Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 010006 (X3) Date Survey Completed 07/15/2010
Name of Provider or Supplier North Alabama Medical Center Street Address, City, State 1701 Veterans Drive, Florence, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0748 INFECTION CONTROL OFFICER(S)
CFR(s): 482.42(a)

A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.


This STANDARD is not met as evidenced by:
Based on observation and review of facility's policies, it was determined the facility failed to ensure blood products were handled according to the facility policy by the laboratory staff. This had the potential to effect all laboratory staff. Findings include: Facility Policy Dept. Laboratory Title: Glove usage - Removal and Disposal Gloves are required when obtaining, handling or distributing all specimens... Gloves in the clinical areas should be replaced when they become torn, soiled or contaminated. Facility Policy Exposure Control Plan Policy: Exposure Control Plan Statement of Purpose: The purpose of the plan is to: Establish individual responsibilities to minimize the risk for healthcare workers of acquiring bloodborne disease to occupational exposure. Definitions: Standard Precautions and Respiratory Hygiene/Cough Etiquette: ... All human blood and certain human fluids are treated as if known blood and can cause disease in humans. Contaminated: The presence or the reasonable anticipated presence of blood or other potentially infectious materials on an item or surface. Exposure Determination: This exposure determination shall be made without regard to the use of personal protective equipment: Category I: Jobs with tasks that routinely involve exposure or potential exposure to blood, body fluids or tissues... (Laboratory/Pathology Department is included in the Category I list) Methods of compliance: General: Standard Precautions and Respiratory Hygiene/Cough Etiquette are observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid type is difficult or impossible, all body fluids shall be considered potentially infectious materials. Engineering and Work Practice Controls - used to eliminate or minimize staff member exposure... The following engineering/work practice controls are used throughout the facility: Hand cleansing facilities - (or alcohol-based hand), which are readily accessible to all staff members who have potential for exposure... Following any contact of body areas with blood or any other infectious materials, staff members wash their hands or any other exposed skin with soap and water as soon as possible: they also flush exposed mucous membranes with water... Personal Protective Equipment: Personal protective equipment is the "last line of defense" against bloodborne pathogens... This equipment includes, but is not limited to: ... gloves (latex or vinyl), in all sizes and hypoallergenic ... Gloves are worn in the following circumstances: Whenever staff members anticipate contact with potentially infectious materials When performing vascular access procedures When handling or touching contaminated items or surfaces Facility Policy Hand Hygiene in Healthcare setting Manual: Infection Control Purpose To provide procedure for correctly performing hand antisepsis. Policy Appropriate hand hygiene is performed to reduce the potential risks of transmission of microorganisms to patients and to reduce the potential risks of health-care worker colonization or infection caused by organisms acquired from the patient. The following are indications for performing appropriate hand hygiene procedure (either handwashing with hospital approved agent or using the hospital approved alcohol-based product - as indicated). ... After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings If moving from a contaminated- body site to a clean body site during patient care After removing gloves... An initial tour of the facility laboratory was conducted on 7/13/10 at 2:10 PM. During this tour at 2:30 PM, the surveyor observed Employee Identifier (EI) # 8, the laboratory staff member reach into the "Blood Bank" refrigerator and removed a unit of blood that had been typed and cross matched with her bare hand. After explaining to the surveyor the procedure for blood that had been assigned to a patient, she placed this bag back into the refrigerator. The surveyor did not observe the staff member wash her hands.