Biohazard Room

Month Day, Year

Exhibit 1

Doors to outside dock area without a locking mechanism

• This door has direct access to the outside without a locking mechanism. Both inside and outside open with the open button.

• There are no card readers or cameras in the area.• This door gives access to the shredding area, biohazard area and the

hospital through back corridors.• There is security risk to the hospital due to both the physical access

and lack of monitoring.

2

Door accessed with button on wall on both inside and outside of door.

3

Entrance to area where sharps containers and other biohazard materials are stored

• These doors are not secured.• This room is located off a main hallway.• There are no cameras or access restrictions in area.• There are three doors of this type in the area: biohazard room,

shredding room and connecting door between shredding and the biohazard room.

• Contents are easily visible from hallway.

4

Surgery drugs are disposed of in clear trash bags after procedures

This is one of numerous 100 ml bottles of Propofol readily accessible in a bag.• Per the National Institute of

Health, Propofol should be managed to prevent the risk of diversion, including restriction of access and accounting procedures as appropriate to the clinical setting.

• Bags of surgical drugs, including bottles, vials, bags, etc. are in clear disposal bags in an unlocked room.

• These drugs are potentially harmful if diverted.

5

Surgery drugs are disposed of in clear trash bags after procedures (Continued)

There is a potential for drugs to leak or be diverted from the bag.• Multiple drugs are noted in this bag.• These are liquid drugs and tubing from be surgical areas.• Drugs can be removed from these bags and remain undetected.• Bags are not logged resulting in the potential for them to be

removed and remain undetected.

6

Surgery drugs are disposed of in clear trash bags after procedures (Continued)

• This is one bag with IV bags, tubing and vials from the surgical area.

• Contents can be easily removed from the bag and remain undetected.

• Liquid contents have leaked into the bag and are pooling at the bottom. This occurred in the majority of bags examined.

• These drugs are transported by Environmental services personnel to the area.

Drugs pooling in corner

7

Pharmaceutical Waste

• Numerous surgery drug disposal bags are placed within each box.• Two black chemo therapy boxes were placed in the bottom of one

box during one visit.• One bag lifted had a leak that was spilling onto the other contents of

the box.

8

Filled sharps containers in unlocked room

• Reusable sharps containers make it possible to remove carpujects and vials that contained narcotics resulting in the ability to divert residual drugs.

• Sharps are becoming a popular drug diversion source per numerous governing bodies.

• Sharps containers are sealed with a removable plug allowing easy access to view and remove contents.

9

Filled sharps containers in unlocked room (continued)

There are two cart designs available. The two-shelf cart is approximately five feet tall while the three-shelf configuration is over six feet high when filled.• Reusable sharps containers used as collection points for needles,

syringes, carpujects and small vials of medication that can be diverted.

• Multiple layers of sharps result in the potential for sharps to fall off cart causing a potential for sticks or cuts from spillage.

• Sharps do not appear to be logged. • Sharps can be removed and remain undetected.

10

Biohazard Bins and Cart

• Biohazard cart is over-filled resulting in the biohazard bags being at risk of being punctured by cart lid.

• Stored in same room as sharps containers resulting in overcrowding and potential for biohazard exposure from bumping into cart, bins or sharps containers causing spillage.

• Biohazard bins are stacked three bins high increasing the possibility of instability or injury when moving.

11

Damaged Biohazard Carts

• Biohazard cart is damaged with a large hole at the bottom of the cart. This could lead to spillage or damage to the biohazard bags within the cart.

12

Damaged Biohazard Carts

• Biohazard cart with damaged handle has been repaired with with a metal wire instead of a handle. In this case, the wire is approximately one third inch long and can puncture a bag or injure a team member handling the cart.

13

Damaged Biohazard Carts

• Biohazard cart with damaged lids are being repaired with zip ties or wire. Several carts were missing three to four of five bolts in the lid. Zip ties and wire can result in injury to the team members handling the carts.

14

Damaged Biohazard Carts

• Biohazard cart with damaged hazardous stickers. Some are damaged to the point they are almost not identifiable. These stickers should remain in good repair.

15

Trip Hazard in Pharmaceutical Waste Room

Unmarked trip hazard between biohazard and pharmaceutical waste rooms.• A ledge exists in the room that is the same color as rest of floor.

• Ledge is sloped and not easily visible.

• Ledge is over six inches high.

16

Debris Blocking Doorway

• Debris is blocking doorway to small dock.

• Door has sustained substantial damage.

• Door does not have lock or scan card to access area.

17

Small Dock Entrance

• Vendors back up to the dock for loading and unloading.

• Door to the left is the entry point.

• Second door is ear marked to become storage area.

• There is no camera coverage in this area making it vulnerable to misuse.

18

Dock Area From Outside Gate

Dock area with access to hospital. • Dock area is not monitored by security camera.

• Only chain link security gate is monitored by camera.

• Gate is supposed to be locked at 6 PM at night; however, process is not hard-wired.

• Vehicles can easily access area.

• Area has open access without badges, keys, etc.