HospitalInspections.org

Based on observation, interview and record review the Hospital's Infection control program:

1) Failed to ensure Biohazard waste containers were emptied once full in 4 of 17 rooms surveyed (Room numbers: 506, 511, 517 and 518).

2) Failed to ensure staff did not store equipment / supplies on top of biohazard containers in 7 of 17 rooms surveyed (Room numbers: 500, 501, 502, 503, 507, 512 and 518).

3) Failed to ensure intravenous / gastric tubing was replaced according to policy (Patient ID#'s 1, 4, and 14)

4) Failed to educate family members regarding contact isolation precautions and the need for personnel protective equipment (Patient ID#'s 17 and 18).

5) Failed to ensure staff used proper hand hygiene when changing dressings in 1 of 2 dressing changes observed (Patient ID # 5).

Findings include:

Observation during initial tour on 7/12/15 from 8:30 a.m. to noon revealed the following:

Wall mounted biohazard containers were full in rooms 506, 511, 517 and 518. The red biohazard containers were mounted to the wall inside a wooden box. This prevented the staff from being able to visualize when the biohazard container reached the marked fill line alerting the staff to change the container.

The Charge Nurse (ID # E) acknowledged at this time that she was not able to tell if the biohazard containers were full due to the wooden boxes blocking the fill line on the containers.


Gait belts were observed draped over the wall mounted biohazard containers in rooms 500, 501 and 503.


The following supplies / equipment were found on top of the biohazard waste containers:

-Room 502: An opened container of Personal Cleaning Cloths.

-Room 507: A roll of tape.

-Room 512: A blue tourniquet for drawing blood, a pencil, and a roll of tape.

-Room 518: Two 10 cc (cubic centimeter) syringes in a sterile wrapper, two 18 Gauge needles in a sterile wrapper and a blue tourniquet for drawing blood.


Observation 7/12/15 during initial tour from 8:30 a.m. to noon revealed the following Intravenous tubing / gastric tubing that was past due to be changed according to policy:

Room 500 / Patient ID# 1: Antibiotic (Ceftriaxone) Intravenous tubing was labeled as follows "Start 7/7 and Discard 7/10."

Room 502 / Patient ID# 4: Gastric food (Isosource) tubing failed to have a label on the tubing of when the tubing was first hung. The tip of the tubing did not have a cap on the end of the tubing. The cap was found on top of the IV pole.

Room 510 / Patient ID# 14: Antibiotic (Vancomycin) Intravenous tubing was labeled as follows "Start 7/8/15 and Discard 7/11."

Record review of a policy titled "Intravascular (IV) Therapy" dated 12/10/2013 stated " Policy: The following guidelines shall be utilized in order to reduce the potential risk associated with intravascular therapy; rigorous infection control measures are necessary ...11. Maintenance and Administration Sets: B. IV administration tubing should be routinely changed every 72 hours ..."

Record review of a policy titled "Tube Feeding" dated 1/8/13 stated "J. Open system containers will be changed every 24 hours."


Observation 7/12/15 during initial tour from 8:30 a.m. to noon revealed family members visiting patients in rooms 517 and 518. Each room had a sign on the door that stated " Contact Precautions." The family members were not wearing personal protective equipment.

Interview 7/13/15 at 12:35 p.m. with the husband of patient ID# 18 stated the staff did not inform him he needed to wear a gown and gloves when entering his wife's room since she was on contact isolation. The husband stated he would wear the protective items if it were necessary.

Interview 7/13/15 at 2:30 p.m. with the Infection Control Director (ID# C) stated that family members should be wearing personal protective equipment when entering contact isolation rooms. The Infection Control Director acknowledged that the staff may need more education as it relates to teaching family members about contact isolation and the need to wear personal protective equipment.


Observation 7/12/15 at 2:40 p.m. of a dressing change on patient ID# 5 by nurse ID# H revealed she placed a new dressing on the patients left heel decubitus. The nurse then proceeded to adjust the patient's electric bed with the same gloves. The nurse acknowledged that she should have discarded her gloves and performed hand hygiene prior to adjusting the patient's electric bed.

Record review of a policy titled "Hand Hygiene" dated 3/5/13 stated "Policy: The purpose of this policy is to provide guidelines to promote hand-hygiene practices and reduce transmission of pathogenic microorganisms to patient and staff ...Procedure: F. Gloves, 2. Gloves should be changed, and hand hygiene performed after using gloves for contaminated activities ..."