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Based on observations, records reviewed and interviews the Hospital failed to consistently adhere to Infection Control standards related to training requirements for staff who are at risk for exposure to a bloodborne pathogens and safe management of multi-dose vials.

1.) Federal regulations require specific training for staff at risk for exposure to bloodborne pathogens. Under the Occupational and Safety Health Administration requirements [1910.1030(g)(2)(ii)] Training shall be provided at the time of initial assignment to tasks where occupational exposure may take place and at least annually thereafter. The training program shall contain at a minimum the following elements: an accessible copy of the regulatory text of this standard and an explanation of its contents; a general explanation of the epidemiology and symptoms of bloodborne diseases; an explanation of the modes of transmission of bloodborne pathogens; an explanation of the employer's exposure control plan and the means by which the employee can obtain a copy of the written plan; an explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials; an explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment; information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment; an explanation of the basis for selection of personal protective equipment; information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge; information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials; an explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available; information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident and an explanation of the signs and labels and/or color coding required.

The Surveyor interviewed Respiratory Therapist #1 at 10:00 A.M. on 9/7/17. Respiratory Therapist #1 was observed caring for one of the patients in the ICU. Respiratory Therapist #1 said he was a new Respiratory Therapist and had started at the Hospital some weeks prior to survey.

The Surveyor interviewed the Quality Manager at 11:00 A.M. on 9/11/17 after it was determined that the Respiratory Therapist had not yet attended Hospital Orientation. The Quality Manager said a new employee who was at risk for exposure to bloodborne pathogens was allowed to work prior to the Hospital Orientation where a full Infection Control and Bloodborne Pathogen program was presented because the Department would present the new employee with interim training. The Quality Manager said the Respiratory Therapist was scheduled for Hospital Orientation that day and he had up to ninety days to attend orientation.

The Surveyor reviewed Respiratory Therapist #1's departmental orientation check list. The checklist indicated that the Respiratory Therapist had reviewed the Infection Control Policy and utilized safe practice as it applied to standard precautions of infection control and prevention, but not the required bloodborne pathogen training.

2.) According to the Center for Disease Control (CDC) publication "Safe Practices for Medical Injections", multi-dose vials should be dedicated to a single patient whenever possible. If multi-dose vials must be used for more than one patient, they should only be kept and accessed in a dedicated medication preparation area (e.g., nurses station), away from immediate patient treatment areas. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients.

The Surveyor toured the Intensive Care Unit at 8:25 A.M. on 9/7/17 and interviewed Registered Nurse (RN) #1 about the use of multidose medications. The Surveyor accessed the insulin storage area and asked RN #1 to describe her practice of using a multidose vial for more than one patient. RN #1 described how the medication refrigerator was accessed and the correct vial chosen. The Surveyor observed pre-printed insulin labels were available to label the syringes after the nurse drew up the correct dosage. RN #1 said she did not use the labels but took the insulin vial to the patients area where she would scan the patient and the vial prior to administration.

The Surveyor interviewed Infection Preventionist #1 at 8:30 A.M. on 9/7/17. Infection Preventionist #1 said the pre-printed labels enabled the nurse to draw up the desired medication dose, label the syringe and then scan the syringe and the patient while the multidose vial remained safely in the medication preparation area.