HospitalInspections.org

Based on policy review, observation, and interview, the facility failed to ensure nursing staff adhered to the policies and procedures of the facility related to chemotherapy administration and hazardous drug (HD) handling for clinical areas.

The findings included:

1. Review of the facility's policy , "Chemotherapy Administration," last reviewed 7/25/2022 revealed, "...PPE (personal protective equipment) is required when handling blood and body fluids (particularly urine) and waste including diapers during and for 48 hours post chemotherapy drug administration....Toilets should be flushed while wearing gown, gloves and mask with face shield during and for 48 hours post chemotherapy drug administration. While inpatient, parents should be instructed not to flush body fluids during this time..."

Review of facility's policy, "Hazardous Drug Handling for Clinical Areas," last reviewed 6/21/2022, revealed..."For patients receiving HDs, the patients will wear yeallow arm bands or have a yellow sticker added to their arm band...."

2. Observations during the walk-through of the Outpatient Chemotherapy Unit on 2/13/2024 at 12:50 PM, revealed that the 2 bathrooms in the unit and the bathrooms outside the unit were accessible for use by chemotherapy patients, family members of the patients and visitors. No bathrooms were designated to be used by only patients who were receiving chemotherapy.

3. During an interview on 2/13/2024 at 12:50 PM, Registered Nurse (RN) #4 stated, "... at one time, patients who received chemotherapy wore yellow armbands; however, they no longer use the armbands. The only notice that the patient is receiving chemotherapy is the patient's medical record. There is nothing in place to signify that patients moving around the unit and/or using the unit restrooms have received chemotherapy within the last 48 hours..." RN #4 confirmed that the same restrooms in the Outpatient Chemotherapy Unit were utilized by chemotherapy patients, family members of the patients, and visitors.