| 94 |
ST JOHN'S LUTHERAN HOME |
275024 |
3940 RIMROCK RD |
BILLINGS |
MT |
59102 |
2019-08-22 |
880 |
E |
1 |
1 |
P5VQ11 |
> Based on observation, interview, and record review, the facility failed to minimize risks of infection, and to prevent environmental contamination by disposing of sharps containers when the internal contents reached the fill line, subsequently by closing the lid on the sharps containers in four out of four areas. Findings include: 1. During an observation on 8/21/19 at 10:51 a.m., on the Garden Court medication cart, the sharps container, located in the bottom drawer, contained hazardous waste that was filled above the fill line, and the lid was open. During an interview on 8/21/19 at 10:52 a.m., staff member G stated she believed the fill line was at the very top of the container, where the lid is located, not where the actual fill line was marked on the container. 2. During an observation on 8/21/19 at 1:46 p.m., in the Transitional Care Cottage, in the locked medication/supply storage closet, three, overfilled sharps containers were on the floor. The lids on the sharps containers were open, and the containers were filled above the fill line mark. During an interview on 8/21/19 at 1:48 p.m., staff member J stated, When the sharps container is full, we stash them in the medication closet, and then put them in a room in the back. Staff member J stated, Every Friday, environmental services comes and empties them. 3. During an observation on 8/21/19 at 2:31 p.m., in the Hansen Cottage, in the locked medication/supply storage closet, one, full sharps container was on the floor. The lid on the sharps container was open. 4. During an observation on 8/22/19 at 9:18 a.m., in the Liggett Cottage, in the locked medication/supply storage closet, two, full sharps containers were on the floor. The lids on the sharps containers were open. A review of the facility's policy titled, Exposure Control Plan, showed: - Sharps disposal containers are inspected and maintained or replaced by Housekeeping and Nursing Staff whenever necessary to prevent overfilling. -During use, containers for contaminated sharps shall be: -Easily accessible and located as close to the immediate area where sharps are used or found. -Maintained upright throughout use. -Replaced routinely and not be allowed to overfill. -When moving containers of contaminated sharps from the area of use, the container will be: -Closed immediately prior to removal to prevent spillage or protrusion of contents. -Place in a secondary container if leakage is possible. |
2020-09-01 |