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Based on observation, interview and record review the facility failed to effectively prevent and control potentially infectious and communicable diseases within the hospital.

· Staff did not utilize personal protective equipment (PPE) while providing direct patient care and while assisting during invasive procedures as required by facility policy and federal regulation.


Findings included:

During an observation in the radiology department on 07/20/15 at approximately 10:20 a.m., facility staff provided direct care during an invasive procedure (liver biopsy) for patient (P#1). The invasive procedure involved a surgical incision through P#1's abdomen area to extract a sample of liver tissue. Staff #9 assisted during the procedure and did not wear protective head cover as standard precaution ppe.

During an observation at an endoscopy suite on 07/29/15 at approximately 12:05 p.m., facility staff provided direct care during an invasive procedure (colonoscopy) for P#8. The procedure's risk to staff included potential exposure to blood and or bodily fluids. Staff #26 did not wear a face mask or face shield as standard precaution ppe to protect against possible splash or exposure from blood or bodily fluids to mouth and or eyes. Staff #23 did not wear eye protection, protective gown or face mask to protect against splash exposure. Staff #24 did not wear a facemask, protective gown or gloves. Staff #25 did not wear protective eyewear or head cover. Staff #23, #24, #25 and #26 did not wear any protective foot covers to prevent tracking and or exposure to blood or bodily fluids on the floor.


Review of the facility's Standard/Universal Precautions for Bloodborne Pathogens policy with original date of June 1987 indicated in part:


· D. Gloves:

1. "Gloves must be worn for reasonably anticipated direct contact with blood and body fluids, mucous membranes, or non-intact skin of all patients; handling items or surfaces soiled with blood or body fluids..."


· E. Protective Eyewear/Face Shields and Masks:

1. "Approved gloves, goggles, mask or face shield, approved gown and/or apron must be worn for all procedures (for all patients) involving insertion of pressure monitoring lines/devices...or any delivery where splashing of blood/body fluid may occur; for any surgical procedure where any type of body fluid splashing may occur."


· F. Engineering Controls to Prevent Employee Exposure: (Sharps, etc.)

5d. "Gloves and surgical masks must be worn for all invasive procedures"

e. "Protective eyewear or face shields and caps and shoe covers will be worn for procedures that could result in the generation of droplets, splashing of blood or other body fluids..."

f. "Approved gowns or aprons made of materials that provide an effective barrier will be worn during invasive procedures that could result in the splashing of blood or other body fluids."


An interview with Staff #3 on 07/29/15 at approximately 4:50 p.m. confirmed facility staff were required by facility policy and federal regulation to utilize personal protective equipment during invasive procedures that could cause exposures to blood and or bodily fluids. The use of protective barriers by staff was to prevent potentially infectious and communicable diseases to patients and or staff. PPE included gloves, gown and or apron, face mask and or face shield, head and foot covers.

During the Exit Conference on 07/30/15 at approximately 3:00 p.m., the facility was given an opportunity to ask questions and provide additional information regarding Infection Control deficiencies identified during the survey process. No additional information was given.