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Based on observation, staff interview, and policy review, the facility failed to ensure that infection control policies were implemented to minimize the spread of infectious disease in seven (7) of seven (7) Dirty Utility Rooms.


Findings include:


On 1/26/17 from 2:35 p.m. to 3:20 p.m. environmental observations were made with The Chief Nursing Officer and the Quality Management Director in seven (7) Dirty Utility Rooms. These observations revealed:

1) The Dirty Utility Room on the Pediatric Unit contained: two (2) uncovered diaper scales; eight (8) uncovered diapers in an open container; one (1) food cart; nine (9) rolls of toilet paper; eight (8) unsealed containers of paper towels; one (1) sealed container of soap; one (1) container of Santi-Cloth; two (2) containers of Ready To Use Acid Free Disinfectant Washroom Cleanser; and One (1) infant bouncy seat.

2) The Dirty Utility Room on the Medical/Surgical Unit on Three (3) North contained: three (3) containers of Sani-Cleanse Disposal Wipes; one (1) container of Santi Cloth Bleach; one (1) opened container of gloves; and one (1) food cart containing one (1) soiled tray of food.

3) The Dirty Utility Room on the Second Floor North contained: one (1) soiled food tray on the counter; an approximately 14 inch square white fan; and one (1) small white bible.

4) The Dirty Utility Room on Intensive Care Unit and Respiratory Therapy Unit on the second floor contained one (1) computer rack with a glass cover. There was no biohazard sign on the entrance door to the room.

5) The Dirty Utility Room on the Labor and Delivery Unit contained: four (4) sealed unlabeled preparation trays; and one (1) supply cart.


Review of the facility's "Regulated Medical Waste-Infectious Waste Disposal" policy (updated February 2012) revealed: "... Purpose: Infectious waste may pose a substantial present of potential hazard to human health or the environment when improperly treated, stored, or disposed of. Adherence to certain practices is necessary to better protect the health and safety of the employees, patients and visitors... Definition: The Mississippi Department of Health's definition of "infectious medical waste" and "medical waste" is as follows: Infectious medical waste includes solid or liquid waste which may contain pathogens with sufficient virulence and quantity such that exposure to the waste by a susceptible host has been proven to result in an infectious disease. Medical Waste means all waste generated in direct patient care or diagnostic research areas that is non-infectious but aesthetically repugnant if found in the environment.
(The facility) has further defined Hazardous waste as any patient's blood or body fluids, or any item that has contact with body fluids. Policy:
Infectious waste, other than sharps, must be placed in red biohazard bags.
Regulated medical waste includes the following items:
1. All waste generated from isolation rooms.
2. Human pathological waste included: tissue, organs, body parts, and fluids that are removed during surgery, autopsy or other medical procedures, and specimens of body fluids and their containers.
Examples include:
a. Chest drainage systems.
b. Suction canisters.
c. All blood and blood Products.
d. Soiled/wet dressings and packings.
Biohazard bags in large red bins with covered lids indicated as "Biohazard". These should be removed, when full, by Environmental Services personnel and taken for storage to await transportation."