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Based on interview and record review the facility failed to ensure that staff are aware and knowledgeable about aseptic technique when collecting urine specimens. This could affect all patients and personnel at the facility.


Findings Include:

Review on 3/25/2015 beginning at 1:00 PM of P/P titled Specimen Collection:Urine/Sputum/Stool effective 2/14/2008 states the following:
-Specimen for sputum, urine, and/or stool analysis will be obtained using aseptic technique.
-Wash hands, wear non-sterile gloves
-instruct the patient to close the container tightly, place it in the bag provided, wash hands well with soap and water after collecting specimen and give the specimen to staff immediately.
-Wash hands after removing gloves.

Per interview with "B" on 3/25/15 beginning at 12:05 PM, when asked what the procedure is for collecting urine specimens, "B" (receptionist) stated the following: Social worker or RN place patient name on specimen container and gives to patient to obtain urine specimen. Patient then presents to front reception desk with urine sample. "B" opens biohazard bag and patient drops cup with urine specimen into bag. "B" then uses a marker to write the time and date on the collection cup then seals the bag. "B" stated gloves are not used when collecting urine specimen from patients. Per "B", other covering receptionist collect urine specimens from patients and there has been confusion in the past with labeling and process and procedure of specimen collections, covering receptionists do not wear gloves while collecting urine specimens.

Per interview with Coord A on 3/25/15 beginning at 12:35 PM, SW A stated staff should be wearing gloves and when collecting urine specimens from patients. Per SW A was unaware of covering receptionist collecting urine specimens. Per SW A if "B" is not present then RN should be collecting urine specimens.