Summary:
Summary Statement of Deficiencies D6084 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1445(e)(2) The laboratory director must ensure that the physical plant and environmental conditions provide a safe environment in which employees are protected from physical, chemical, and biological hazards. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the laboratory director failed to ensure four of four hazardous waste/toxic chemicals (Reagent Alcohol 95%, Denatured Alcohol 95%, Eosin Stain, Hematoxylin Gill II) were not being disposed of down a sink where an eyewash was mounted for one of one eye wash observed in the laboratory. Findings include: 1. During tour of the laboratory on 7/25/2023 at 10:27 am, the following was observed: a) An eye wash station was observed mounted on the countertop right next to the only sink in the laboratory. b) Hazardous waste/toxic chemicals were being used in the laboratory: -Reagent Alcohol 95% -Denatured Alcohol, 100% -Eosin Stain -Hematoxylin Gill III 2. On 7/17/2023 at 1:34 pm, SP2 (histology tech) confirmed chemicals used in the processing of staining histology slides are disposed of in the sink with the eye wash. 3. Review of Material Safety Data Sheets (MSDS) for each chemical indicates the following for eye exposure: a) "Reagent Alcohol 95%" Section 4 pg. 2 of 7 reads, "Immediately flush with plenty of water for at least 15 minutes, separating eyelids occasionally. Remove contact lenses if present. Get immediate medical attention. b) "Reagent Grade Alcohol 100%" Section 4, reads, "Thoroughly flush the eyes with large amounts of clean low-pressure water for at least 15 minutes, occasionally lifting the upper and lower eyelids. If irritation persists, seek medical attention." c) "Hematoxylin Gill III" Section 4 pg. 2 of 8 reads, "Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Call a physician immediately." d) "Eosin" Section 4 pg. 2 of 10 reads, "Rinse eyes with water as a precaution." 4. Annual volume of Histopathology tests = 1200. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 1 --