HospitalInspections.org

Based on observation, review of hospital policy and interviews with hospital personnel, the hospital failed to ensure that hospital personnel adhered to surgical policies. The findings include:
a. During tour of the operating suite on 11/15/11 with a Director and OR Quality Representative, multiple operating room personnel were observed to have hair exposed around the perimeter of the cap chosen to cover the hair. During observation of H 403 at approximately 11:10 AM, a surgeon that was leaning over a surgical site was observed to have the bottom two inches of hair at the nape of the neck outside the cap. Additionally, personnel with facial hair failed to cover that hair entirely when in the restricted area of the OR. During interview on 11/15/11, the Director and Quality Representative stated that management routinely reminded staff to ensure coverage of all hair when in the semi-restricted and restricted areas of the OR. Review of the hospital policy for perioperative dress code directs that disposable head coverings must cover the full head of hair in the restricted/semi-restricted areas of the OR. A disposable hood must be worn to cover long sideburns, long neckline hair and beards.

b. During tour on 11/15/11, observation of between case cleaning of rooms identified that stacks of clean toweling were stacked on top of anesthesia machines and on the tops and shelves of metal carts. The stacks of towels were observed to remain from case to case. Review of the hospital policy for cleaning of furniture and equipment in the OR between cases identified that all tables, stands and non-electrical equipment should be cleaned with a disinfectant between cases.