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BRENTWOOD HOSPITAL
INFECTION CONTROL SURVEILLANCE, PREVENTION
Tag No.: A0750
40957
Based on policy review, observation, and interview, the hospital failed to have an effective infection prevention and control program as evidenced by placing uncovered and uncontained brown paper bags containing red bio-hazard bags used to dispose of personal protective equipment in the hallway outside the rooms of patients with active infections.
Findings:
Review of the hospital's policy labeled Infectious Waste Management, IC7.009 (last revised 10/2024) revealed, in part:
I. Policy
It is the policy of this facility to establish and maintain a plan for the safe handling, storage, management and disposal of infectious waste to reduce the risk of exposure of patients, staff, the public, and the environment.
II. Procedure
1. Definition
1. Infectious waste is defined as any waste, solid or liquid, that is or has had, known or suspected contact with any bodily fluid or body substance.
2. Examples of such waste include, but are not limited to:
3. Isolation trash (in part)
2. Collection and Packaging
1. Infectious waste will be segregated from other waste by containing in disposable red plastic bags labeled as bio-hazardous at the site of use. The bag is securely tied and then carried to the biohazard holding room and placed in an appropriately labeled biohazard container with a lid.
Observation of the 4 South hallway on 01/14/2025 at 8:15AM revealed bio-hazard red bags placed inside of brown paper bags were sitting on the floor next to the doors (two different doors adjacent to each other) of three patients who were quarantined due to Influenza diagnosis. The red bags protruded over the tops of the brown bags, which were open to air and uncontained.
During an interview on 01/14/2025 at 8:20AM, S1 Performance Improvement was asked why the red bags stay in the hallways. S1 Performance Improvement reported the bio-hazard bags were for PPE (Personal Protective Equipment) disposal.
During an interview on 01/15/2025 at 9:30AM, S1 Performance Improvement confirmed the bio-hazard bags were open to air and the bags should have been contained properly.