HospitalInspections.org

Based on staff interview, policy and procedure review, review of documents titled "Patients' Rights," "Employee Incident Exposure Protocol," the facility failed to maintain and a clean and sanitary environment to avoid sources and transmission of infectious diseases by allowing exotic animals (monkeys and McCaw) to be temporarily housed in an inpatient area not currently being used in the facility, and having monkeys in a cage sitting on a gurney in the Emergency Department (ED) during two (2) separate reported incidents.

Findings Include:

Review of facility Patient's Right Acknowledgement Form, Revision 3.0, dated 10/02/2023, " ...Each patient has the right to reasonable access to care ...including matters of applicable laws and regulations ...Each patient has the right to receive care in a safe setting ...".

Review of the facility Employee Incident Exposure Protocol, not dated "...Notify the Supervisor of the incident ...no later than the end of shift ...complete the Employee Occurrence Form ...fill out the Accident Investigation and Miss. Workers Comp Physicians Choice Form ...Employees are to register and be evaluated by ER MD (at no cost to the employee) and receive a Tetanus Booster ...follow up with the employee health nurse ...".

Interview with Director of Nursing (DON) on 09/11/2024 at 11:48 a.m. confirmed Employee #1 sustained a bite from a monkey, no medical evaluation was performed after the bite, Incident Report was not filed, and documentation of the incident was not recorded in the Infection Control Surveillance Log.

Interview with Employee #1 on 09/11/2024 at 12:59 p.m. confirmed a bite from a monkey was sustained and a medical evaluation was not performed, and an Incident Report was not filed.

Interview with Nurse Practitioner #1 on 09/11/2024 at 1:07 p.m. confirmed a monkey was brought to the facility and an employee was bitten on the finger.

Review of facility OSHA policy and procedure, policy number 28A, dated May 2015, " ...The Federal Occupational Safety and Health Administration (OSHA) published the standard of Occupational Exposer to Blood Borne Pathogens ...all healthcare employers protect workers against occupational exposure to ...blood borne pathogens ...The regulations require the following ...Exposure Control Plan ...Follow-up exposure incidents ...Compliance with all the above is mandatory ...".

Review of facility policy and procedure Employee Health, policy number 24A, dated March 2024, " ...The Infection Control Program ...in important in protecting both patients and personnel from unnecessary risk of disease ...establish a system for detecting and reporting infection illnesses in hospital personnel ...All personnel ...having on the job injury should report to their supervisor and Employee Health/Infection Control Nurse ...personnel having on the job injury must complete an Employee Occurrence Form ...First aid will be provided in the Emergency Room for any on-duty employee ...Employees ...exposure incident should adhere to the established guidelines ...".

Review of facility Infection Control, Policy Number 1A, dated May 2018, " ...recognize, prevent, and control ...correction and follow up determine the problem have been corrected ...".

Review of facility Infection Control, Policy Number 3A, dated May 2018, " ...implement and maintain a clearly defined system of identifying and resolving problems pertaining to infection control ...".

Review of facility Infection Control Performance Improvement Plan, Policy Number 6A, dated May 2018, " ...hospital wide system for surveillance, prevention, and control of infections ...Identification and resolution of problems ...efficiently monitor ...surveillance activities ...measurable variables related to structure, process, or outcomes ...Prevention indicators ...a specific problem or an opportunity for improvement, a plan will be formulated ...actions taken ...the ...goal ...is to provide services in an environment that is safe for both patient and employees ...resolve problems that are identified ...".

During exit conference with the Administrator and the DON on 09/12/2024 at 1:53 p.m. survey findings were discussed and no further document submitted for review.