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Based on observation, staff interviews, and policies and procedures, it was determined that the facility failed to audit hospital personnel in their designated work areas for adherence to infection control policies and procedures. Specifically, the facility failed to ensure personnel did not eat, drink, store food, store beverages, and store personal items in the surgical decontamination area.


Findings include:


During a facility tour of the decontamination handwashing room, a beverage-filled Styrofoam cup was observed on top of the sink. Further observation revealed bags of unopened snacks in a paper bag, cheesy pasta with bread inside a Styrofoam plate, and staff personal medication bottles were observed underneath the sink cabinet inside the decontamination handwashing room.


Review of policy titled "Bloodborne Pathogens Exposure Control Plan," number 2.062, approved 7/19/24, revealed the purpose was to establish a plan to give criteria by assisting employees who work in occupations where they are at risk of exposure to bloodborne pathogens. Procedure: III. Methods of Implementation and Control, F) Safe Work Practices, 1) Eating, drinking, smoking, applying cosmetics or lip balm, or the handling of contact lenses was not allowed in contaminated work areas. 2) Food and drink may not be stored in refrigerators, freezers, shelves, cabinets, or counter tops where blood and other potentially infectious material (OPIM) are present.


An interview was conducted with Registered Nurse Educator (RNE) BB on 4/14/25 at 1:45 p.m., in the decontamination handwashing room. RNE BB stated she currently managed the decontamination and sterile processing areas until the facility finds a replacement. She said food and drinks were not permitted in the decontamination and sterile processing areas. RNE BB stated she was not aware that a sterile processing technician had improperly stored personal belongings, food and beverage in the handwashing room.


An interview was conducted with Sterile Processing Technician (SPT) CC on 4/14/25 at 1:45 p.m. in the decontamination handwashing room. SPT CC stated it was his backpack, lunch plate, beverage, and medication bottles that were improperly stored on top of and under the handwashing sink. SPT CC stated that he was aware that food and drinks were not allowed in the decontamination handwashing area. He said he improperly stored his items and won't do it again. He said that he was aware that there was a break room for employees and a designated locker room for employees' belongings.


An interview was conducted with Director of Quality and Patient Safety (DQPS) AA on 4/14/25 at 1:45 p.m. in the decontamination handwashing room. DQPS AA stated she also served as the facility's Infection Preventionist. She said employees were not permitted to store food and drinks in the decontamination area or handwashing area. She said employees had a designated break room to eat and a designated locker room to store personal belongings.


An interview was conducted with Director of Quality and Patient Safety (DQPS) AA on 4/15/25 at 4:24 pm in the conference room via telephone. DQPS AA stated that as a part of each employee's orientation, they were informed about the activities that were permitted and not permitted in their designated working areas and completed an online annual review workshop that informed them of those limitations.