procedures likely to generate splashes of blood or body fluids or when soiling of clothing is likely.