Improper Sharps Disposal Leading to Needlestick Injury
Penalty
Summary
The deficiency involves the facility’s failure to properly dispose of contaminated sharps in accordance with its infection prevention and control program and Sharps Disposal policy. A male resident with multiple medical conditions, including encephalopathy, anemia, diabetes, depression, anxiety, heart disease, kidney disease, and liver transplant status, had an order for IV fluids that was changed to clysis after an unsuccessful IV attempt. A clysis line was inserted into the resident’s left upper arm and later became dislodged, with clear fluid leaking from the site. The site was cleansed and the MD was notified, and there was no order to re-insert the clysis. After the clysis was dislodged, RN A reported that she hung the tubing and used sharps high on the IV pole in the resident’s room with the intention of returning to dispose of them properly, but she became busy with other residents and forgot. The used sharps remained attached to the IV pole instead of being immediately discarded into a sharps container as required by the facility’s Sharps Disposal policy. The resident did not have a roommate, but the used sharps were left in the room accessible to others. The facility’s policy stated that whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers that are closable, puncture resistant, leakproof, and properly labeled or color-coded. When the resident was later found unresponsive, CPR was initiated and EMS arrived and took over. EMS B entered the room to assist with CPR and, while removing a bag of saline from the IV pole, was stuck by the subcutaneous sharps that were still attached to the tubing and hanging from the pole. EMS B reported that she did not see the sharps before being stuck. RN D then removed the bag of saline and used sharps from the IV pole and initially placed them in a garbage bin at the nurse station instead of a sharps container. EMS B later asked to see the bag, and RN D retrieved it and the used sharps from the trash. Interviews with RN A, RN D, the ADON, and the Administrator confirmed that the used sharps should have been immediately disposed of in a sharps container and not left on the IV pole or placed in regular trash, and that this incorrect handling of sharps was contrary to the facility’s policy and created a risk of exposure to communicable diseases and infections for residents and staff.
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