Unsecured and Improperly Stored Biohazardous Waste and Sharps
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program related to the storage, security, and disposal of biohazardous waste and sharps. A community complaint reported that trash and biohazardous waste were blocking the back side of the building and that such waste was stored in unlocked, unsecured rooms. Surveyors observed, off the back entrance, a room with the door half open containing multiple boxes labeled "Infectious Waste" and "Biohazard Medical Waste" overflowing with sharps containers and red biohazard bags, with additional red bags and sharps containers on the floor extending to the doorway and visible from outside the room. The facility’s policy on storage of sharps required all sharps to be stored and secured in designated locked containers and areas at all times when not in use, and not to be handled by residents with functional or cognitive limitations. During subsequent observations, in the presence of the Administrator and the Assistant Maintenance Director, the same back entrance room was again found half open and filled with biohazardous waste, and both individuals acknowledged that the room was unlocked and contained biohazardous waste. The Assistant Maintenance Director stated that the contracted biohazard waste removal company had not picked up the waste due to non-payment by the facility. A representative from the contracted biohazard waste removal company confirmed that services had been placed on hold months earlier due to non-payment and that the last biohazardous waste removal had occurred in late May of the previous year. Review of facility records did not show evidence of any licensed biohazardous waste removal company being on site for waste removal and disposal since that time. Surveyors also observed unsecured biohazardous waste and sharps containers on multiple resident units, including a secured memory care unit. On one unit, a box was overflowing with sharps containers, with additional sharps containers on top, including one open container with exposed needles and other sharp objects. On another unit, boxes were overflowing with sharps containers, with multiple additional containers stacked on top. On the Cortland Unit, fourteen sharps containers were observed on the floor, along with multiple IV lines visibly containing blood and hanging from the sharps containers. On the memory care unit, a box was overflowing with sharps containers with additional containers on top. The DNS acknowledged that these unit rooms were unlocked and contained sharps containers with biohazardous waste and could not provide evidence that sharps containers were stored in secured areas not accessible to residents. During these observations, multiple residents were seen ambulating and self-propelling near the unsecured rooms, including on the secured memory care unit housing residents with cognitive impairment.
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