HospitalInspections.org

Based on review of the facility policy, observation, and interview, the facility failed to provide for safe storage and disposal of medical waste for 1 of 1 facilities observed.

The findings include:

Review of the facility policy "Hazardous Materials and Waste Management Plan" last revised 1/2019, revealed "...Proper Storage and Disposal of Trash...[the facility] manages its non-hazardous solid waste (trash) consistent with regulatory standards and in a manner consistent with good housekeeping practices..."

Observation and interview with the Safety Officer on 5/7/19 at 9:50 AM, of the waste disposal area outside of the kitchen, revealed 4 of 4 uncovered trash dumpsters filled with trash. Further observation revealed the dumpsters were opened in the front. Continued observation revealed paper waste on the ground beside one of the dumpsters. Interview with the Safety Officer confirmed trash was on the ground beside the dumpster and the dumpsters were open. Further interview confirmed the facility failed to maintain a sanitary waste disposal area.

Based on review of Centers for Disease Control (CDC) recommendations, observations, and interview, the facility failed to maintain a safe and sanitary environment in 1 of 1 Computer Tomography (CT) rooms, 1 of 1 Intensive Care Unit (ICU) Nourishment Rooms, 1 (#1) of 2 Preadmission Testing (PAT) Rooms, and 1 of 1 Radiology Department.

The findings include:

Review of CDC recommendations for "Injection Safety" updated 8/2016, revealed "...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. If a multi-dose vial enters an immediate patient treatment area, it should be dedicated for single-patient use only..."

Observation and interview with the Registered Technologist, Radiography (RTR) and Lead Sonographer on 5/6/19 at 3:00 PM, in the CT room of the Radiology Department, revealed 1 hanging bottle of contrast medication 500 milliliters (ml) with 350 ml of Iodine concentration. Interview with the RTR confirmed the contrast was a multidose bottle, was stored in a patient care area, and was used for multiple patients.

Observation and interview with the ICU Manager on 5/7/19 at 11:27 AM, in the ICU patient nourishment area, revealed twelve 0.2 fluid ounces (fl. oz.) packets of nectar thick liquid thickener (food and beverage thickener) expired 3/22/19 and one 0.4 fl. oz. packet of honey thick liquid thickener expired on 3/22/19. Interview with the ICU Manager confirmed the thickener packets were expired and were available for patient use.

Observation and interview with the Laboratory Director on 5/7/19 at 11:44 AM, in PAT Room #1 revealed 4 blue top micro-lab specimen tubes (blood collection tubes) expired on 12/7/18. Interview with the Laboratory Director confirmed the specimen tubes were expired and were available for patient use.

Observation and interview with the Lead Sonographer on 5/7/19 at 2:59 PM, in the Radiology Department, revealed 1 packaged biopsy needle (a thin needle used to obtain tissue) expired on 10/2017, and 1 biopsy needle expired on 2/2019. Interview with the Lead Sonographer confirmed the biopsy needles were expired and were available for patient use.


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