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Based on observations, interviews, and document review, the facility failed to administer blood transfusions in accordance with approved medical staff policies and procedures.

This failure created the potential for negative patient outcomes through the possible spread of bloodborne pathogens and infectious disease.

Findings:

1. The facility did not ensure that staff followed facility policies and procedures regarding standard precautions during blood administration.

a) On 09/04/13 at 12:20 p.m., the surveyor reviewed the facility's policy titled, "General Infection Control Policy: Isolation Precautions in Hospitals", last revision dated February of 2010. The policy stated that gloves "Will be worn when it is possible that there will be contact with blood or any other body substance, mucous membrane or non-intact skin".

b) On 09/04/13 at 11:30 a.m., a Registered Nurse (RN) was observed administering blood to a patient in the facility's Ambulatory Care Unit (ACU). The RN explained that he/she would be starting a second unit of blood for the patient and that the second unit would be attached to the same intravenous (IV) tubing used for the first unit of blood. Without donning gloves, the RN detached the empty first unit of blood from the IV tubing and attached the full second unit of blood to the IV tubing. The RN was then observed taking the empty unit of blood to a closed door, entering a code into a key pad located next to the doorknob, and opening the door, all without washing his/her hands first. The RN then discarded the empty unit of blood in a biohazard container and washed his/her hands at a sink located next to a coffee maker.

c) On 09/04/13 at 12:05 p.m., the Director of Quality was interviewed about the surveyor's observations of an RN not wearing gloves while administering blood. the Director of Quality confirmed that the RN was not wearing gloves and that the expectation would be for staff to wear gloves while in contact with blood or body fluids.

Based on observations, interviews, and document review, the facility failed to administer blood transfusions in accordance with approved medical staff policies and procedures.

This failure created the potential for negative patient outcomes through the possible spread of bloodborne pathogens and infectious disease.

Findings:

1. The facility did not ensure that staff followed facility policies and procedures regarding standard precautions during blood administration.

a) On 09/04/13 at 12:20 p.m., the surveyor reviewed the facility's policy titled, "General Infection Control Policy: Isolation Precautions in Hospitals", last revision dated February of 2010. The policy stated that gloves "Will be worn when it is possible that there will be contact with blood or any other body substance, mucous membrane or non-intact skin".

b) On 09/04/13 at 11:30 a.m., a Registered Nurse (RN) was observed administering blood to a patient in the facility's Ambulatory Care Unit (ACU). The RN explained that he/she would be starting a second unit of blood for the patient and that the second unit would be attached to the same intravenous (IV) tubing used for the first unit of blood. Without donning gloves, the RN detached the empty first unit of blood from the IV tubing and attached the full second unit of blood to the IV tubing. The RN was then observed taking the empty unit of blood to a closed door, entering a code into a key pad located next to the doorknob, and opening the door, all without washing his/her hands first. The RN then discarded the empty unit of blood in a biohazard container and washed his/her hands at a sink located next to a coffee maker.

c) On 09/04/13 at 12:05 p.m., the Director of Quality was interviewed about the surveyor's observations of an RN not wearing gloves while administering blood. the Director of Quality confirmed that the RN was not wearing gloves and that the expectation would be for staff to wear gloves while in contact with blood or body fluids.