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Based on document review and interview, the facility failed to promote patient and employee safety through the mishandling of biohazard materials.

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure an environment that avoided potential for transmission of infections and/or risk.

Based on document review and interview, the facility failed to promote patient and employee safety through the mishandling of biohazard materials.

Findings include:

1. Facility policy titled "Standard Precautions", policy # IC 4-4, last reviewed 04/2023, indicated always wear gloves when handling trash; infectious waste shall be placed either in a red bag or bag marked with a Biohazard label.

2. Facility policy titled "Routine Daily Cleaning and Disinfection", policy # IC 8-1, last reviewed 04/2023, indicated "Standard Precautions" will be observed at all times; transmission-based precautions will be followed as indicated.

3. Facility policy titled "Medical Waste", policy # IC 8-8, last reviewed 04/2023, indicated the sharps container is exchanged and maintained by housekeeping staff. Gloves are to be worn when servicing the sharps system. All infectious/biomedical waste is placed in red biohazard bags at their point of generation, tied, and/or secured, and then placed directly into the biohazard containers in the dirty utility area. The infectious/biomedical waste bags should not be dumped or in any way transferred from one bag to another; infectious/biomedical waste bags or containers should be handled carefully so as not to destroy the integrity of the package; gloves and other personal protective equipment will be worn as needed to protect the health care worker.

4. Facility policy titled "Scope of Services", policy #ENV001, last reviewed 08/2020, indicated ensure that all trash/soil linen throughout the Hospital is handled in such a way as to minimize potential for infections and hazardous exposures.

5. Facility policy titled "Trash Collection", policy # ENV024, last reviewed 08/2020, indicated when trash cart becomes full it is taken to the basement where biohazard is put into the biohazardous waste storeroom until it is picked up for disposal.

6. In interview dated 05/03/2023 at approximately 0930 hours with N5 (Environmental Services Manager) and S3 (Chief Nursing Officer), it was indicated by N5 that biohazard bags are carried by himself/herself or other designated Environmental Service Technicians downstairs to the biohazard storage room located in the basement. The bags are then sorted by N5, he/she explained the process: two trash cans (one grey and one red with biohazard signage) lined with clear trash bags are placed in front of the grey boxes lined with red biohazard bags; one can is available to open the red biohazard bag into and the other is to place soiled linen that was mistakenly placed by staff in the biohazard bag. After sorting is complete, trash gets put into the trash receptacle, and linen gets placed with the rest of the accumulated dirty linen.

7. In interview dated 05/03/2023 at approximately 1030 hours with N8 (Environmental Services Technician), he/she indicated that he/she is not allowed to take biohazard bags down to the basement for disposal, only certain technicians are allowed. He/she indicated that N5 at times sorts the trash from the red biohazard bags in the biohazard closet located on the unit. N8 indicated that N5 dumps contents of suction cannisters, after removing them from a tied biohazard bag, down the sink in the biohazard room or dumps contents in the patient room toilet when terminal cleaning is taking place. N8 indicated that he/she observed N5, without gloves, dumping contents of suction canisters down the toilet, rinsing out the canister and placing it in regular trash. N8 indicated that N5 tells staff that he/she is saving the facility thousands of dollars by sorting the bags. N8 indicated that N5 checks sharps containers without gloves, shakes them to make contents settle and allow for more sharps material. N8 indicated that N5 popped open a used sharps container to show technicians that the box can hold more and would like for them to be filled to the top.

8. In interview dated 05/03/2023 at approximately 1045 hours with N1 (Infection Preventionist), he/she indicated the following is considered biohazard waste and should be placed in red biohazard bags: items that are visibly soiled with blood or can potentially have blood, disposable chux, heavily blood soiled linens, sputum, sharps containers, etc. these items should not be placed in with regular trash. N1 indicated that it was reported to him/her by environmental services technicians, that N5 was sorting the contents of biohazard bags, he/she spoke with N5, provided additional training, and reported situation to S2 (Chief Executive Officer) and S3. EVS technicians had no longer complained, he/she assumed biohazard trash sorting was no longer happening.

9. In interview dated 05/03/2023 at approximately 1100 hours with S6 (Environmental Services Technician), it was indicated that red biohazard bags contain blood covered bed items, used wound care supply, feces, etc. S6 indicated that N5 will remove bags individually from the biohazard room without gloves and take them downstairs to the biohazard storage room, where N5 sorts through the red biohazard bags separating the linen from what he/she considers trash. S6 indicated that N5 spoke to staff and indicated that not all items placed in the biohazard bags belong in there and it costs the facility a lot of money. S6 indicated that N5 left a needle box (sharps container), on the table of the staff break room, the box had originally been placed in the red biohazard bag and sealed after terminal cleaning of a room with a patient diagnosed with C. diff. (Clostridium difficile), he/she also indicated that this happens often when a sharps container is pulled out of a biohazard bag by N5 and the container is not full. S6 indicated that a patient was discovered to have bed bugs, they were instructed by N1 to wear gown, gloves, shoe coverings and head cover prior to entering the room for terminal cleaning; all linens were to be placed in biohazard bags; all linens had been placed in biohazard bags and sealed, N5 entered room with no Personal Protective Equipment (PPE) and opened red biohazard bags, removed the used linens from the red bags, placed them in regular linen bags and laid the bags on top of a clean cart.

10. In interview dated 05/03/2023 at approximately 1430 hours with S1 (Director of Quality Management), S2 and S3; S1 indicated he/she was not aware of anyone sorting through biohazard bags; S2 indicated that an audit is conducted at times to ensure the contents of the bags do not contain intravenous pumps or monitors, as it has been a problem in the past.