HospitalInspections.org

Based on observations, interviews and policy review, the facility failed to monitor compliance with polices /procedures and implementing of infection control measures related to hospital personnel for 1 of 12 employees observed (The Medical Director of the Pathology Lab).

The findings include:

1. An observation in the surgical suites of the facility on 02/25/2014 at 11:00 AM revealed the Medical Director of the Pathology Lab (MDPL) in the surgical suite bending down and placing his bare hands into a large container. The MDPL picked up a smaller container which looked to be a specimen container with fluids in it. The smaller container did not have a bag over it.

2. An interview was conducted on 02/25/2014 at 11:05 AM with the MDPL. He stated, " You caught me and I should have gloves on. "

3. An interview was conducted on 02/26/2014 at 2:10 PM with the Infection Control nurse. She stated the MDPL was expected to have gloves on when checking specimens and that the MDPL should know this.

4. A Review of the facility ' s policy for transporting patient and specimens (revised 12/2013) revealed, " 1. Patient specimens including blood, tissue and body fluids must be placed in a Ziploc plastic bags or sealed specimen container for transports. 2. Treat all specimens as potentially infected ...5. Gloves should be worn during specimen transport. "