The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BAYHEALTH HOSPITAL, KENT CAMPUS 640 S STATE STREET DOVER, DE 19901 Feb. 25, 2014
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, staff interview and hospital policy and document review, it was determined that staff failed to follow the hospital's infection control policies potentially effecting 231 of 231 inpatients. Findings include:

The hospital job description entitled "Infection Control Manager" stated, "...responsible for ongoing oversight and continuous improvement of the...Infection Control program of surveillance, prevention, and clinical response regarding infectious disease exposures and hazards...Responsible for...ongoing compliance with...CMS...requirements..."

The hospital's policy entitled "Waste Handling" stated, "...to handle and transport infectious waste in compliance with all federal...guidelines ...employees shall...follow proper hand hygiene protocols..."

The hospital's policy entitled "Hand Hygiene" stated, "...Hand hygiene is required...After touching any source that is likely to be contaminated with pathogens...after body fluid exposure risk...use of gloves during procedures does not eliminate the need for hand hygiene before glove application and following glove removal...wearing gloves does not replace the need for hand hygiene..."

1. On 2/24/14 between 11:25 AM and 11:46 AM, the following was observed during the handling of infectious waste by Employee #1:

- donned gloves
- picked up red infectious waste bag out of bin
- picked up tape and applied tape to red infectious waste bag
- placed red infectious waste bag in cart and closed lid
- pushed cart through hallway
- touched button to open doors
- touched identification badge (ID) badge
- picked up red infectious waste bag
- opened bin and placed red infectious waste bag in bin
- touched ID badge
- removed gloves
- obtained tape
- donned gloves
- picked up red infectious waste bag
- applied tape to red infectious waste bag and placed in bin
- pushed cart to elevator
- touched wall elevator button to open door
- pushed cart into elevator
- touched the elevator button

2. On 2/24/14 between 1:45 PM and 2:30 PM, the following was observed during the handling of infectious waste by Employee #1:

- removed gloves
- donned gloves
- touched ID badge
- picked up red infectious waste bag and placed in bin
- picked up red infectious waste bag from emergency room entranceway and placed in bin
- removed keys from pocket
- unlocked door and turned knob
- picked up red infectious waste bag
- placed red bag in bin
- pushed cart
- removed gloves
- performed hand hygiene with soap and water

Employee #1 failed to perform hand hygiene:
- after glove removal
- after contact with a source that was likely contaminated with pathogens
- before donning gloves

The observation was witnessed by Director A, who confirmed these findings on 2/24/14 at 2:40 PM.

Interview on 2/25/14 at 10:16 AM with Infection Preventionist A and Infection Preventionist B revealed that the observed practice did not conform to the hospital's infection prevention policy for hand hygiene.

3. On 2/25/14 between 9:20 AM and 9:40 AM, the following was observed during the handling of infectious waste by Employee #2:

- donned one glove to left hand
- touched ID badge
- donned second glove to right hand
- picked up red infectious waste bag and placed in bin
- touched ID badge
- picked up red infectious waste bag and placed in bin
- removed gloves
- performed hand hygiene with soap and water

Employee #2 failed to perform hand hygiene:
- after contact with a source that was likely contaminated with pathogens

Interview on 2/25/14 at 10:20 AM with Infection Preventionist A and Infection Preventionist B revealed that the observed practice did not conform to the hospital's infection prevention policy for hand hygiene.